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Clinical Nursing Skills

20.2 Substance Use Disorder Assessment

Clinical Nursing Skills20.2 Substance Use Disorder Assessment

Learning Objectives

By the end of this section, you will be able to:

  • Verbalize assessment considerations for identifying alcohol abuse
  • Describe assessment measures for identification of illicit drug use
  • Describe the nurse’s role in substance abuse assessment and management

An umbrella term used to describe the misuse of drugs or alcohol that can lead to severe physical and psychological consequences is substance use disorder (SUD). Misuse of alcohol, drugs, and prescribed medications is estimated to cost the United States more than $400 billion in healthcare expenses, law enforcement and criminal justice costs (due to drug-related crimes), lost workplace productivity, and losses from motor vehicle crashes (U.S. Department of Health and Human Services, 2016). The Centers for Disease Control and Prevention (CDC) National Center for Health Statistics estimates that 107,622 drug overdose deaths and 52,000 alcohol-induced deaths occurred in the United States in 2021. Chronic substance use disorders significantly impact individuals, families, communities, and society. According to the 2020 National Survey on Drug Use and Health (NSDUH), 40.3 million people in the United States aged 12 or older (14.5 percent) have an SUD.

Assessment of Alcohol Use

Assessing a person’s use of alcohol is critical to getting them the right level of help. Obtain the following information from a patient:

  • history of substance use, including alcohol and illicit drug use
  • detailed history of previous withdrawal treatments
  • treatment history
  • mental health history
  • social history
  • medical history, including any recent physical symptoms

The patient should receive a comprehensive physical examination to evaluate signs related to current withdrawal symptoms and symptoms of concurrent medical and mental health diagnoses. Assess also for signs of complications, such as liver or pancreatic disease. Several tests are available to determine a person’s current relationship with alcohol and whether it is pathological (Table 20.4).

Test Description
Alcohol Problems Questionnaire (APQ) Forty-four-question test filled out by the patient, assesses various areas of the patient’s life and whether the patient’s alcohol use impedes them
Alcohol Use Disorders Identification Test (AUDIT) Ten-question test that helps a patient estimate their daily use of alcohol
Clinical Institute Withdrawal Assessment of Alcohol Scale (CIWA) Ten-question survey to be used to monitor and evaluate a patient’s withdrawal symptoms
Leeds Dependence Questionnaire (LDQ) Ten-question survey that assesses the importance of alcohol or drugs to the patient
Severity of Alcohol Dependence Questionnaire (SADQ) Twenty-question test that assesses the severity of dependence on alcohol
Table 20.4 Alcohol Misuse Tests

Alcohol Use

The nurse needs to assess the patient’s alcohol use behaviors. Questioning the patient about how much alcohol they consume (e.g., daily, weekly) can help the nurse determine the patient’s risk for alcohol misuse.

A moderate alcohol use in a healthy adult is considered one drink daily for women and two drinks daily for men. An example of one drink includes the following:

  • wine: 5 fluid ounces
  • beer: 12 fluid ounces
  • distilled spirits (80 proof): 1.5 fluid ounces

An alcohol use disorder (AUD) is a medical condition characterized by a person’s inability to control or stop using alcohol, despite the possible adverse events resulting from their drinking. What was previously referred to as alcohol abuse is now called alcohol use disorder. The severity of AUD—mild, moderate, or severe—is based on the number of criteria met (Grant et al., 2015).

Clinicians often gauge a person’s AUD severity by risk, recommended treatment options, and eligibility for various treatment programs (Table 20.5) (National Institute on Alcohol Abuse and Alcoholism, 2021). Having any one of these symptoms could be a reason for concern. The more symptoms present, the more urgently the patient needs treatment.

Severity Number of Symptoms Present
Mild alcohol use disorder Two to three symptoms
Moderate alcohol use disorder Four or five symptoms
Severe alcohol use disorder Six or more symptoms
Table 20.5 Determining the Severity of AUD

A destructive pattern of alcohol consumption that causes adverse physical, psychological, or social side effects is harmful drinking. Alcohol consumption that threatens a person’s health, safety, and well-being is considered at-risk drinking. It consists of binge drinking, drinking while pregnant, underage drinking, or any other form of potentially hazardous alcohol use. An excessive or dangerous intake of alcohol that leads to considerable impairment in physical and mental health is considered hazardous drinking. Inebriation caused by alcohol or other psychoactive substances, resulting in behavioral and physiological changes is referred to as intoxication.

