Mental Health Chapter 11-12

KEY TERMS mau---

confusion reversible confusion @h+nm] hypo& hypothenia electmIytes data calldon psyehosoeial bistary mental sfatus amnmiii

~UTLIWE Aging Canfusion Revemible Confwion Ddh'hm) Causes of Rever~ibleConfusion Data Cdeceion Nursing Care of the ConfUsed Client R d t y Orientathn Irreversible Confuson Disease Pragression Nursing Care Depression intheuderly SqmrPt-s Comnnicamg with the Depressed Client Treatment Medications

agnosia aphasia d t y orientation irreversible eonfusion Alzheimer's &ease depression, endogenous depression, r e a d pseudodanentia eIectrownMllsive therapy (ECT3

Geriatric Mental Heath

Z@@ Chapter 11 I'

AGING Old age is arbib"aa1.y d&d as sixty* years and older. "I% @~poup contains a very divme ppodation phpf*, mentally, and m o m l ; ally U ~mimy peopk~ d lbelieve the ~ s t e r a a,d pi-, of the aged as debilitated, povs i d w n 0~~~ and confused. @ronie &eases are more preadent in the a g d but the per: ceatage that is diSabIed is very siilaa. Perm& doe8 not p a d i m change as one becomes old= ItgraduaUydevtlaps throughoutThelifi cycle. Ifthe individwl is able tu meetthe developmentd tmb of* age b d and cope with d e &es$em wcountered, the older persea pill not ijuddenIy become cranky oh his or her six@-% b-ar C d w i o n is not a part of normal gin$ but a S y m p D ~of d&WZil Althoagl~there are ce* poor elderly, most law adequate incomesand assea to live wmEnfab& l?xe agingpersonmaybe dealing with a cment mental h d t h ptoblm as well as a g e n d medid condition, such as heart W s e , chronfc obstmdive lung @we, diabetes The n&r of &rlyhasgreai&naz&sedin the past f e w p a 6 and is expected ta mntiaueto & stead^ Thisis prinoarily due to the mtimpmvement8 in m&md and child health, h e r e 4 technalo~ in heal& as well as the large and agio$ babYhomer pop~hfibn There i~ a big dBkrence between the old old and J T O OM. ~ Those who are t m h g dxtycfive today are healthim, better dn~ated,~ more afnuent and more outspoken than their oIdes p m . They speaking up and letting their needs b e h o r n They are using porn& power m push through impmvments in their lives and p d m k r l y f ~ health care. As a mdt there has been a surge of inter& ih the prab lem of the aged. The care of the aged with mental health pmhlenas bas unfomnatdy lagged bebind D e i n s t i m t i o n ~ o nbad the e%et of m o m the mentally dW!essed elderly into nii"ghom~s,tyharethefacilities and p r e p d m of the p m n d are gene&' ina-te to m e %bf &en Although rhs situationis improving, most of the health &+ dplioes find little challenge in w~rkhgwnh the elder~y,The more comfno~smental healfh pro6ledis of the aged, melr adW66m, dementia,and deprasbn ans amsidered to be within the realm ofthe general pmctitiona iUWugh the elderly who are meW& distressed are more con cenzated in nursing homes, many are being taken care o m theit fmllies. In the future, it is likely that fewer elder& persons d lbe cated for in SW nnrsingfacilitiies,Nmes m r w in hgspid~,in inetb~s' offiw, and in the anmnxmip are more apt to be the %.to see these dients. Xfhur~esm abIe to m e o w the dB-f types ofpmblesl~~ I.. r

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thzy may be able to save Borne cIigreat expense in kz-rms of time, money, stre%, &%stemand independence. More than a few elderly &me pmblems are die find tbemsel~8in instimiom rather than Eying independently at home simp&because the d m i m was patmoed

Confusion is not deatly detined. It means different things to d@erent people. tJienh canbe termed confused if they do not ~ W Wwhere they are or the day's date. If the answer to a .question is #nappropr&e or behavior does rrot meet acceptable standaide, the older person tn*SIl be labeled codwed. Ifthey appear to have a blank stare or $porn 8irnple dfr&ns, older pepple wiU m;ost a&&ly be comidered canfused CimtMon is one of the maat cornmen problem in old age and ISe x t x d y detrimentalto the qualtty of lifeb i n y e m . Colifusion

kmtandp~af~butwMtRomthemtemalaTul~nal sf?t%~orsoil any ofthe older pmm's body 8ystems. Confusion is divided &to fhree main caregories: (1)c o W o n referred to as delirium, rwults &omacnte ilhms, drugs, emotional strew, or en&onmenen talfa(this 46 the most common type of conftlsion Sern inthis age group and is g a d y rwers,ible if baed wlyl; izS confusion wdting ffom brain damage, wmmonly referred to as dme* and C3] m n h i o n associated with &&e disordem and pychosis.

Befare labeling a client as confused, the m s e must be certain that the problem is not a result offafactors that mimfc confusion (Pignxe11-1).It is assumed tha~everyone living in the same area shares the same culture and speah Zhe same language. It IS hard for mosr young people to reaIize that the d t u r e of the elderly is quite merit f h a the culture today. The amoms and mannersleamed in youth are canied into old age. The elderlyperson's owncultu~econtinues to influence his or her behavior even though the world a r o d is changmg. For emnple,

Mrs Jones, age seventy, was admined to fhe hospitd two days ago. Her nurses had labeled h e r d e d . While grow%up in the old country,her f ' y ate lunch at noon and dinner at 10:00 EM, a custom she continued to &e. When her dinner .tray was served at 5:00 P.M., she refused to eat because itwas not her dinnmime;At 1o:OO P.M., after eveqone was in bed she demanded her dinner, stating that she had had nothing to a t since noon Although her nurses did

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Causes of Reversible Canfuslon

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f as a visual ~u&%ltio~. ~~~1~~~~ mad by fieamal @ng process ineoawos%of canfusion inyet :mother the && of i w e g ~WWiry *@ IseeaflSe&e mdOf heaidg 4 range there is dw & ,po&izay 6f selxmy up the*bh3@ pidual turpsaka fpvorite $e ot she has to heap.the%ha ~~it&" ~ , mlk . layer d the aeraw.&s pkon ahearthese M ) ~ ethe h~ & am d @p ~m d t s fiedde]:&pmn is a,&ii& w~ is,~fr- ma one &y am wsund,,it iiiea~y-for=P@ ' ,fao iqe &a den& w e . U&rtnnately. when fie to fOOrger ae&re or d~e~this~&~~!5heisWXAd~*d usst admitt& the ho$pit& aderlp dims maywaka:Q. .middle of%e night and wheac they 'ng$ gg^ ~ of bed and tMan&:h,an a m , p ta orient & d W *Wayr&g & I a blank lost look on be @ ~gure w s no doubt be cantiidad confusede and D s& a m w ! be pput ba& &j bed and m U & X e d e d & is prob4wility. &pJ&

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Reversible confusion is the mosf common type of confusion & aged Until d&tdy proved acbmvise, confusion ,&odd be sidered revemible so tha't attapts wilI be made to k d and ek the causes Dhle ll-1). H Y P d a is aladr 0fsxpp;en in the brain. ApprcKimately 20 percent ofthe total Oqgen conmption is used by the brain. Nme *@ m o t live for more than a fmminut@ WQW it B@we &re no storage a% the brain must get s acatinuous supply of m e n . Conditions such as respiratory disease, cardiac pwbIems7 k=&yp roidism, hypotdop,and anemia &ern t h e o a e n sup& to *bo@ and thm to the'brain. Hmothermia is a lowaing dfthe body temp& elderIy Ev S-itib?. to this cc1nditi:m They do not sense cold as ewily as younger people do, andtheir tempmmm can,&OP to OUS Ie-1~ 9 q~dddy. P1emperatp-e mt?p 1029F wn~itI@ed,mthand it toot erin presetitas c ~ n f u s i inthe ~ n elderly 'ThtrstiS ~ f ? e n = i g I by L ~older ~ people. Theym y n& be atyHTe of rnt@?,$ impol'tane~to them it maybe too much trouble trt get a Brinkq 02 water m y be inae~ssiljle to theaaehydxatia & a very dangero* cbik-iiflonfor the aged, ,&d fhe ~nlly'mptommay be confusioa T& is W P ~ true ~ Pwhen electmlytes a& involved. Electrolytes me ~~emicaIs necwary for the hctloof the n m e a. m a g hq in balance with eaeh other, confusion m h .

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IRmectfVe Er#m qellPuft@o@t~@ bticise ova fack.of~&&~lw AdWrSeIV:+ffb~bialnewfo@m@nf Brrcinishesbrain cell fun&fanfng ChaWs bmm envfr~nment. slaws braln cell .&nettoning DtmlnTSh%',b@thcell ftinctloning fns-the brain's environment Dimhismes rirp cell furicf15h1nd as a Wult oi stress ef~aots.

,

DRUG

EFFECT

mnhion, part of which is treatable. If drug-induced confusion fs recognked, another drug can be substtbted that haeases dariQ in the client's mind Too often mnfirsion is atttibured to old age and is not treated at an.

Mrs. Stevens, age eighty&e, was visiting her daughter. The daughter noticed rhat her mother seemed mnfused. She set her suitcage down and the next minute could nor $nd it She turned d e faucet aq saying she wanted a drink of water, but t h a quickly forgot and I& the wata running. v

She never did get her drink Even though she had been in fhe house many times, she wnld not seem to remeruber where the bathroom The daughter to& Mrs. Stazns to see the doctor, who admitted her to the hospital. -

Mrs. Stevens had been on a maintenance dose of digitalis follpwiag a heart am&several yeafs ago. She told rhenurses that she did not want h a heart pill anymore. Because it was believed that she needed the drug, it was given to her by injection As time went on, she became more wnfbed. hally, the doctor told Mrs. Stevens's datlghta that ahe must consider nursing home. placement for her m o w . "After aU,PUT mother is eighty-five.It is -time; the doctor reasoned! The daugbtpl-relnchntly did as b a e d She t h a

chapter 11 sold her mother's house and disposed of mast of her furhitun?, clothes, and household goods. Mer aIZ her mother had no use for them anymore, and she needed the money to pay the expensive nursing home bib.

