Substance Abuse & Use Disorders

Alcohol

100

Complete CIWA-AR Assessment

Contact HCP to initiate CIWA Protocol

-Lorazepam

-Phenobarbital

-Chlordiazepoxide

-Dexmedetomidine (off label)

Thiamine & Folate Replacement (IV/PO)

Initiate Prophylactic Seizure Medications

-Valproic acid

-Gabapentin

Antipsychotics

Beta blockers/clonidine

Nursing Interventions for Alcohol Withdrawal

200

Confusion or Altered Mental Status

-Hallucinations

Safety

-Risk for falls

-Risk for aspiration

-Risk for violence

-Risk for injury related seizure activity

-Risk for ineffective breathing pattern

-Respiratory depression

-Imbalanced nutrition, less than body requirements*

-Self Care Deficit*

Nursing Diagnosis for Alcohol Intoxication & Withdrawal

300

uCoarse tremors of hands, tongue, or eyelids

uNausea/Vomiting

uMalaise/weakness

uTachycardia

uSweating

-Elevated blood pressure

-Anxiety

-Depressed mood

-Transient hallucinations or illusions

-Headache

Signs & Symptoms of Alcohol Withdrawal

400

-IV access

-O2 readily available

-Suction equipment set up

-Thorough alcohol history

Nursing Interventions for Alcohol Intoxication

500

-Disinhibition of sexual impulses

-Disinhibition of aggressive impulses

-Mood lability

-Impaired judgment

-Impaired social or occupational functioning

-Slurred speech

-Incoordination

-Unsteady gait

-Nystagmus

-Flushed face

Signs & Symptoms of Alcohol Intoxication

CNS Depression

100

-Amobarbital

-Phenobarbital

-Zolpidem

-Temazepam

-Alprazolam

-Clonazepam

-Diazepam

-Lorazepam

Barbiturates, Non-Barbiturates, & Anti-Anxiety Medications

200

•Long-acting phenobarbital (Luminal)

•Used when the withdrawal is from a nonbarbiturate CNS depressant

•Collaboration with HCP on Tapering

Nursing Interventions for CNS Depressant Withdrawal

300

-Imbalanced sleep and dreaming

-Respiratory depression

-Hypotension

-Increased liver enzymes

-Decreased body temperature

-Decreased libido

Effects Of CNS Depressants On The Body

400

-Maladaptive behavioral or phycological changes

-Inappropriate sexual behaviors

-Inappropriate aggressive impulses

-Mood lability

-Impaired judgment

-Impaired social or occupational functioning

-Slurred speech

-Incoordination

-Unsteady gait

-Nystagmus

-Impaired attention or memory

-Stupor and/or coma

CNS Depressants Intoxication

500

-Cannot stop Benzos "cold turkey"

-Autonomic hyperactivity

-Sweating

-HR > 100

-Increased hand tremor

-Insomnia

-Nausea/Vomiting

-Hallucinations/Illusions

-Psychomotor agitation

-Anxiety

-Grand mal seizures

-Delirium

CNS Depressants Withdrawal

Opioids

100

-Drowsiness

-Respiratory depression

-Diarrhea to Constipation, with impaction

-Hypotension

-Decreased sexual function

Effects on The Body

200

Rest

Adequate nutritional support

Antiemetics

-Ondansetron (Zofran)

Antidiarrheals

-Diphenozylate HCL + Atropine sulfate (Lomotil)

-Loperamide (Imodium)

Medication-assisted Treatment (MAT)

-Buprenorphine/naloxone (Suboxone)

-Methadone

-Lofexidine (Lucemyra)

Nursing Interventions for Opioid Withdrawal

300

-Risk for ineffective airway clearance

-Risk for injury r/t impaired judgment

-Impaired communication

-Altered mental status

Nursing Diagnosis for Opioid Overdose/Intoxication

400

-Initial euphoria

-Apathy

-Dysphoria

-Psychomotor agitation or retardation

-Impaired judgment

-Pupillary Constriction or dilation

-Drowsiness

-Slurred speech

-Impairment in attention or memory

-Respiratory depression

Opioid Intoxication

500

-Drowsiness

-Respiratory depression

-Diarrhea to Constipation, with impaction

-Hypotension

-Decreased sexual function

Signs & Symptoms of Opioid Withdrawal

CNS Stimulants

100

-Crack

-Cocaine

-Ecstasy

-Adderall

-Caffeine

-Nicotine

Types of CNS Stimulants

200

-Crashing

-Fatigue

-Cramps

-Depression

-Headaches

-Nightmares

-Dysphoria

Signs & Symptoms of CNS Stimulant Withdrawal

300

Calm, non-threatening approach

Reorientation

Suicide assessments

Seclusion/restraints-last resort

Medications:

Chlordiazepoxide (Librium)

-Haloperidol (Haldol)

-Antiseizure medications

Interventions for CNS Stimulant Intoxication

400

-Altered mental status

-Risk for injury

-Risk for violence

-Risk for falls

-Electrolyte imbalance r/t nausea, vomiting, diarrhea, sweating

-Self-care deficit

-Risk for suicide

Nursing Diagnosis for CNS Intoxication

500

-Maladaptive behavioral or psychological changes

-Memory loss

-Psychosis

-Violent aggression

-Tachycardia or bradycardia

-Pupillary dilation

-Elevated or lowered Blood pressure

-Perspiration

-Nausea/Vomiting

-Psychomotor agitation

-Muscular Weakness

-Confusion

-Chest Pain

-Confusion

CNS Stimulants Intoxication

Miscellaneous

100

Disulfiram (Antabuse)

Naltrexone

-ReVia(oral)

-Vivitrol(injection)

Acamprostate (Campral)

Alcohol Abuse Medications

200

-Korsakoff's Psychosis

-Cirrhosis of the liver

Irreversible Alcohol Complications

300

Barbiturates, Non-Barbiturates, & Antianxiety Medications

CNS Depressants

400

-Administer naloxone inhalant

-Monitor airway

-IV access

-Monitor respiratory status

Nursing Interventions for Opioid Intoxication

500

-Depression

-Risk for seizures

-Risk for suicide

-Inadequate sleep

-Imbalanced nutrition

Nursing Diagnosis for CNS Stimulant Withdrawal