When a person begins drinking excessively, they can develop alcohol dependence, a complex condition that results in a compulsive, chronic reliance on alcohol for physiological and psychological gratification. Dependence on alcohol is marked by the inability to stop drinking, even if a person wants to quit due to experiencing the symptoms of withdrawal. Over time, the person can build a tolerance to the alcohol, or the physiological capacity to withstand the effects of a substance with repeated use or exposure. In tolerance, the person needs to drink more to get the same effect. The term addiction refers to the changes in a person’s behavior, such as seeking out alcohol despite experiencing negative consequences from using it, that come from having developed a dependence on the substance.

In a controlled environment, such as a hospital or treatment center, the treatment staff are available to help the patient eliminate those things working against their recovery and maximize their efforts toward remission. A controlled environment is an artificial atmosphere that is carefully regulated and monitored to ensure maximum accuracy and precision. The first milestone in remission is early remission, which is when a patient who previously met all the criteria for alcohol use disorder has been sober for three months but less than twelve months. As the patient continues to work through their program, the next milestone is sustained remission, which means they have maintained sobriety for more than twelve months.

Drinking Measures: Descriptive Information

The nurse has several evidence-based tools that can help them screen patients for risky alcohol use and assess the severity of alcohol use disorder. The United States Preventive Task Force Services (USPTFS) recommends that clinicians use one of two brief screeners: Alcohol Use Disorders Identification Test (AUDIT-C) or Severity of Alcohol Dependence Questionnaire (SADQ). Both questionnaires are short and allow the nurse to quickly get information on the patient’s drinking habits.

Importantly, these tools frame inquiries about the patient’s alcohol use as open-ended questions rather than “yes” or “no.” For example, in the AUDIT-C, a patient is asked to note the frequency of their alcoholic drink consumption within the last year (on a scale from “never” to “four or more times a week”), rather than asking the patient whether or not they have consumed alcohol within the past year (“yes” or “no”). The SADQ likewise asks patients to give a specific number—for example, asking, “How many times in the past year have you had (four for women, or five for men) or more drinks in a day?” rather than asking whether the patient has consumed four or five or more drinks in a day in the last year, to which they would respond with a closed-ended “yes” or “no.”

The results of these shorter assessments can help the nurse identify any risky alcohol use behaviors that may need follow-up and additional screening. Even patients who score no or low risk still benefit from proactive, preventive steps to help reduce their risk for alcohol misuse in the future.

Alcohol Withdrawal

Symptoms of alcohol withdrawal range from mild to severe, depending on the severity of the AUD and length of time since the patient’s last drink (Table 20.6). The symptoms can be organized into three categories: mild, moderate, and severe.

Time Frame Withdrawal Symptoms
6 to 36 hours after last drink Anxiety, minor agitation, restlessness, insomnia, tremor, diaphoresis, palpitations, headache, alcohol craving, loss of appetite, nausea, vomiting, diarrhea, sinus tachycardia, systolic hypertension, hyperactive reflexes
12 to 48 hours after last drink Withdrawal hallucinations (visual, auditory, tactile)
6 to 48 hours after last drink Alcohol withdrawal-related seizures
48 to 96 hours after last drink Delirium tremens (DTs) with agitation, fever, severe tachycardia, hypertension, drenching sweats
Table 20.6 Withdrawal Timeline

Nurses in medical-surgical hospital settings or emergency departments commonly care for patients receiving withdrawal treatment for alcohol. Furthermore, patients frequently underreport alcohol use, so nurses must be aware of withdrawal signs in patients receiving medical care for other issues and notify the healthcare provider.

The prevalence of alcohol use disorder (AUD) is estimated to be high among hospitalized patients (Elliott, 2019). Approximately half of the patients with alcohol use disorder experience alcohol withdrawal when they reduce or stop drinking, with as many as 20 percent experiencing severe manifestations, such as hallucinations, seizures, and delirium tremens. Severe alcohol withdrawal is a medical emergency, best managed in an intensive care unit.

Without treatment, symptoms of mild alcohol withdrawal generally begin within six to thirty-six hours after the last drink and resolve within one to two days. Symptoms of early or mild alcohol withdrawal include anxiety, minor agitation, restlessness, insomnia, tremor, diaphoresis, palpitations, headache, and alcohol craving.

Patients often experience loss of appetite, nausea, vomiting, and diarrhea, and their fall risk often increases when they try to go unassisted to the bathroom with these gastrointestinal symptoms. Other signs at this stage of alcohol withdrawal include sinus tachycardia, systolic hypertension, and hyperactive reflexes.