In the nursing home, Mrs. Stevens told the new nurses that she did not want her "little yellow* the digitalis. When it was bmght to her,she clenched her teeth and steadfastly &wedto takeit% time,no injectionsweaegiven The drug was offeredto her when it was due+but if she refused, no attempt was made to f m her to take it Mr6. StmmS's confusion, having been caused by the digidigitalis, began to dear up and eoenkdy she was discharged. U n f o r m n a ~ , by thatshe had no home to go to and no belonto call her own.%is happened because the confusion was wrongly assumed to be irrevmible.

m.VIL &red a little better. H e w diagnosed as Alzhdiner's disease. He was confused, presented bizarre behavior, and was hostile toward his wife When the chgnosis was made, his wife got him to sign a power of attorney and then admitted him to a riming home, Becausethe nursing home was in wfher town, the client had to have another doctoz The new doctor saw no reason w h y phenytoin OMantin), an anticolrrmlsant had been ordered and began to wean the client from it As the DiIantin level felL Mr. Kobeas' &ion began to daar up. The nmi& s M n o M the change ib his behavior and soon questioned his diagnosis They asked the dodor to order a serum phenytoin CDihnth) lev& which was done Although hrlr. %Roberts w e improving, his Dilanti~l e d was dangerously high. With the problem and treate& however, he continued to improve He w a t to senior amtm and to c h d socials He made many &ends and one lady fiend in particdm m t he got bis p o w of attorney back and then decided to divorce his wife in order to be with his new Mend. He W able to leave the nursing home and move in with his kdy friend far a happier ending

In addition, wimple thin@ Eke constipation pain, immobilit~~ other forms of emotional and physid stress can also cam ~ n f U in the ettefly

Data collection The thsf part of fhe nursing process is assessment data r0lIeetion contibutes to the total w w m e n t The LPN/LVN gathers data and gives infmation to the RW. Before doing any assessment for confusion, the nurse 111ustsee that dients have their glasses and hearing aids, if needed. The nurse also must be certain that he or she knows the answers to the questions. For instance, to test long-term memov the nurse can ask 'What is your birth dater Clients may be confused and have no idea, but they may know enough to realize that the nmse is askmg for a date and give ane.To recognize a change,the n m e must be aware of the Jient's his* and past behaviors. This information should be contained in a good psychosocial history. A psychosodal history c o n ~ u t e to s determine the type of confusion and is the h t step in asseasing conflwion or any ofthe other problems of the aged If there is reason to believe that the client is confused, information should be obtained from family membw or at Ieast M e d by them. It isbest to obtain the history in an informal setting (see Chapter 7 for interviewingW q u e . 9 . The family andlor client must first be aware of thereason for the bistoq Time should be taken to establish some rapport. This can be done taking a b u t noncontro& subjeers like the weather. The basic iden* information can be collected eacjly after that Qienfs name,address, maritalstatus,nder of children,rebgious preference, type of work done, and educationallevel are example^ ofbasic identifying information @gm 11-31. M s m e n t tools are &o availabIe Cbmmanlyused tools are the Brief Cognitive Rating Scale (BCRSI and the Mini-MentalStatus Exam (MMSE). These tools look at changes in wgnition or m& s t a t m The minimum data set (MDSI or another appmved form con'aining the same information,is required to be wed by all nm!hg homes having ce&kd Medfwe beds (see Appendix). It is a comprehensive assessment tooL but it is a minimum data set and other information may be needed This assessment must be starzed on admission and wmpIeted within f o m m calendar days, The assessment, along with its accompanying prmcols and %ger rap sheets, help the nurse determine needs and tmsfer these needs to the care p h Rotowls help the nurse understand the probIem he or she has assessed and to about other problems that might be related. The rap key gives rime guidelines in care planning. The MDS must be monlinated a nurse, but 0th d i s ~ p h e may s complete aspem of the MDs.

Geriatric Mental Health

Arizona Elks M@r Projects, IRC. LONO T@RMEARE UWff DATE: SOCIAL HISTORY Hospital NO: Tne tnfoymation on thts f o m WI be used solely t o alU in theacUusment ~f your relative and youto the nursing home 11%. YOUare not obllmefl ta anewer any auestfons that you d w m intruSIVe or U~neCemW,bur ail InFormationaven wlll be Comlderefl confldentbl.

clienfs name: Age: mte of birih: Marl@l-us: M I I W I 1 D f 1 St 1 m~iglotx ResBonsibleperson: amnosis: I. A. Tell me about befwe he m m e in. Wna9 tyse OF pewon w s hhV3 (How Would YOU deSWlbB hTma) 9. HOW waul@you dMCflbe his rel~onshlp wlth hls famHV7 IRremeyableto visltP) C. HOW wauid W M ~ ei850it)B his ~ela%lonshlp wffn prtgnds? fire Utey abie €0VlW D. was rel@ionan ImPorta~ pamr m nrs rife? E. Whatllind ofWOrk dld he do? (EdudlOtlal leV&I%i IHW m g UWPIOW? tMred?) E HOWdid ne usuallv handle pmbtems Or dlfflcUl8eSl

Date admttted:

How long InTucson: PreulousaW: c~ergman'sname: and address'. R,&WOnShlP:

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c wnat thmgs does ne parncu1ari~ asl~ks? coblac%,attitudes, aetlonS. adlvltier~ o. DffiEflbe nfr dany mutlne prior to qomlng t o me EBS. e. m a t pOSSeSlOhsare most Important to him? LONG TERM CAR#? UNIT PSYCHOSOCIALN U A T M N

RdatMnshlD:

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n. AFTER IUNESS A Date w d n s k B. whtcn of me dhaneesmat YOU hsye &iced concernedYOU themom C, matfactors did vou considel' before deciarng on nursm home placement7 UI. M E 5 WO DWJKES A Does he have any wlents? tsnglng, dancmg, pslntina. writing, 6tc.L

FIGURE 11.3 psychosocial history and assessment samples.

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IFIGURE 11-3 Continued. - .4.

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stageof 10s ~enlal() Anger I 1 18ar9em S Dgpreslon ( I Resignation 1 1 8. Rel&mnnnlpwrtn slienk IV. PO'PEW1IRLPRDBLXPIIS k la^^ M s t [ i n ~ ~ n I J A

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Geriatric Mental Health

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The p~~ history provides a haelink to u\thicb present behavior can he mrnpmd It proaides ihf'omatiidn on the client's srrengths and sup~oft system available t?shim or her. The Mary. can help det&dnewhe@er the confusion is rwersible and pmdde dues as to the cawe and Wtment of the c0nWan. The hbmq can be taken at a f o d but mom rrften the inftnm@i(mig o W e d &ugh inEennal c o n ~ t i o n (Eigwe s 11-%I, Mer rereipcing the basic identity Wrmatio~ the nurse can ask the M y fernhe majm problem, thebehaviorthat led themto believe the clienf needed help. How the hefam1y views the henfbion and how they ta& about their eIdwiy relative will give the nntse an Sdea ofthe amoun! and m e of fa^@ support avafkble. The number of"Mends with whom the clierit still bas hasntact aad the strength ofrehgotls belie& are also indicators ~fmpport avadI&le to the client To detamine whether the pment behavior is a w e I the nurse needs to h o w what the client W& Wte m o a i y Was he outgoing or ol bnw? Was she fastidious or sloppy? Did he slwp well at n&ht a wake often? TXIas she practical or a dwmez? Rid he m abwa drugs? Dfd shekep busy or appear bored?Did he hold B ~ problem B in or did he tallt them OWa t was a fspicalday.like? Concerning ~e h e i o n , the nwse shoukl ask que%timsueh as the ii,Itavin$: W e n did the confused behavior stiu~?~ T a s the omer gradmi or s u d d d Tan the funfly think of Borne sW& event &at happened just before the co-n hegap?" %&at af b&avi~i+does the dient e&iiit nwf" W tbe ca&sian gottenWOM or betterr"

3. What sari? are we in?

e \what is to&ys date1 5. isthi this? It is possible for a person to m a k a mistake with the day's date Without bebg &ed The par is anather matter. Ifit is Em2 a d the cIient says it is 1945, mnfUsion is pment Thne is the most eas& lost sphere oferimtaion; therefore it is important to detgrmine all fair sphw. Abstract Thinking. Thb is the abiiiyto generah anti categodze things. It h a htgher cagnffim pow~lrthat is loa when wnfusign Be@ in. 'Ib resf &sttact thc clfent ccm be asked k, ina ptoverbsnr$as'"Ilze~s isahYa~$reenerontheothet+side"Some ather pmcibs we % "atitch in t h e wvm nine" or "d& m tyour

chickensbefmtheyare hateheddEthe Ehnt is stiilaMeto&&k &stmet$, he orshe willbe able to generabe the pmverh.For insma!, the cornbed pason may interpret the k t p r o d as The neig&m bas peeher g w P This is concreb 'ff'the client k able to g e n e r h , he ox *he d say that it means that pesple o h see o r h a as hiroing ttimgsbEtterthantheybase. Amorhwway to test fbr tib$tFact thinking is to ash sach quektio~~

as 1. H m are un apple and an q e alike.? 2. How are a b i d and a pIme alike?

It does n8t matter what fhe client mwem as 10% as he or she vsesthewordsrhq.both.The client cmw'Thgrbotheat,th$i.bcrth have hair,or theyboth makegood pefs!'Wbaf the nume is lookul$ for is the abiliy ko g m a W The cat ha hatr and the bM has feathersd isa~~hcreteassluer.~he&ientmpondirrginthiswaywouldfailthe taat H ,&rp a r e d t w Muen& ~ ifBngZish is his OF her second1angu~,the cUent Mtinnot m d m d the pprouerb.

Judgment.The client inrho lorn judgment is m d a A person who is not c o ~ w i u g i v m e w e m to the fo11omhj~ qttestiona that reflect his or her underspandkg of s a f q What would do i f p u sinv SDm%anedrop a I i g M &game bn the caipet?s "How wuld you get somethjag bicrm a high s h e State of Consciausness. This area is obseryed. Do &en= show an interest in &bigs a r m d them?Are therial& and amre

Intellectual Functtoning. The dient'g ability to cnmuniEate is an in&cation of his or her intellectnalfunctioning. Can the client carry on a logioal wnve~sation? Does he or she use words conecw IS t k canvemlion cm&.t&t? h e the anrelevmtl U: the dient & poststroke,the client maJT have:

sa afmda-itn k

b i i to r

d past eqmlences (mmpkte or

partidl

agnosfa-failure to req@ze or identify objects. Sensorgability is intact.

aphasia-difficulg or i n a b w to express w d s and phrases A couple of sther ways to assess i n t e g d h ~ t k d n g are W ean f o h at least a Uhree-8tep iss@~Ctim "Take&s see if the paper, fold it in half,then fold it in balfagain, and then tearit along the folded Iin& is an m p l e of a mdt4,Ie-step &?&on The client can aIso be aked to de a m a t h m a 1 problem such as S& threes or sevens.

