Question

Mental health nursing (Addiction)

3. Mary has been admitted to your unit after hip replacement surgery and you are taking care of her on evening shift. Over the last few hours, she has become increasingly irritable and agitated. She is diaphoretic and tremulous and is complaining of GI distress. Her blood pressure and pulse are elevated. Her daughter tells you that she has a habit of having one cocktail per night. What do you think is going on? How do you assess her? What interventions might she need?

Answer 1

Alchol addiction

Alcohol addiction, also known as alcoholism, is a disease that affects people of all walks of life. The severity of the disease, how often someone drinks, and the alcohol they consume varies from person to person. Some people drink heavily all day, while others binge drink and then stay sober for a while.

According to the symptoms seen in Mary , she  is alchol addict ,to be specific , addicted to cocktail.Mary is suffering from alchol withdrawal symptoms. The symptoms are as follows;

Psychological Symptoms

• Feeling jumpy or nervous

• Shakiness

• Anxiety

• Irritability or becoming excited easily

• Rapid emotional changes

• Depression

• Fatigue

• Difficulty thinking clearly

• Bad dreams

Physical Symptoms

• Headache

• Sweating, especially the palms of your hands or your face

• Clammy skin

• Paleness

• Rapid heart rate (palpitations)

• Nausea and vomiting

• Loss of appetite

• Insomnia

• Elevated blood pressure

• Tremor of your hands

This is  the assessment cretirea that can be used  on Mary to assess her

The Interventions that can be carried out on Mary are as follows;

Interventions with Rationale

• Perform complete nursing assessment and assess vital signs

Get baseline to determine effectiveness of interventions.

The sympathetic nervous system response may cause elevated temperature, high blood pressure, tachycardia and severe respiratory depression.

• Determine stage of AWS
  • Stage I – hyperactivity
  • Stage II- hallucinations and seizure activity
  • Stage III- DTs, confusion, fever and anxiety

Help determine appropriate interventions and prevent progression of symptoms

• Perform 12-lead EKG per facility protocol

Monitor for cardiac dysrhythmias and irregularities.

• Monitor respiratory status and administer supplemental oxygen

Severe respiratory depression may occur and requires immediate intervention.

• Maintain patent airway and monitor for aspiration

Clients with vomiting and respiratory depression are at risk for aspiration. Advanced airway may be required.

• Initiate IV access and administer fluids

Vomiting may lead to dehydration and fluid imbalance. Maintain cardiac function and cardiac output.

• Monitor lab results and administer supplemental electrolytes as needed

Dehydration, diaphoresis and vomiting may result in electrolyte imbalances that can cause cardiac dysrhythmias.

• Initiate seizure precautions per facility protocol

Seizures are often contributed to low magnesium, hypoglycemia or elevated blood alcohol levels.

Antiepileptic drugs are not indicated for seizures associated with AWS as they typically resolve spontaneously. Symptomatic treatment and safety are recommended.

• Provide calm and safe environment, free from clutter, noise and shadows

Sensory disturbances, hallucinations and confusion can lead to severe injury. Hallucinations often occur more at night and clients in advanced stages may experience anxiety and fear.

• Monitor client for signs of depression or suicidal ideation. Initiate suicide precautions as necessary per facility protocol

Confusion and anxiety may prompt client to attempt suicide or self-destruction.

• Provide isolation or restraints as necessary per facility protocol

During periods of excessive psychomotor activity, hallucinations and anxiety, restraints may be required temporarily to prevent harm to client or others.

• Reorient client to reality as often as needed in a calm and supportive manner

Confusion, anxiety and hallucinations may cause periods of delirium. Reorientation helps calm fears and relieve anxiety.

• Administer medications as appropriate and required

Anti-anxiety medications may be given to reduce hyperactivity and promote sleep.

• Benzodiazepines are also used to prevent seizures and manage severe tremors and withdrawal symptoms.
• Specifically lorazepam.

Antidepressants may be given to help client regain control of daily functioning and improve ability to concentrate and participate in therapy or counseling.

• Provide education and resources for client and family members

Resources, support groups and counseling services may help client and family members manage client’s needs going forward and help maintain relationships and daily functioning.

thank you....