Some patients develop moderate to severe withdrawal symptoms that can last up to six days, including withdrawal hallucinations, seizures, or delirium tremens.

  • Hallucinations typically occur within twelve to forty-eight hours after the last drink. They are generally visual and commonly involve seeing insects or animals in the room, although auditory and tactile phenomena may also occur.
  • Alcohol withdrawal-related seizures can occur six to forty-eight hours after the last drink. Risk factors for seizures include concurrent withdrawal from benzodiazepines or other sedative-hypnotic drugs.
  • Delirium tremens, or DTs, is a rapid-onset, fluctuating disturbance of attention and cognition sometimes associated with hallucinations. In its most severe manifestation, DTs is accompanied by agitation and signs of extreme autonomic hyperactivity, including fever, severe tachycardia, hypertension, and drenching sweats. DTs typically begin between forty-eight and ninety-six hours after the patient’s last drink. Mortality rates from withdrawal delirium have been historically as high as 20 percent, but with appropriate medical management, the mortality rate is between 1 and 4 percent. Death is attributed to cardiovascular complications, hyperthermia, aspiration, and severe fluid and electrolyte disorders.

Benzodiazepines may be prescribed to treat the psychomotor agitation that most patients experience during alcohol withdrawal as well as prevent progression of the minor symptoms to more severe symptoms of seizures, hallucinations, or Delirium tremens. Diazepam (Valium), lorazepam (Ativan), and chlordiazepoxide (Librium) are used most frequently to treat or prevent alcohol withdrawal symptoms.

Special Developmental Considerations

A patient’s developmental age and stage of life affect the nursing assessment for use of alcohol. The nurse first needs to establish whether a patient has the capacity to understand alcohol use and its consequences. For example, a young teenaged patient may not be able to fully grasp the risks of their alcohol use, either in the short or long term, due to the limitations of their still-developing brain. The nurse needs to consider the context of the patient’s development when both assessing and discussing alcohol use.

There are also special developmental stage considerations that are not related to comprehension, but rather, to life events at that stage that may be important for the nurse to note. For example, women of reproductive age who could become or are currently pregnant need to be counseled about the risks of alcohol use as it pertains to conception, pregnancy, and breastfeeding. Another common clinical situation would be an older adult patient who is taking multiple medications to manage chronic health conditions who may not be aware of the potential for these drugs to interact with alcohol.

Adolescents

Alcohol is the most commonly used substance among young people in the United States. Data from several national surveys document frequent use of alcohol among young people. The 2021 Youth Risk Behavior Survey (YRBS) found the following statistics among high school students over thirty days:

  • 22.7 percent drank alcohol
  • 10.5 percent binge drank
  • 4.6 percent of drivers drove after drinking alcohol
  • 14.1 percent rode with a driver who had been drinking alcohol

Adolescents who binge drink are at an increased risk for school, social, legal, and physical problems. They are also at an increased risk of alcohol poisoning, alcohol-related motor vehicle crashes, burns, falls, and drowning. The brain development changes noted in teens who binge drink may have lifelong effects.

Children and adolescents use alcohol and other substances for many reasons, including as a maladaptive coping strategy. While many of these reasons for alcohol use would also apply to adults, the nurse also needs to be aware of the following unique factors that may influence alcohol use in young people more so than in older populations:

  • peer pressure and influence of social media
  • school stress, academic performance, competitiveness in sports, and hobbies
  • difficulty coping with hormonal, physical, and emotional changes of adolescence
  • curiosity and drive to establish independence and/or test boundaries
  • lack of healthy, effective, coping skills

Older Adults

AUD appears different in the older adult, as AUD could have been a lifelong activity or a newly developed coping mechanism. The Short Michigan Alcoholism Screening Test—Geriatric Version (SMAST-G) is used to evaluate alcohol use in older adults. The short evaluation allows the practitioner to assess alcohol consumption in a way that is specific to older adults, as it may be affected by variables like changes in metabolism associated with aging, liver function, and interactions with medications.

The following questions are asked during the evaluation:

  1. Do you ever underestimate how much you drink when talking with others?
  2. After a few drinks, have you sometimes not eaten or been able to skip a meal because you didn’t feel hungry?
  3. Does having a few drinks help decrease your shakiness or tremors?
  4. Does alcohol sometimes make it hard for you to remember parts of the day or night?
  5. Do you usually take a drink to calm your nerves?
  6. Do you drink to take your mind off your problems?
  7. Have you ever increased your drinking after experiencing a loss in your life?
  8. Has a doctor or nurse ever said they were worried about your drinking?
  9. Have you ever made rules to manage your drinking?
  10. When you feel lonely, does having a drink help you?