Emotions.The n m e mmt obseme the c l i d s behavior. Dee8 i8 rn

Hwrt mtd lung functioning

inappr0priate-l If it do= the nume must Then detamhe wh&wiS i~ a &mge in b&ai01 B~ardleessof hav biz= ~r bppropriilte the clients b W m , be or orhe m a he tonsidered confused unless fha behavior is a change.

When Shirley Adam, a&e eighfy4woIwas admitted to the hosph& she was in need of a bath. Her hair war; messed and clothes were db+qand ton Shortly after admissfon, she had aciphed a stack of paper -6, toweb pins, match pads, a d pens.Shs had hidden them in her bedside table ThiS behavior dow mt m ~ eata q t a b l ~ stand@& SO she would most emtaidy be cansideEd confu8ed. However, $ 8 a o a hishad been Wn, it mnld have r m d d &at $hirlq bad b m this way dl her He.She was brought up in a very poor fkidy. dpater was a pfdi)m commodii and there was little for bathing md wahing clothes. .The M y had ver$ litile,$0 thq savd whatma item they could find TI&% was $one in case &ere was a use fomd fbr &em W.Sbirley'g's action8were p a ofher lifelong paShe WBSnat r& confused,

Ras the. &nt reoently s h m & g f ~ of~depression, anKiq~or pa.rm&? T h e conditions, vvbi& w W€ablerhaoe been lmotraW c-e amfwioa

Heartaqd Iung sounds CQIOT and canamon of the skin Puallty of the pulse and refpirafton

Pain

.1. Vml signs.These are very sensitive indicaton of change in the state of the elderly's hcalth 'I3r.v can indicate dehydration, poor circulation w d the prescnn- of disease 2. IIraring. The nurse must ask simple yes-and-noquestions. Ire or she can also ask a clicnt to repeat what was heard.

Gerimic Mental Health

5. Nutritional Sttitus. Has there been a weight change?Are there loose &nturs or bad teeth? How good is fhe dienfs appetite? \W"nat 1 of foad is he or she eeariag?Who does tha cooking? How many meals per daF 6. En*-% Ha6 there been a recent k g e m the client's life'?Does hc or she b e f w t h i n g s around? Is M e enough S~TJ.WV stimulationvdthout being too m&? Are there orienting ifems amwd such as docksi calendarsdend newspapers?Ts thm a windm m the client can see night and day??Is t h e a night-lightturned on? Z Eliminatim. Is &me a problem with wm~parionor diarrhea? Is fke &ent able to get to the ba&oarnT 18 there embarrassmaat about using a bedpan? mat does the &ent w u d y takefra constipation? 8. Paia, Is pain present? Where is it?When did it start? How m e is it?Is it wmtant or %term%fimtPIs there a n w g that priggem it? D m the ordered medication help? 8. Mqbili@ The nurse must dewtnine wherher clients a ~ abIe e to walk w i d or without t19sistancc Me They like@to f . Are they able to turn themsdw inh i?

!

20. Chronic Disease Has there been a change in any of the present chronic diseases? The nurse needs information about the diseases that d e c t f3ecirculation or endocrine s y s k m in particular because these are most likely to cause confusion tl. Medicatiom. Tt is important to determine what medications the clieht is taking. Is tbe client raking any over-the-counter drugs? When it is determined that confusion results, the nurse should think about medications &t There are many medieations that cause amfusion in the elder&.

U. A m Q x How much activity does the client have?What kind of activiiy does he or she enjoy?

The nurae is only one of marg who assist in determining whefher confusion d t s . If it is determined to &st the confwion should always be thought of as reversfble. The psychosocial l & t q and the assessment should give dues as to the cause.Treat the cause and the confusion will di8app;n: It is important to remember that there can be a reversible coconfusion supaimposed on irreversible con-

Nursing Care of the Confused Client Rwmible wnfusion canbe prevented. Nurses have control wer many of the aspect4 that can cause or contribute to the confusion That m e w there is much they on do to prevent it Vhenevez nun= have an elderly client admitted to their care, t h q should sce that the client has orienting item in the environment such as clockszcalendars,and reality orientation boards. They shoula encourage *its by l k i l y and &ds who have familiar faces. It is irnpoRant too, that they make sure their elderly client has sufficient fluids. Nmes must attend to other activities of daily living as we& such as adequate nutrition?good hygiene, and physical activity. Be alert for sundowner syndrome. This client confuses day and night and wants to sleep aU day and be awake allnight The client can become agitated and quite difEicuft to redire&

Reallty Orientation Reality orientation is a pmms by which confused people are reminded of orienting cues inthe environment They are taught to use these cus to reorient themselves in time and place. Reality orientation goes on for tww-fow hours a day. lmmediacp, 8impliagr1and consistency are the main @am.Immediacy means that the nurse must respond to c3ienlts quickly.If he or she asks them a question, she must allow them time to aaSWert but not so much time that clienf9 lose interest Clients' q ~ e ~ fmbus ~t be ~ answered right away, and they

I

GeWilc Mental Health

As with the aggressive client a l l tasks need to be broken down into simple steps. The direction$for each step are given one at a time. Clients rhenneed time to respond Their cbncentratlon is limited ivld memory for recent events is poor, sq it is a good idea to call confused clientsby their first m e . Generally, the earlier something is learned, the longer it is retained. For some clients, reality orientation takes weeks to accomplish a simple change, and for others a takes months. Some clients do not benefit from it at all. The important thing is that the nurse not become discouraged. Without consistency, the process will defintdy not work The reasons fca e~nfusionand the stage of the ilInes6 will be factors that will affect the appropriat~essof reality orientation. If used at inappropriate times, it can frustrate the cIient Really orientation goes on twenty-fourhours a day. The client is told where he or she is, the day, the date, and the nurse's name first thing in the morning and several times throughout the day. Other i n f o d o n that can be induded is the time of the next me& the weather, or upcoming events. A reality orientation board is often pasted in a prominent plare (Figwe 11-7). It s e s to provide the same orienting information The board should have a colorfulbackground.It mnsr be at eye level. It may be necessary to have twe boards, one for ambulant clients and one for tho~ein wheelchairs. Needless to say, all reality orientation boards should be current

IW

This is t h e E l k s Long T e r w Care Center

The d a y is: Friday

The date is: M a y 8,2002 The city is: Tucson The state is: Arizona

The next H o l i d a y is: M o t h e r s D a y

1

The weather outside is: Sunny

I

1

Getiatilc Mental Health

WP Chapter ?I Mimy institutim aJso have a formal oirgutation clas5 to supplement the twenrj-four-honr prue;ram, The classes me hdd ti^ a dlighted, quier place 61@&.en to thirty minutes each day, %ch d m s h d d be limited to h e w s h p"p1e Besides enmm@g redky, these @essimare used to help clients r e l m a task such as telling time ?@ga s h o or ~ writing with a pencil Audio&nals such as picmm, word and picture cards,large blo* and puzzles, felt boar*, mhmm, and a tape r w d a as well as mock-UPSof docks and calendars, are necessaq to m a k q the 1es8m con-, h p e udshing to m a formalpro$ram must begin by c o all theau&o ~ and ~ Vjsua1d a l available. The elass must be weli planned, The leadmshdd have a set goal and objectks in mind and should go slowly to allow eaeh client to progress a c e t a b or her ab&ies. The leader should try to keep the class lively and maid putting my'client on tke s p d If he oz she & a &nt a qwtTon and geD no response,the txZr&e C a n q 1 9 f i *I would h t o helpyou idmtf@this or read this or m r this?' whatemr fhecase may be. The idea is k?p m e a loss of selfesteem @ cow@ ammrem or wm attemps atB-IZI should be InajsedThe %qmtance of touch should n e w be forgo= A typical seasion may go like thL%

Nurse "Good morning, John Stevens! Sbe wauld then pro&togreeteach clientby~ldmkRemeddngtheimprW e of much, she would d d e their hands. l k b is OLE reality orientation &a Itis pIafined to he@ h p ~ V ~ m u n ory and exercise themind It is ela;aen o1&Ckinthe m m ing. The sun is shining and The t m p m m is e m f i v e w e e s . .

XSaan,mwtenmNhatmon@b?Vthereis no answerJshe would wait a minute and thas;tyl would m e to help you answer that qne&on, B m It is s u m m a n m DoyoulikesmwBm~XSam orno, his e f b t d d be p h e d A"Bfc0u~se summer is a great We, isn't it? Georgq can yon&& of some good things to do in the summ&eT If Go* says "G0 a ~ ~ @the id~ aurse ~ might mppd with "That5 dght W s a g m t idea Ve couldsithdesunortakeadAndre~r~do~touenjoy going outside? Names are ahyap mentioned ~ w h ~ a q u e s t iis o to n b?bed. This alerts the cliJiept to &e 03ngatiion. m e co* dlishuld never be given a nkhatbe bp the care$=, ineluw Top;" "Em:' of 'Deadeat: C. 7 ,/r; 8

t

Not aU & n t s M m e e d to fhe same degree?and some nm succeed at all. It is essential that the ppersomel d&g with them do not become &conraged Redii orientaton-tskes time. Reminiscing is an integral part of orientation and b I v a the discussion of We experienw Yaithin a group. Because the person with demen6awill remember past events longer than Current ones, the past wents provide a topic for communication Gommunication is means by which people validate their self worth If a person f a accepted by a group SewFwteaa. d l be improved. Most ofken the group bacomes supportive. Their acceptance acts as a h S e r a g h t the manly lossm felt by the elderly Verbalizing about We experienm give8 clients an opportuniq to rethink and reorganize. their Em. lloey fan then see the meanings of same p a ~events t and fmd new m e w s for ofhers. These rn-s h&lpto &te the woah fffthe clients' h'es. a e m n is iw provides a means of e f k t b interaction with the mentally impaired elderly It also provides a tie te presentday r&qs The n m e or therapist takes people kom where they are in memory and guides &em to fhe prpresent

IRREVERSIBLE CONFUSION There is no sure way ta tell whether a &at has reversible or inevexsible eonfusion; therefore, it is bRst to as$ume that confiasion is revmibIe qnd rule out all possible mUses. The nnrse is only arre of m y who vvillpaaidpate in malting fhis detennkdoa but he or $he is in a position to &many dues. Immmible eonfusion is mned dementia, 0Cbrain m o m e COBS), $Mile&anent&or, incorrectly,senility. S ~ S i m p l y r e f e r to 6 old age. The was popular when dementia wes believed to be a normal part of aging, but nnfurhlnatdy it mnahs in use. The cause ofirrwmiible Eonfafiion is brain damage. '&ere are several. causes of brain datnage, but the most common fs Alzheimer's disease. Other major causes are muior s m r a1small strob, which aceounts far 2b t~ 25 percent Ahheher's mult%oEarctwhich a r m s for 5 to 20 percent; and an others, such as amiosclerosis, Creutzfeld-Jakob's disease, and adult hydrocepbalu~, which account for 5 to 10 percent Eable 1l-f). Mukih&ct refers to a series of smsU vascular accidents tmmody called si?vk.The most common cawe &strokes in the elderly is a blod dot in one of the brain vessels. The clot nrts && wgen and glucose supply bebind it The result is dearh to the pan ofthe brm denied mygen. Fkfmrhagea can also be a came of brain &age but are mom apt to o m in a younger person,

Gerlatrlc Mental Health

1 "-

h adult hydrocephalus, t h e k a ddkn in the oe9sek that drain

the cerebrospinal fluid fmmrhe brain The fitrid builds up in theskun

..> .

.

hemlplegp Wemhslon, dlniness,. - .. o r e h d t i c hypotenSief3, : beridaclles, %t@pl,qes6 HtaZlacbe,&~!&l%ibh$.. 4 blurred~tsten,severesnx~&~ ~ n v o i mu$o$ y ~ ..* movemen*,

,i

Intmmlal neoplasm

usually aff&.gliomas cause ut@hwb ~nhe~iwd ~ l o c ~ a~n g etne dmlnwe of cere~r0splnal fluid ~lowmtingvlrus.

~~ogmrsslve daemtatton, erasses Peet when walking

lnjuw

lmrn,@late nonprogres%ive detBf!oraMon

R~P~#PT@Q~~.@A, mu.ple atroppy i

Alzheimer's

May tiav? ,beepl,o@@a, ,.,,, sevare.paln, instdlau§ I,, begmnlng, grog&sl$gle , : .;..,'1 deteriotatron; , . Progiesslve ifreveBID@' ~trophvof me rrontql and Gemporal lobes& memow ~ossand! . ;1 ':i dptgloratlOn dP thebmin, aqo"oig,m wttn a~aono~tsm inkmIfw6ig~,, 13'

Mulilpte

.:j

,Y.

pick's

and c a w damageto the brain &. The damaae &adv done m o t be repaired, httt futllre damage w be p m t z by ~m&calIypiacing a shrmt in the bra& Ag long as the shmt remrdna open, it drah &thtt excess fluid' Alvheimer'a is by far the most cammon cause_ of dementia, a~counting for EJ ro 60 percent The ornet Is 8bw and gradual B then p ~ ~ ~ g mvvith s e sitlaw@ngconfbion until dmth QCCLB'S, asuaIIp from pneumonia, d n q urinary hfectbns, or other complications ofinnnobilits. The f w y may redl same &essfirl eu~nt,suchss s u r p y , that happened shortly befine &e mConfon became a p p m Stress does not came demenrh but tf seems to sped up the progrim of Alzheimer's &ease, The co&d~n awming bgfm the eve~tmay have been so tilight rhat the -paid M e a f t e n or pasmi it a f F as no& f o ~ ~ . Thexe am two major changes that ocnrt m &e tend n m u s system, Deposits d a starchlikeprotein in the brain me 5 m on a m p sy; These plaques, a% they are d& intm&e with t r m s i o n of impulses through the nem die, The neaiby nemns Eigme 11-81, undergo the seamil dban$e.The nemon abtapbiw, and the axan and Writes then map ammd tbe EeIls and entangle &em in a mass of tissue, These are a W y &m$a~.They develop mostly Qthe COP texwd cause forgetting ofihe high* C O ~ V functions E Grst

,

When dementia results from small sfrokes, the m e t is abrupt Confusion starts as soon ss the blood flow to the brain is jeopapdid but it does not increase. Each time the client has a small stroke be or shebecomes more confused. There canbe some impmvement as brain edema subsidqd but the client never my recovm. Alang with the mental symptoms, the client will have the usual physical symptem~of stroke, such as weakness, pmalysis on one side, or loss of speech Arteriosckosis is hardening of theaftaies.Because this results less blood going through the vessels, blood supply to the brain cen6 iS diminihed. Arteriosclerosis is also accompanied by high blood greS sure. Ifthe pressurebecomeshigh enough, brain hemorphage can0Creutzfeld-Jahb's disease is also very r e It is causes by prior% and the WUIS~of the disease is rapid.

FICURG 11-8 m e neuron. In Alzhetmerersdisease, t h e axan a11d dendrites entangle themselves around the atraphied bodV of the cell.

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__

,' 3Q6 Chapter 71 -

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The muse of the & w e is not known, ~ L m G earchis on%O%. Swemltheories have been advanced,b u t n e u m m m m i ~ seem ta be &e m W pmmisiog at fhe mdment The posqible factom associated with the dwdopment a f A & e b ~ s&dude: e her^. A gene has clearly bwa identivied that muses one type syndrome almst of &z&imer's disease. Clients with De,wnwng & d y develop Aleheim&s E they b e pphst fhirty. Isi r$ge. The M d e n e of M e b d s @ a w e s with ge.AUpeople get 0 1 6 they ~ ~ s e a to bemme mare vulnerable to thc dbea&e,

m

,

nIuiihm crmam&rn tn &miinThese has been .aa increased duminm (Ymc13ntratbn hmd in fhe brofpw ple with z&l&&f$ &ease For a time it was &ohought an increased ingaiion of aluminum might be the culprit P d e r studies have shown that it is p r ~ b b abresultmther =thana muse of b a n a n a

I&

=&

B e r a ~ s esyrnptams of m e l d - J & o b ' S to ~~s disease, some eta& have looked at as a came Thus fkr
Slopa-@a&ngwifirs.

@

@

N m m e . A chrmge in the amount ofthe neWtfanSthe mftter, amtycha,ba in a client wltb a f d tendmcy disease seems ro be the mrst a e c e p b l themy ~ w d a Within ~

the next f~ pm, therewill be new & o l W ~ inhmitors e on the mad&. Currentlr, donepezil (Meept) is themost fr& q u e d y p r e s a i ~ medimaon d In mild to modsate Meimer's d i s e , Arhpt has helped to make a Wepence in etient's pas-tickpation in basic actntities d d@ living:toiledressiqp, personal *gene and groan&% feeding, b a w t and &around inside and ouatde the home. Shopping, Using the Ed&phone, perfonnmg household tasks, and impmOemmt in the &Q to understand situatiom are notvble W@when the client is meedT@ti~nmmpliani. Re&%cruhds are makin$ rapid . progress in.the d d o p m e n t of an Nzheimer'~va&e. mereis no c n r ~atpresent ThP diaease d c o with the client E?&g $om two tD twelve ye;trss through stages,aWIoq& t P L q are nor aleasy are not Wly defined and mi malap.

IYsease Progressian rn the first saga -is

m a o r y lass CfabLe U-53. As m d n e lie, itis so $t@t lhat ft can b%&&lo&d or mefed up.The getl~~dlapSian%d, to bme a d plaa He or she

First

Slight memow loss: some behavlor changes: may wander ana

get lost: dlsorienteu as to tameand place Second

FurfRwdeteriomti~n Ulth lmrwed Msmory loss; togrc, reah sonlllg, atXijudgment are ulminrshwl; neglectsgroomng and D F O D ~ Peatlng habltS; exmbies amisoclal wehavlor

Thlm

ForgettmB increases; may not re~ognlzpfamllyand self; conVeWOn is irrelevant: may scream Incessantly:unsteady gait; may be incontinent Not able to ambulate well or at ail; mwherent W c h : to$lty mcontinent; seeurea occur p = J;,

-.

.

;

.1

be able to find the way to the comes store where the client had been @hgfor years. His or her a b ~ ltoi &?~ t logically and judgmen? are dected. There can also be emotioM or behavioral ehwes. l h e is further reduction jn memory in the 8econdu sfage. L a % "asoning ability, and judgment are also further dhmhhed. These people can forget social standmdb They can neglect grooming and proper eating habits. T h y can undress in public or use profanity where thewould not have wed it before.In the third stage, forgetting inm@a$es.Perception changes, and clientg map not recogme familiac faces or objects. They u&y became mwntinent of both bowl and bladder, Readmg, unitmg, md the a b w to problem solve are most likely gone. Although the client can still pronuunee some words, conpersation is irre1emt and, at tima, be unrecognizable. The dient can s c r m and yell incessantlyand not know Why h d the end of this stage, there can be an wteadygait and ftequent fXs may occur. During the fourth or last stage, symptoms become worse, CEew are probably bedridden and unable to feed seE They will have no mntrol over their how& or bladda Their speech is incoherent, and ifaey speak at all, it is wualtg only sounds. Seizmes ofteh occur.

Nursing care %ere is no cure. Drugs be used PO p&tidy mntrol specific b&awia~r but they may or may not be U E m Though the conh i o n is irrewmfble, mality ofiatation shonld be employed Many times these clients have a revmi& m ~ o sqa-hnposed n over the u e i m a ' s , making the condition appear m e than it is. Research has shown that reaIity orientation slow down &e progress ofthe COeion, even when it is due to organic reasons.

I

Nurslsag Care PBa;n: The tlient with kizlselmer's Disease

I

J e s b Robbb, a sfny&gh~ye%r-oldformer $choolte&er, is admitted to the Shady Oak Numing Radlitywith a diagnosis of stage 3 Akheimefs d~sftase. She is awornPaa;ed by h a seventyyearald husband foe, and aaugh6er who are asd5tb1g her to walk by inta1ork;irig their arms. The dau@m states that Jessica has become pragpessively more fagand mnfused over the last four y&s. She rwedygot last going to the gr6cay sfore inthe mall tow where she Em%. The police faund her and mti5ed the daughter, The daugbrer relates &at Joe reinin& hes to bathe and to change her do-, bshe drmleb hemelf,she at times puts ha bra onthe out6irte afher blouw and her sacks m r her shaes.Two weeks ago she staaed vvetting hem% As the danghm elates the information to the m e , term start rolling d m Joeia 6%FinallyIhe says 1 do not to admit her,but her we is heeatao much for me Recently she has stamdyehg at me when I &agee withher.' ZAe nurse completres a thorough assesanem aacertaining whether data indicate p~9siblewuses for mmible confY&on. He relam his assessment dab. to thephysh and they agree that there is no euLdwce fm rwemiHe c&sion and the diagnosis is i%heh&$ disease.

I

L Jessica w*). 2. j&ca

bathe hm&three times a week [widin three will apply dothiag in c o r n order twfthin six weeks3.