The Patient Who Is Pregnant

The nurse needs to assess alcohol use in patients who are pregnant both for the health of the patient and the fetus. While the nurse can use adult alcohol use screening tools, they should consider the context of the patient’s life stage. For example, pregnancy may introduce new stressors and physical/mental health changes that may influence a patient’s health behaviors.

The patient needs to be educated on the risks of using alcohol while pregnant, not just for themselves but for their baby as well. A fetus is exposed to alcohol before birth when alcohol in the patient’s bloodstream passes to the fetus via the umbilical cord. It is unsafe for patients who are pregnant to drink any amount of alcohol at any time during pregnancy. All types of alcohol are considered dangerous to an unborn baby, including wine and beer. Fetal alcohol spectrum disorder is preventable if patients who are pregnant or suspect they may be pregnant refrain from alcohol use. People with fetal alcohol spectrum disorder may display any of the following signs (CDC, 2023) (Figure 20.3):

  • low birth weight
  • poor coordination
  • hyperactive behavior
  • difficulty paying attention
  • poor memory
  • difficulty in school, especially math
  • learning disabilities
  • speech and language delays
  • intellectual disability or low IQ
  • poor reasoning and judgment
  • sleep and sucking problems as a baby
  • vision or hearing problems
  • problems with heart, kidneys, bones
  • shorter than average height
  • small head size
  • abnormal facial features
Image showing graphic information about fetal alcohol spectrum disorders (FASD) and data about alcohol use during pregnancy.
Figure 20.3 Fetal alcohol spectrum disorder is a range of effects that can occur in people with prenatal alcohol exposure. (credit: modification of work “Alcohol Use During Pregnancy” by Centers for Disease Control and Prevention, Public Domain)

It is important for nurses to be nonjudgmental but, at the same time, not downplay the urgency of not drinking while pregnant. By being honest with patients, nurses can earn their trust and have a greater chance of the patients being more transparent about their drinking. Nurses also have an opportunity to educate patients when they discover any patient misconceptions about alcohol use and abuse and the effects of alcohol on an unborn baby.

Patient Conversations

Pregnant Patient with a History of Alcohol Use Disorder

Scenario: Esme is a nurse on a busy OB unit. She is caring for Jill, a patient who is twenty-one weeks pregnant with her second child. Her first child, now age two, is living with family members because he was born with fetal alcohol spectrum disorder and had to spend three months in the NICU after birth. Jill was admitted today, and Esme is performing her assessment.

Nurse: Hi, Jill. Now that we have performed the physical assessment, I will go through some questions about you and your life so we can provide you with the best care, okay?

Patient: Hi. I don’t even know why I am here. My doctor’s appointment seemed okay today, but the doctor has been worried about my baby’s small size and told me I had to come in for some tests. My first baby was tiny too. My babies are just smaller, that’s all.

Nurse: I understand. Let’s see if we can find the answers together.

[During the alcohol and substance abuse portion of the assessment]

Patient: I do drink some alcohol, but only wine and beer. I drank the hard stuff before, but now that I know I’m pregnant, I cut down to the weak stuff so that I won’t hurt the baby.

Nurse: Okay, I understand. How many beers or glasses of wine do you drink daily?

Patient: I always have a beer in the morning, then another at lunchtime. In the afternoon, I get together with my friends, and we finish a bottle of wine. I may have two or three glasses. Then in the evening, after dinner, I like to sit on the porch with my boyfriend and share a six-pack. He usually drinks three to four, and I drink the rest. So, I guess that’s seven or eight drinks a day, but it’s okay because I never get drunk, and I still know where I am and who I am, so it won’t hurt the baby.

Nurse: Thanks for sharing that information with me. Jill, I want to be honest with you so I’m sure you have the correct information. Any alcohol at any time while pregnant can affect your baby. It doesn’t matter if you feel drunk or not, and it doesn’t matter if you’re drinking wine, beer, or vodka. Any amount of alcohol can affect your baby.

Patient: Oh wow. I guess I didn’t realize that. I have another son who was taken away from me because he had to go to the NICU after birth. He had a tiny body and a very small head. They tried to say that it was my fault.