I

r

Nursing Intenrentions

Rationales

Detexdne and mntinue with present habitual bathkg time prment memory pattern will and mannef. be d o m e d . board Win.' Develop a W q orientation A reality ~rientatisn b o d far Jessica and state assist in dentating Tessiira PO,1 bath day an appropriate days. date, time, plaee, a d bath $ay;.l Assist with the bath as needed. Assistance with d e ba&!

I

Decrease exfernal stimidi d ~ r ing bathing task

Keep batlmom and water t m p m m wann Ea d e n t s preference

I

Evaluation

focused an the twk at

,

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Eertatri~Mental Health &I&

--dL

F I G U ~11-15 ContriDuting f

a e s to elderly sulclde.

befote their death. Although hanging k+ the chiefmode of d& for p u p seventy-fbet~ eighty-fourthere has been elda1y men, in the an i n m e in deaths due to fkirms. Spousal hoxqicide+uicide occmrs with lnanyofthe perpetcaro~~ bein$ &e eldetIy p e r m who has taken on d ~ w e egiw! role. Depression b probab1y the mo&cmmon problem of the eldetly and the mest %as%treated,yer ff is the most underdiagnosed and least treaEd of d . OPher conditions mask The. depression, and $ymp tam, if apparenf, are often no* taken seriouslp

svmptoms The p w n who is &pressed has prolonp3 or etrtrme sadness. E is a g e n e r M sadness; that i$l it b not mmected to a p a r t l loss. ~ These diem are wT&dram and s~mtimesagitated, hostile, and pmne to xumhati~n.They can also be confused Called psendodementta [Table 11-63, depression inmhres amclaction in acttvq"obsesSmemrqyhgand sleep disturbances.The clien.tZsabiliityto reason and member is dhidhetl ahd he or she is mote pessimistitic The elderly depressed person usuaUaf has more physical mmplaints. In In& h q i p o c h ~ B Wis wmmea Physical mmpainta: e m even be the symptom ofdepres$ion. Eld* depressed c l h t s are more apt tp be *qStipa;red. and they meven be inconihatt

EwkttVc Mental Hmkh

lmpatrment is inconsistent

Irnpalrrnent is cons~stentand progressive

Onset is mpld

Onset ISstow and InSidiOUS

--

More llKelV to answer quetitons More likely to cover up bv givlng with "Ido not know." More likely to give up easlly

an answer that may be close to correct Tles to stay independent as long a! possible

Communicating with t h e Depressed Client

v

1

WiththeclientTbirlets h i m o ~ h e r ~ w ~ i t i s a l l r i g h t . t o h e s i l e n O and puts no presm-e on the client to taac It also lets him or her h e w dat the nume cares aou.gh lo take the time After sitting silentlyfor a tima the nurse m b e g ito talk abbof nonthreatming things. He or she mu b@ to build &en@' s&

there needs repeaTed.

be a h i t on the numher oftimes an incident an he,

AS 6all other d$tregsed &ensI the n m e ne& to ETlX&!l ralnz He or she usee simple, concrete sentences and does nut a W P ? to argue, probe, or jntmagate. The n m accepts dim'ts'anger*hufp I above a& he or she eontindy strestres r d t y

Treatment Treatment o f dep~e$siohdepends on the mast%Depression can be a ! re%& of physic& illness or drugs. It It be the mdt of h g s in

9

&&

C&rWcMental Health

to &e surgical or KT unit by ;c or wheelG Them i s some memory loss following the procedure that is usu-

MEDICATIONS Because elderly d i e are de&rg with both their mental health prohlems and ftzeir ~oniclIlnesses, it is extreme%i m p o m t to cmdnet a d o t i o n =view. A h o w r teoim the number of meditations pre %&bedM u i b i n g multiple medications is railed p&pharmacp; A plwmdst nee& to be u)~SuItedto assist with information about dnrgmos dmgdmg inw.meti0n.k Cnrrent d o q e is imp~rtant@ ?he

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:@ - ~.<-,$ @ chapter 11

Galati%

elderly needinitial low dosing and frequent asassessmentof body weight &tentinee or we10s. Some clients. wperience paradecal fbppbsitd &&fs h m medimtions. IrritabiliQ, coBfnsion, and diso~%@Won can occtti. Working with tbe aged lyh0 he mental healrh pmbIemS is a s m f i t I job. It can be f%snaringring and dem21nds enormausus patienM d sup&wbw w g ,car@%eE.is one~irnp.o~it &@edient in &cinp joh ,ms, A pasite attitude b needed Although this will nat change the disease proma, it can improw wnaitiom,and maBe good mte more &bie tethe ei8e~1yGmaalogknurse apeualkta are an &mt mnum for support and w e plans.'Th& sonsultation should be sought when powi6Ye Ifa national p&o&yis to d u c e &life smi* ad*, fhto be increatid emphis onl@a~ernmiaIhealth

SU,MMART

Mental Heal-th

~mmunivttionis +he majpr tool when workmg with the w&hdr;rwnclient Worein$:with an distressed &en@ mpixes some d e s . Ranain &speak in simple8mncmte semence$;aubid qnesti-; and do not ptsh tke @lent to anewer Be very attentive to hig or her physical needs,Qberve nonverbal cues carefully

SUGGESTEDACTIVITIES E-4Vohteer W Visit a dieat in a nUTSfng borne.

Attend a d t J P orienwon class. B Contacf a local Wzheimefs support group and plan to attend a

mw. .-...

With a group, d b a s S €he effect of commonly.beliwed myths on the care the elderly xeceive. a Examine your own BeUngs about @rigs % Find out ?.be mrimk€legishion &e&ag nursing hangs in your area Are t$ex helpN or ref;triaix? @

.

group 14 tWms of'e~onomics~ b@%rnw, mental &d ~pkpical.B e stereatvpe of the dddy en, aanky,a d mnfused js sirnp1y not Tma The com.on m ~ t hdd t h p m H m in fhc! aged in:& delirium. d&nQa, tind d&rwicia The @3&qft& do riot re@@.: tmatmm bemuse wf ceaain m+s and &adea %,at eonfinue.~$@' pe&t %~&D*g am some -$@: ?&epb1ofhe.& . furbed &q&'~:@@i@&?i @ di thm &n@Dseme iq-b &emmor 'T&ing with the elderly i4 infaror to other fo,Wd$' '. heal& ism, and t h i ~ p q l e w h woik a with.are either ~&t$,:L@~Tii ' atlpitdP &=em-$& anothelip&e p ~ ~ , ~ & ~ $ ~ ; l itwill im:ipmW @n&ti@is a d ni& good b&rhcare m~e -axei. ' bk to the elderly. . Conhion m = b em d i z or b e v d l e . krs&ble s m is &11& M a . f i ~~~~ she& be &dt&+J!' ?wers@l% The a w e sb$d beb6rrght out and Rm%-&1d co&ionw $0~0 ghiw,saqdil ~ t s rdm . @6 'i ewimnmw&d f%Wm, ~h ro&&on, is due to b m . damage. A &@~'t~.@?)t' ham&& m & l ema M=&Ie w & ~ ~ m e ti&? T& majority ofpeo@~3ew&&de-a &.vg 'ihe. AizheimePw W:Q, is a ppqpssiue &e@e for y&ii&e@ b !@ a@, l ! b r & 4 : . n ~caused t by but . s t f c ~*& up thepa@@,.B@$m modifimtiontmhqucsamt dmg&&e used to,w&d beh&@E6 b@ &&@, [email protected] 4 ¬reatmmf&~&e ,&ad%&

-''

REVIEW

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-

KNOW AND COMPREHJ3ND A.

Multiple choice. Selectthe one best answer.

The arises ofmsibke mnfusion indude 5 h vascular acciden* and brain w e 5 B, dehydratlor?,eleva€ed€emperatme, and drug$. 5 C. Euntington's disease and arkxiosderosis, U D. Alzheimer's &me and cerebral infarcts.

2,Thethree of conkion are D d mrsibIe, k m s i b l e , and chronic 5 B. Ahhebnefs, rwersible, and m ~ a r c t . U C. psemiodementia, dementia, and delirium. 5 D. demenria, m d W a r c t and reversible. 3. Tbe poss%e m s e s oEAIzheimer's disease are unknown bsa a dear effect of the disease is 5 A. a rapidly developing delirium 5 B. an increased risk EBl. i n k m d hemorrhage Q C. an inabiliitp.to cope with stress.

ChaDm 1 4

4. The most mmmon mental h &

o A. depmion

problem inthe eider& iE;

P B. mnfasI.ot~.

C.Alzheimefs disease. P D. dementia 5. Beactitre ddq;l+essionis a r d t of D & some stressfd event 0 B. a change inneur0tWBmiEm.

a C.byposhanWie. a D. dm@.

6, Em elderly client is d"pre9sed without a preripiBW cBz1se6

is &loa-, and feeJ.8 gtd&, the dient probably h;rS 0 A, reqdepression. D B. endegennm depzesgioa GIC, bipolar dlsordec P D. pseudodepfession DA.af3~am P B. blood chembay.

P C.sisual ob$eMatioflof the brain. D D. a mental status e % ~with g o d %WW 8, The path010~in Alzheimer's &ease inel-udes 0 A. ta@e8 aad plaques. inthe Brain. O 8.d e m ~ ~ & W of the m mom. P C. de9m3ction a f the b l o o & - wb d m . 12d. i n m e inmagnesium in fhe bmIn 9. Clients &a m coafw~dneed U A. fimtmgb &ectim5. P B. change and aabw. ti C. simple directions. R D. &&one given in a IOU& f%m mice. ~

,

g .,

10. m e most &&ve tool fbt bdpbg the mafused client& Q d pgychotherapy 0 B. arpmentation. 0 C, WE^ orientarion. P D. conffmtatiotL

APPLY LEARNING 3. Multiple Choice. Select the one best answer. 1.A practical nurse contribbutes to the plan of w e for a 79-yearold client with advanced &heimer"s disease. It would be imponant to contribute interventions f w e d on D A. ~dacing the rigk of infection. P B. @&ping different caregiwm ~ a c hday; P C. indudiqg the cknt in @ouptherapy. J2 D. isolating the dient from others. 2. An elderly client is diagnosed with pneumonia and admined to a medid unit The client becomes irritable and sestIess an$says fnthe nurse, '?need to feed my cat" A family memher Sate6 thed i d has been living indepenrtenty and managing ahousehold. Which problem should the nurse smpect? R A dementia with irreversible confusion D 3.dekiurn with rever~ibleconfwioh CI C. depression accompanied byeodbion 0 D, ear& stage Alzheimer's disease 3. The nurse gathers data to defermine a client's orientation Which question belm would thp nursemt use? Q A. T h a t is trxbfs daWX Q B. "What is pourfuII narae?" 0 C. "Whatkind of place are we in? D D. m e r e were you born?' 4. The nume ina. skilled care facility prepares a reality orientation board. Which information would the m e incrude? P R today's menu for breal$ast, lunch, and dinner a B. daily visiting ham at the f a W 2 C, todify's day>d date, and identification of thc place U D. namc and phonc numbcr of the client representative 5. A nurse p.lans care for a client in the secdnd stage of dlzheimefs disease. Which inkerventianls?would be ma& anaromiaw? 2 A. assist with grooming and fceding 2 B. provide dcviccs to aid ambulation D C. strategies for care of incontinence D D. a n t i - d e p medimtiom for hostility

.. .

2. List the nursing needs of the client with dementia.

4. Dierenfiata betweea dementia and pseudodemen~

2. The pros and cons of treat@ the elderkin n

m homes

rather than rnenfal health facilitia.

3. The ways in whlch prevalent attitudes toward aging aff0.dtb care of dients =&threumible confns'10n.

cent; thus inkacing alcohol prefepence and leading to an inmxsed risk for aicohoUsa The role of environmental factors and genefic cou~seliitgneeds to be moredearly delineated It is often a progressive and fatal &east? and &aracmhd bv imvaired control over dridine, preoccupation with alcohol. use of aiwhA with adverse consequences and distortion in thinking, and denial of the siffnificanceof the drinking and awarenas that aIwhol abuse is a probfan. There are a of dehitions f a alcoholism but most de6nitions indude the ~oIIQwing four k e n * 7 '

Excessive consumption of alcohol PsyCholopical disturbances caused by alcohol R Distmbanw of social and economic functioojng Loss of control over alcbhol cansumption ... .. EM. Jellinek, a pioneer in alcoholism research defines alcoholism as any use of an alcoholic -age that causes damage to the individual,sod* or both The person with alcoholism is often thought of as a skid-TOW bum. However, only seven percent of people w i t h alcoholism fit this stereotype. The remaining 83 percent are found in every l e d of sodety and in eve@y occupation, The rmmber of women wirh alcoholism is inu'easing. Clients with almholipmmay show signs of 6nd rejection of the mrld about them. They may withdraw from personal contact with othess and not evenattend to their needs of daily lming.The clientwith alcoholism needs empathy and not misplaced sympatIq hovatke approaches for care m necessary for each client The nurse should demonstrate qualities of consistency, h f i r m n e s s , honesty, and patience To do this, he or she must first determh p o n a l prejudices mc e w the c k a withalcohelism. Prejudice is a prejudgment UsuaIly, it is an unfavorable judgment based on insufsdent reasons.Nurses need to examinetheir own pmdices beeawe they canbe reflected in n m b g carp.Nurses should think thmugh their prejudices and recognize their fears and lack of information, FeWs of Weriorityand inseapityneedto be Wt with Once prejudices are mghized, nurses can takeresponsib'ity for their aM behavior with others. Nurses p&&iy need to be understanding -in their interactions with a l l clients They render rare and do not pass iudBment . Th"& is no single cause of alcoholism Alcoholism is a disease, not a habit Researchen have found that sodeties that induce milt and confusion ~ g drinking w b e h i o m are more m y to';u.oduee a l a h l i ~It~ alw . has been found that people w h o d d o p dnnlang

1,

ad

~haptsrl2

Y '

c 6

HISTORY OF ALCOHOL ABUSE

I

/I,'

1

F~GURE12.1 FM, mends, and lots Of IfQuor.A good--or very dangerouS-trio.

m m &dy to experience interne relief a d re ha ti^^. pmbfems &om alcohol. The person with afcoholi~m Wa ofsons for he rrutsom may d u d e the fofI&(I:

m,

gg Relienngt m i o n B1 Helping UmKind @

.

'

,,,, ,, ,/'a

Droaatng mmow

pa Making one feel free @ Helpin& one be sociable '

~~y people expdmce increclsedaCbIXyrh q h m , ad sma5fh. flowing s p e d d t h the conmmption of alcoholic b~verW@j 12-13. &coho1 can produce a tmporaty feeling of but ' n w system. ~ Alcohol ~ abuse can have n e g i m .' $epresses the I sea m d ~~ezsonal co~~quences. AD& 1Far d nW while (and public intojration [PD can oulut With al] the hem~li*b I .ed lad ~ l v ~ m tI-Eealth s . problems &er disease, gamin*d ' b l e w ~ o ~ ~ o - gvarices], e a l a m m o H e and = @ o d acciden% and bpw job functioning can tuntribute to a &~1?td =@e. dependace causes an inmased ~ ~ U m P t i @falcabbJ on and an to sop dnnkuq:until intoxkated. Thhking becomes anfused and &oqanized M-, concentration, jdP-6 and " peroeptionaredulled Depression, &wkaZi0& a d d @ ? V are tfie problem mused dehok

inam

i

.

The use, misuse, and abuse of alcohol is thought to date back to primitive tunes. During the Stone Age, humans found that chewby: certain berries made their heads light This accidental discoverybrought about the international manufacture of alcoholic beverages. By 3,000 B.C., P@pt had perfected the IT of manufacturing beer a n d wine. The making of wine also became popular in the Mediterranean countries. Dun% the Middle Ages, grapes were cdtivated throughout Europe, and monasteries began perfe* the manufacture of wines. Distillation introduced a new and more potent alcoholic beverage. Instead ofbeers and wines containing G to 14 percent alcohol, heveragm containing as much as 50 percent alcohol were made. The literature of this period reports drunkenness as a scrim problem. Alcohol was available for rehgxous and medical use when the colonists settled in America Alcohol sometimes accompanied family meals. However( some rel.iom scorned the excessive use of alcohol. Factors such as the diminishing family structure, the Iessening influence of relrpion, and the dislocation ofwar helped cause an i n w e in alcohol consumption Alcohol became a social concern toward the end of the eighteenth century. At this time the temperance movement which stressed moderation in the use of intoxicating beverGesbegaa Strong support for the movement came from religious groups, legislators, fanners, businessmen, and schools. By 1919, twentyfive states participated in the Prohibition Amendment The amendment made it unlawful to manufacture, distribute, or sell alcoholic beverages. Thirteen ~ a r s later, it was repealed as a failure. Denying people access to alcoholic bevera$es was a simplisticway to deal with a complicated issue Alcoholism is a problem among an ages. It can be seen in the nmborn as a result of maternal alcoholism and in the child, adolescent and adult Alcohol eonsumption is a way that some people cope with stress. One method to screen clients who have problems with alcohol is to have them complete the CAGE questio~aire(Table 12-11.

There is an increasing number of teenagers who drink on a regular basis. Liquors such as vodka and tequila have become popular among teenagers because they are difBcult to detect on the breath. Parents do not always recognize alcohol as a drug. When told their child a drinking problem. many parents are extremely ththat at least their child is not on drugs. Parental influence can be a factor in teenage .d~nany households, children see their parents enjoying daily cocks before and after dinner. Peer pressure is another influence in teenage drink%.When people have equaI standing within a group force or cajole

I

-

Alcoholism

'&* la, Guilt f e w without drinking Inability to dlsccus problem Inuease in memov blackouts CRUCIAL

Loss of contml W&tion of drinking behavior Failure in &brb to control drinking Grandiose and aggressive behavior Tmuble with f wand employer Self-pip Loss of outside interests Unreasonable resentmeat Neglect of food

Tremors Morning drinldng CHRONIC

Prolonged intoxication Physical and moral deterioration Impaired thinking Indekdle meties Obsession with drhkiq Constam dibibis given

PHYSIOLOGICAL BFFECTS OF ALCQhDL

STAGES OF ALCOHOLISM

Occasional drinking constant relief drinking I n w e in dcohol tohance

The nurse should have an mderstand'i of fhe physiologjcal effects of alcohol. A small amount of aIcohol may bring about skeleml muscle rel?~xatibn. An maeased amount Can impair the respiratory and card i o v systems. ~ AIcohol physically depwses; while tensions and fear8 appear to ease. W1th alcohol constunption, mental activiw changes and judgment and seEconm are reduced With increased LweIs of alcohol, a staggering gait is noted. DifBculty in standing Pollows. Rnally the person falls and i s unable to get up. A larger dose of alcohol can produce stupor. TBis is a serious comphca'tion that usually follows a prolonged drinking spree. Wheh almhol is taken on an empty stomach it is absorbed immediaely and the effect an the central newom system is felt in Iemthan twenty minutes.

IN THE HOSPITAL

PRODROMAL

THE CLl@lUTWITH ALCOHOLISM

,onsetand inof memory bIackout8 Seaetive drinking ~eoceup&n with alcohol

The majoriw OfcJkrm with a l c o h o h in m & d and departmem of a gaS@ ho~pftd are admirced wiih a diagnosis orheF rhan almlroli$m,The COI dy seen dia@06& include

Gulping firstdrink

W~ - -

-

--

,,c&pwqg

a .~. ~ g l q , ,..- ,

r

we m:

-

Alcoholism

@

&=I*. ml $ q d m &b&&B. U*

~

&

~

B Vitamin therapy @he person with alcoholism usually has a defldency of magnesium, thiamine, B complex vitamins, niacin, and f& atid] ilMonitoring for alkmtion in serum gluwse *rAntic~h~&ants fdilantin,phmobadzital) The client with alcoholism needs to be observed closely fox Gflmpli@tions associated with long-term alcoh~lism are Wernitke-Ko+sakoffqnilromeand hdts disease: s Wernicke-Ko~akoffsgmbme is chmara-ed by c o e ~ disorientation and amnesia witb confabulation. Pick's disease is ehractwhed by early onset in the m i m e s with p r m i l e dementia. There is a genetic predisposition.