Nurse: Well, I’m so sorry you didn’t get to spend time with your baby after his birth. Let’s discuss how to improve your health and keep this baby healthy.

Patient: Okay, that sounds good. I’ll do anything to keep this baby safe.

Nurse: There’s something called fetal alcohol spectrum disorder that affects babies born to mothers who have used alcohol during pregnancy. Some of the symptoms are low body weight, attention deficits, poor memory, learning disabilities, vision and hearing problems, and potential issues with their hearts, kidneys and bones, to name a few.

Patient: I didn’t realize it was that bad. I just thought it might make the baby relaxed or something.

Nurse: You have done a great job of transparently sharing your drinking with me, and I’m so thankful for that. If you feel ready to talk about ways to improve your life and give your baby the best start possible, we have a treatment team who can make that happen, but it takes your total commitment. Do you think you’re ready?

Patient: I’m ready. I have to change for both of my kids.

Assessment Considerations for Substance Abuse Disorder

The Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR) gives the provider a systematic way to accurately assess patients for SUD. A diagnosis of SUD can be categorized as mild, moderate, or severe. Mild SUD is characterized by the existence of two or three of the following criteria; moderate SUD is characterized by four or five; and severe SUD is characterized by six or more (American Psychiatric Association, 2022):

  • substance commonly taken in larger amounts or for a longer time than the patient intended
  • persistent desire or one or more unsuccessful efforts to cut down or control substance use
  • excessive time devoted to activities necessary to obtain the substance
  • cravings and urges to use the substance
  • impaired occupational, social, or recreational activities
  • continued substance use despite the recognition of a persistent or recurrent psychological, social, or physical problem that’s caused or exacerbated by the use of the substance
  • avoidance or giving up of occupational, social, or recreational activities due to the substance use
  • continued use of the substance despite the dangers of doing so
  • continued use despite awareness of a psychological or physical problem possibly from or worsened by the substance
  • marked tolerance (evidenced by a need for significantly increasing the amount of the substance to achieve intoxication or the desired effect or a significantly diminished effect with use of the same amount of the substance)
  • characteristic withdrawal symptoms relieved by taking more of the substance

Many times, people who use substances develop tolerance. Tolerance is when someone needs more and more amounts of the substance to feel the same level of intoxication or feeling they previously had. This means that when they take the same dose, the physical effect is less, thus necessitating the need for a higher consumption. Additionally, the patient begins to develop withdrawal symptoms whenever they cut back or stop using the substance.

Special Developmental Considerations

As with alcohol use, the nurse also needs to consider the developmental stage of the patient when assessing other substance use. While many risk factors and consequences of drug use are shared by patients across the life span, there are also some specific risks that are unique to patients based on their age.

School-Aged Children

School-aged children are at risk of being exposed to illicit drugs by caregivers and other adults in their lives, as well as older children (including schoolmates, friends, and siblings). A child may also learn about drugs from online content, social media, and television.

However, a child’s understanding of drugs and their risks is often limited because of their developmental stage. They may not have much “real world” context for what they hear or see about drugs and may have many questions and misunderstandings. The nurse needs to be aware of the child’s possible confusion and consider this carefully during the assessment. It’s also important that the child understands that they can be open and honest with the nurse, and that it is a safe space to talk about drugs (which the child may broadly understand as being a “bad” topic).

The drug use screeners that the nurse has available may be adaptable to a pediatric patient, such as the Alcohol, Smoking and Substance Involvement Screening Tool (ASSIST). Tools such as the Car, Relax, Alone, Family, Friends, Trouble (CRAFFT) Questionnaire are validated for children ages 12 and up. The nurse also needs to emphasize to a child patient’s caregivers the importance of discussing drug use proactively. Prevention starts at home with having open, honest conversations about the risks of drug use and setting clear expectations—that is, making sure a child knows that drug use will not be tolerated.

Adolescents

When assessing SUD in adolescents, it is important for the nurse to understand what the patient considers to be drugs or abuse. For example, adolescents may not realize that painkillers can be just as harmful as illicit drugs. During the assessment, the nurse should ask the patient about their use of pain medicines, including prescription pain relievers. They should also ask the patient if they take and use medicines not prescribed to them or obtain medicines from sources other than their healthcare provider.

Adolescents need to be specifically asked if they are hiding drug-related behavior from their parents or caregivers. The nurse must assess the patient for physical signs of SUD, such as slurred speech, drowsiness, shallow breathing, disorientation, and lack of coordination.