NURSING CARE Many diEculties that occur with dimts with alcoholism are a result of withdrawal symptoms b e g h h g 6 to B hours the last drink Clients m miIrTwitl&awal may suffer only trembling and agitatim A more smre withdrawal.in~~Ives d-um trem& W3.In dehilrm b m s the&eat has extreme restlessness and posS@&sekqes. Delirum tremens may not o m u n t i l the second oftilM da~rdftreatmentor later. The client must be mefully observed for any w i t h h d sympxm. These may indude

r ETO*

sweating

P increased agitation

Hallucinations Increased blood pre&m It is'impartant to noteZhar antimx&eQdrugSare intended to premt deliriumwemefls (DTc) and, therefore, should lye Ye l i b e r a The presence of d ~ t r e m e n @s a m e d i d emergen9 .,may;s f i r @ ~ a@ii$t atfempts to feed orbathe them The nurse mu strew^ thwdientstswgd f& be aware &.&

Alcoholism

a

to alcohol? What has led to relapse iathe pmt? Rdapse is not *mud and the Jislt nee& to pay irEenti0n to warnine; signs. %dayr m y pmgmm hdu&ean aftercare pmgraun to help the client with the asition &to abstinence and evqday life experiences. IndividualgroupX and couple wansehg and job guidance are pravided to build selfesteem and s e I f F d e n c ~

POSTACUTE WITHDRAWAL P o s withdrawal ~ ~ PAW) initid9 w oaur wen to fourteen days abstinence but may peak at 3 to G months after abstinence begins. Bymptoms indude &3 habiUty to think clearly a Emotional overreaction ar numbness B Memory p~ohIemsCshon term and sign%oult pa& pasteat@ €8 Sleep disturbances (dreams m nightmares) B Physi-1 coordination problems

REPLACEMENT THERAPY Naltrexone (Revial is an opioid aniagonist ihat rednees chances that the clic~ientwZldrink i n k f i b y h m f i n gplwurable &Q. Itis well tdwated ly most clients, although side &eds can be nilusean Wnm, headache, or an rmbappymood,hepatotoxicity rbhmustbe mnsidefed lr is impor~ant to note tbat drug9 with opiate-Ifke properties [Le,, morphine, heroin) carmot be e e n with ndttexone. Naltrm one therapy quires a cEentLs ibfbrmed c0nseXt a d the client needs to cany a naltre?conewarning w d to show to doetom and den&ts.

REHABILlTATlON OF THE CLIENT WITH ALCOHOUSM In 1972, k-Deparmtent &Health, E d u e a b and V V b estabkhed the National Institute of luwhol &we and Alwholism mIAAA1.Tn . purpose is to help thc nation @TI a bmerknowIedge of the &cfs of alcohol and to bemme aware of the reresp~mibilitiesw d a t e d with wing alwhol. The instifute encourages public discussion &cgrfmunity drfnkmg prob1ems. Tbk brces w e fomedto study malor drinking patterns Of problem @ups within the mnundtg, Prevention is now behgremgnke+las eesential in the base to reduce alcohol abma lb minimize alccllrol abuse, atteation should be given to the general population and wt m 4 Y the problem dmker. It is important to a@ eady in discowaging primary alwhol abuse patterns.

I

'T. Nursing Care Plan: 9 The Client with Aleoholl Abuse

& ~ ~ l fmfbeemdngherektefto ~ i w the n W W & Miif& a barin oBmand he has m a t e d alcohd on h@ br& swerd time laply when she mmes 'home &omw d Re states &at wfientbe couple &9h has be=. ha* two drinks,to his on%

'NURSiNO W N O S i S ~'i

NUrSlng Interventions la. Spend time with Sarah eneouraging her to discuss her job respomibjlities.

Rationales

I

la Having &ah discuss pres

eat job r e s p o 1 1 s i ~will

assist h r in iden* pz"t~mtsaesses ~ b~iamsa: . $ 4 &-em@ lb. Discussing smsses will Inher life. give b i g h t to &+hatSarah sees as StreSSOrs, Ba UtWe therapeutio e m Za Diswiry: premzt stress mmicatioti and cgwelin$ management &ts in skills, a n d discuss wap iden-g &edive and S m h is prmentIp handling in&* coping stratemess. gies. 2b. Make r~?fhaIs ta tom2b. O W resourcw may be dm and communiy able to wsist Samb in cuporgadmtions a8 neaed. ing with ,%tress. 3, h&t in helping Sarah 3. Newcoping metbods b d new ways to mpe give S ~ p o e i t i v 0urLetp e with swwes. for handling saw,

Evaluation krqh is ab1e ta list present swsors in her Job. She a b l g e a that she is not effeslively hmdling sixes now. Samh Iistens in* as the m e s b w some o p g m h t h u that help people handle stress dkctively.

I

NURSING DIAGNOSIS 2

Nur'singoutoomes L ~ef01-e &hhai-ge S a r a h d iden*

~tms@inhe~Ef".

h t e q t w d famf~p@W$@-@:aWi b,Siz+aorsiandinmeswd Use ,ofali%hoI~ is &uide@& 'bS& a&% ,&&:she h~ job -. a w * a 4 worW,:lerrghems, md her mf he ha3 w&d &whOl on her br& InQE efrequqy and hwwd mnsrinztytion at $o@al.&&ts. I.

ofhospitalbation

.

_.--_

Nursing Outcomes S M ' s family will c o m d c a t e eonofjob reqonsikditit% tD each other and implement effective coping m a hbllls.

I

holic and needs rehabilitation. This is re&?& bytimilies,who m d to protea persons with alcoholirm and frequently deny the problem lbIeraalag stress is a probtern for p o n s with alcohoIism. I m p e d methods of coping must be learned It is necessary to 6nd a satisfactory substitute for alcohol because alcohol aas as a tehsionreducing agent The values and mmms of the wmrnunitg in wbkh the individual influence his or her drinlring behavior. Par example, a l e h ~ l i nis t a significant pmblem among N a t k Amaican9. A commun i y s attitudes, concerns, and involvement with the problem of a h hohm need to be Community resources such as m y services agencies, mental health clinics,visiting nurse agencies,police, and departments must be made available to help the alcoholic It is interesting to note that recent stndie$ have shown that the black pop ulation is dispropordonately targeted for liquor adm-kimnents. Billboards are rammed into poor areas,and the piuwx%vividly connect alcohol ~ t romance, h p m , and succm. Cognac and malt liquor are two beverages fiequatlydepicted In some neighhhoods, community leaders are banding together and wbihwhing biIbmr& as a show of d e h c e and to deliser a foreefol message to cha~ge

&sesging 6id.y dynatni*~ in id@mles and

f i n ~ ~ ~ ~ q g e f f u n i l p d e BY r ~m to ~ w d * verbalize their feelings. -bertosharehisorher ~t"+ons Qfthe mtidn, the staff ga& a c k m p m e of m y intern-.

ad~&e&&ml.sasdedlag, t~ SON work&, , o m n ~

~&lwwh ~

m o m ta deal &&the

11

siN-

p~&&~q&&& ation. e & s m - - m

b s , &pe Mim .&boa 81~0- 4 n o n v . f

have fleedm to interact as needed &&@-

A s q p t W k W ~ t eacomages aaustW6ns@

~the&&familBfaciW

ne&lecephreto&~b didienrwithalcoho~

approaches.

It is important that the community offer diversifred rehabilitation programs. These pmgmm.9 might include emergency medical care, OUtcIient dinics,inclient facilities,and haIfway houses. Outreach workcan be helpful in oisiting ethic areas of communities to iden* their particular needs.The nurse can play a role in m e finding, referraL and morrtination of wmmwity services The person w i t . a psychiatxic illness and a coexisti~gaIcohol abuse pmblem is a major challqe The goal is to monitor within cmmtmities seriously d~$~~~bional clients, attempt to stabilizetheir behavior, and fmprove their social hctioning. Careful assessment of combined alcohol and drug abuse isneeded because persons with dual diagnoses can be noncompliant, and reshant to treatment These clients d lusually deny or minimize their substance ese/abuse, yet an astute mental hezlth professional will note increased psychiatric hospifdhtions and exacerbation of e d psychotic symptoms It is important to note that theincidence of alcoholism in womm has risen and has contributed to increased suicide, death &om acddents, and othea alcohol-related diseases. The literature desaibes women as drinking in response ro many stressful events: ma&l pmb1-, POveap and single p a r e n . , midlife crisis, empty-nest syndrome, and w a n t e d pregnanw A great mncem with pregnmt females who drink alchohol is fe&d alcohol syndmme WAS).PAS a&% the cenid nemoua system of the fetus. Growth patterns are

f a s crfpeerrelationsMps ~

~ ~ U ,z.z R E init+&wkl

&I alcohol syndrome. rinted wltn permlsslan. Rtrelssguth kndesman-~wyer,S., Martin, J. C.. % Smith, D. W. (qc~so).-rerat-,- r~c effects of alcohol in humans andl laboratOlV animals. science, 209tIS): 353-361)

1

inhib'idtvith lowbirthwekghw and tad infwo.UnusudEa&&@* act&tics are present i n d u n g eye slits, low p l a m m t of ftre &, and a wide Bat forehead with a flat nose @gae 1Z-2).

ALCOHO'L USE &ND YOUTH

MI^& b I 'She media mess* to you& % ht&&&q batem* -day life Mini-markets even seK beer and wine, dang With gaS0-b e , food, add snacks. It is easy tO obtain an alcoholicbeverage ?aus% m a rewad a h a sports victory or completion of a day at wurk & o d Studies reveal bat addiction to alcohol is anderb@xosedM &e young although &t leading cause of death menqane years of age is alcohol-related mo .efFectsof alcohol we or abuse on youth are as folows: sl Family d c t s a Problems & school perfofmane S&QO~ a b ~ ~ C emmq, 6( inmeasea dropmt rates

Unprotected, unplanned sexual intercourse U hff- risk of physid or sexual abuse Suicidal thoughts and possay a pIan If the youth has a parent who abus~salchohoI studies have observed that these children are at high risk for delinquent behavior, lmmbg disordem hyperactivity, psydbasomatic complaints, and problem d l h k h g as adults. Adolescenrs at younger and younger ages are being presented to 91coh~lrehabilitatian emtiera They are brought inby their parents, peers, or thejwenile judicial system, The elderly are at risk for alwhdsm Many experience longperiods of iaolatioo and lonehess and drhkiug go0rtre.g &we f e w . Family members can mnttse their p e w s depression and p a ~ a ~ o i a with growing old iaseniLiWand fail to recognize the need for alcohol mafment The elrlery frequently a ~ excluded e from intense alcohol treatment pmgrams. Howeverhif alcohol use or abuse is suspected it canJtopar6izeth& g-c health we and possibility for residentid placement Nurses can also develop alc~hohm.Impaired by alcohol consumption, t h q will lack .sufficient insight and judgment to practice thek profession It i s a moral and le@ Sef;poesibilityto report the impaired nurse. Many areas provide intensive therapy program rn ather an inclient or outcIien? and the pmm'e job position remains intact d w the rehabilitation period.

TREATMENT fa contrast to the. rapid respoase to treatment elf many physical illnesses,response to treatment is genedyvety slow. Beatment methEyds for alcohobm v q . Mmy authorities believe &at a mnlti&ceted appr0ar.h i s best in meetlng the needs of the cUent with alcoholism

L%@k"=*q.

- -ltifaceted Approach t o Treating AlGoholis &[Coh~lhsAnunymous @ ~ f i oemotive ~ l : Wlerapy Plndustrlal alcohol program* !Antabuse. /&lcohoip r o g m for fhe aged :Walfwayh0ust.s '-.mL? mK!& - -

~ omeal t urommc .-.,.,v.--.-...~~

hl%a

!jet@gmmt@m ce~tefs Judtcta'lmhabilitatibn ~~ansaceonal an&i6

I

Chapter 12

Alcoholism

b1oohol~~cs Anonymous 5Ieelildiw a P a n m 64AI is an organkition m @former dcoholirs whose pezmnd expenen- with aIcoIrol enable theni t~ understand the p b 1 m of the persoa wi€hdmholfsrn. T h q learn &om d i r e obsmtion ofthe ntanyremvered &om aleohoTism ia the organization, B e goal of Aloohnlies h n y m o u s is for members to ahstab &om drid&g gne day at a tirae Sobriety help to provide &g person with dmholim wiih a grawing sense ufse&cn&%71, a&evemegt and mgsteqz This provides M e r mativation to &dm fr-oan drhkhg. There is an inmasedaof self as the p m m begh to d e r s m d his or her prob1e.m and feeliqp- tlA meetings use a stmdmed gmup approach with a w&-d&i?d W d d e p prognun [.Table l2-32.%& membr has a sponsor and takes m e v&tb a A lead is a presentation of a pesson's struggle wifh pltwln up it1~0hU1 and the devamjlfing &kc@ of al&l on bLs or her lifk Each persog defines his or her own spiritual&? an6 hipher power and tbW&F irmw selk+kemand hope AA bemmes a d]N&al part of8fd sob&&on (family p u p s ) and Ahteen ( v j &ircus on tkq : eEects ofalcahon family and dhil&rmACOQ (Adult Chjldren Q$ AlwholicsJ provides p e m d contaM vwreh other9 who grevv up in d p f h m t i o ~f& network This p m n a l eontacf is therapeutic and provides emutianal 6uppaR.

mtronral Emotive merapy Almhobn b seenby proponents ofratiaQal bmotiye k a p y as b q , ,, a means of coping, The gad of this the~apyis to help the pason @ aleabolism Itam to tolere rhe stixssors &at eome with ]i&g use coping meihnbnm @@ are less seIf.de-. It teaches pwa;F wlrh aleohobm to ~ e c o g n i z e i n a ~ din e stheir By &@& ing ffi& views ofthemsehrrs and t h e envitonment, they ma % !!heir behvior. The rational emottve thempi& ME%@ that imtiend thinhg leads to irrational drfnkhg.

Transa~tLonalAndysis ~ a c e f o n adl y s k & another W a p y &pproa&to aItoholism tW-3 has f b d some sueow. The g d of transactional and* is to help with &oholism stop playhg gain@ and M &e meir satpta, AIwhoIism inoolves s d F e 8 and a variety ~fpa* With ?he cafsatim of game plawg, t-he mderIiqg psohlemS met$@ more cI&a~Ay.Clients are &en able to wpc with -theirprmhle~m9te dir%al$

*

Psychoanalysis Psychoanalysis invalves the direct interaction of the client wftk a therapist The objective is to gain insightinto behavior throughtaIking.The therapist assists the client to clarify and work through stressful areas in his or h a life. The client may be in therapy for a long time.

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Chapter 12

Group ~herapy Group therapy involves meaningful interaction group. The group members relate their p a d other. The main objedive is for each group memb her impact an others through i n m e d ~ r n mbehavior and relatiomhips. The ichapm 77).

Antabuse (Disulfuram) Antabuse (dimlfuram] is taken daily nence from alaohol Antabme interferes with the metabolism hol and poduces a toxic reaction when combined with it how they will suffervery unpleasant reactions if they do nUat &om deinking. The drug is usually well tolerated, but t h m rimes side egects. These side eff& usually &appear as adjusts to the druggThe most common side eff& indnde fatigue, acne, and a metallic aftertaste If clients drink alcohol while this drug is still in their

effects may last hmtbirtg minutes to several hours; times ouw~edDuring the reaction, the client is in situation and should be and consent W clients should be thoroughly m c d agsuming alcohol in any form. Over-the-countm medication

tal iuness. Success with Antabuse depends on a firm r person wIthalcoholim to abstain from w g . seldom used because it is a simptistic approach to a cornplW ,, p T

people permission to do Eor t h e can be dtfRclalt to put into practice. M a $ personal choices md developing the ab@y to say rn M y djmiubhes their sympton~.in recawery,the codependent must be aware of 9abof~girrg behaviors of other6 and identify those people Nho m&ently "suck them innMonitoring passive or a@Rssive behaviors wi!J assist with inmmed numbm of as&e&iveencawm with &ers in their personal and workplace endronments. h o t l m hcipful approach is ehe praetce of daily personal affirmation& i4flkmdom are1 statements chmt~d sfienay or out bud to oneaPX I desem satisfittion, cmtenfment a fmEIling rehtkmship q x e s s my feelings todag~act fn an a s s e e I d manner today hewering codependen@make their own daily choice8 and w e their beIi@vahxe s;ystems through acriofl-oried belmiors.

TREATMENT FAClLITlES Various treatment fadlitie are mailable to meet s p d c or g a & d need@of the & a t =with alcoholism Detoxffication cent= axe p h ~ where the &en€ with aleahobm r&es treatment and care duriiag the withdrawal proces~.They comprise the ikfirst s%p in treafpeflt Ia~w, the &nt patidpat@in a canttnuisgw e and rehabiliation prP @a.m. Refen& ate fpequdy made to l a - t e r m f r e a ~ ~ eprogtam~. nt Other times, the & a t is transifered to a residentid treatmment center: The h a h y home is a n i n m d i a t e r & h c e for the client befbi~ he or s h e ~ a t e t nhe c m u n i v (Hgure; U3). PPequ&, the &We is located in the client's commUrn:ty. W i v i d e d a n d o n d L homelike atmosphee are just two advwtages of tbe program Mo~t ihalfcvsv houses are oriented to AlAlcoIIes Amaymow aad enmm&ge

$SUE12-3 A halfway house may look like ally m e r home in tne communiw. environment is an exellent s e w for early-idenand @eatm a ofproblem drinkm. For more thaa 35Qyeam pubficimoxica6on w a under the jurb dictian of aimhal law The penniless drunk; m h r e d through a prows of afiegt jail, release, md reatTest Sn the past I I R prs, p r o m h e been made toward fmn&king theproblem drinker 6om thP penal $ys€emto treament pragrams. It is now recognize8 that the person with aloohcJlism needs eattreatnwt and rebabihrim.Legfslatim is providing the h e w o r k for this needed treatmeac 3chQal aIa,h01 program are a preventiw measme+T e e n m need alcohol education programs .intke scfioeIr;.The rommticrtlea of alcohol e sem in the media must be challeqgxt The r d facts and patined Iiteratwre shonld be presented Alcaholism is the mstneglected health problem in America and msds to be p~smredto the ado1esmt in fits true light Few treatment W t i e s @tpe for the nee& of the aged with a ~ g p r o h l e mThe . a@d need therapeuticprogritms geared to t k k underlying strpssors.%earmat fficUitles should have an h d i v t d u m approach that attemp@to &cover the pmitcdar problems of each a$tng ~ W D Dewl~ping . new &adships and a sense ofwell-being &+ goup tneetkgs helps all& lonelinms. Lo%-goals of a pmgram for tbe aged person with aicu h~lismme to make we wmhdile to help him Qrher see h&ans, 12~ther than dead eads,

Oganize a resource file on alcoholism. Obtain fnformation by writing for literature concaning alcoholism &om The National Cornoil fbr AlwholiFmInc. 2 ParkAvenw New Yo&, IVY l 0 O l G The National Institute ofAlcoho1 Abuse and Alcoholism 5600 Fiscber Lane Room 11A 58 RoclaSlle, MD 20852

REVIEW

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XNOW AND COMPREHEND A Mdtiple choice. Select t h e one best answer. 1. The amendment Eotbiddtng the manuFacture, distributian, and sale of alcoholic beverages was the D d Temperance Amendment El B. Psohibition Amendmeat P C. DBtinatim Amendment O D. Alcoholic Amendment 2. The treatment method that fowes on changingbehavior by changing the clients'piewrs of themsdw and their eravirok ment is termed P k transactionat analysis. D B. rleto*cation method 0 C. Alcoholics Anonymous. Cl D. rational emotiw therapy 3. h treatment approach Bat tries to help the client to stop game playing and rewrite his or her life saipt is P A. rational emotive therapy 0 B. transa&onal anal*. P C. drug therapy D D. AlfflholicAnonymous. 4. Which of the following below arcurately describes alwholiam? D R a serious problem that develops &er adolescence P B. a pmpsive, fatal, and mmplex disease t l C. an effective way to cnpe with stress El D. a habit of drinking more than m e infended

Alcoholism 4. A practical nurse

w& clients in an alcohol treamertt center abwt their disease. XVhich client is in the earliest stage ofthe rehabilltation process? The client who sap: O A *I understand that alcoholisfn is a lifelong tiisease proces8: 5 B."My chinkinghas a w e d prablens in my family relaticinships? U C. "I've never had a problem h d t n g or Keeping a job." 5 D. 'Tve often M guilry about my drinkhg? 5. The mrse cares For an Mtnt with feral alcohol syndrome PAS). Qahich characteristic is moat likely present in the

APPLPTOURLB, WaMple Cholerr, &led fbP onefa&

answet:

infant? Q A. low Weight &f & P U B. m w pointeil ~ nose a c.wide, bulging q e s 5 D, edematous extremities 6 You are a nurse tYarking on a m & ~ ~ s q unit i d Durbg the s h i change repm at the b e g i g of a new shiR you notice the sm$ of alcohol on another nuwe's skin and breath. Based on tbb o b m t i o n which action would you hplement? A inthe nutae of your obsemttion 5 B. observe fhg nume for impaired performance 5 C. ask a wwmker if they smeli alcohaI 5 D, noti@the nursing supervisur ofthe obsemtion C. Briefly m w e r the following, 1. ?%%atis the pnrpose of the Wa'tionalInmimte for &&I

Abase and NcohoIlsm?

4- List siX sympt~msof almhol withdrsd

5. List ten nming interventionswhen caring for the client with

alcoholism.

6. B r a y desuibe the objdves of=&

rnunity programs. A. AEcohoUres Anmyraous

I),hot meals psograms

o f t h e folloMimg cor