According to the 2023 results of the Monitoring the Future survey conducted by the National Institute on Drug Abuse at the National Institutes of Health, teens are using prescription drugs without a doctor’s orders less than in the past. In 2023, about 9 percent of twelfth graders reported ever using a prescription drug without a doctor’s order. Even so, prescription drugs are still a risk for adolescents. Compared to other illicit substances, prescriptions can be more readily available to teens—for example, because someone in their home has been prescribed medications.

When assessing adolescent patients for SUD, the nurse needs to ascertain the teen’s awareness of drugs, their understanding of the risks, and their access to substances. Much of this information can be gleaned from screening tools, but the nurse must also be sensitive to the needs of a teenaged patient who may be hesitant to be open and honest.

Young people may get inaccurate information about drugs from their peers, the internet, and the media they consume. They may be curious or confused about drugs but not want to ask questions for fear of judgment, ridicule, or punished. While the nurse is assessing the patient, they should be cognizant of the fact that an adolescent may have misinformation about drugs and the risks associated with them.

Many people, not just teenagers, also hold the misperception that prescription drugs are somehow less harmful to their bodies than other drugs. This is, unfortunately, untrue. In doing the assessment, the nurse has an opportunity to identify gaps in a teen’s knowledge as well as address any misconceptions or misinformation about drugs. The nurse can explain that each drug class has short- and long-term health consequences when misused:

  • Stimulants have many side effects in common with cocaine, including paranoia, dangerously high body temperature, and heart rate irregularities, especially if used in combination with other drugs.
  • Opioids act on the same part of the brain as heroin and can cause drowsiness, nausea, constipation, and slowed breathing (depressed respiratory drive) if a large amount is taken.
  • Depressants can cause slurred speech, shallow breathing, fatigue, disorientation, lack of coordination, and seizures upon withdrawal from chronic use (Substance Abuse and Mental Health Services Administration, 2022).

Older Adults

According to recent studies, illicit drug use declines after young adulthood. However, about 4 percent of adults aged 65 and older in the United States abuse substances (Jaqua et al., 2022). The nurse must consider the possibility of substance use in older adults as well as understand the specific age-related factors that can affect the assessment.

Older adults may have physical and/or cognitive changes that may require the nurse to rethink their approach to asking about substance use. For example, a patient who is partially deaf may not be able to discuss their substance use easily. The nurse may want to write down questions or use visual aids to help get an accurate assessment. Patients who have cognitive impairment or memory disorders may not be able to reliably recall their substance use or may become confused during the course of the assessment.

Taking multiple medications, also known as polypharmacy, is another concern for older adults. Older adults may metabolize drugs more slowly and can therefore be more sensitive to them. Patients who have multiple chronic health conditions to manage are more likely to be taking multiple medications. As more medications are added, the risk of drug interactions increases, putting them at even greater risk of side effects and adverse outcomes. Many older adults use prescribed opioid pain medications and take them long-term for chronic conditions.

Older adults, like patients in other age groups, can also experience life stressors and changes that may drive substance use. For example, the older adult may turn to substances to cope with depression, poor health, injuries, social isolation, a loss of independence, the deaths of spouses and friends, as well as worries about their own mortality.

The Patient Who Is Pregnant

Caring for a patient who is pregnant and experiencing drug addiction is complex, because two patients require care, and their future health depends upon the patient’s choices (Table 20.7). When a patient who is pregnant exposes their unborn child to illicit drugs in utero, the fetus is at a higher risk of certain short-term and long-term complications. The baby is more likely to experience congenital disabilities and/or withdrawal symptoms after birth. The baby has a higher risk of losing their life to sudden infant death syndrome (SIDS) and, as they age, their risks of poor growth rates and cognitive and behavioral problems also increase. Likewise, the patient is at an increased risk of miscarriage, preterm labor, or stillbirth.

Drug Effects on Baby during Pregnancy
Opioids Miscarriage, low birth weight, neonatal abstinence syndrome
Cocaine Premature delivery, low birth weight, deficits in self-regulation and attention in school-aged children prenatally exposed
Methamphetamine Premature delivery, separation of the placenta from the uterus, low birth weight, lethargy, heart and brain problems
Nicotine/vaping Miscarriage, low birth weight, stillbirth, learning and behavior problems
Benzodiazepines Higher rate of Cesarean section, baby three times more likely to require ventilation after birth
Marijuana Babies born with problems with attention, memory, and problem-solving
Table 20.7 Drug Effects on Babies Exposed to Drugs during Pregnancy (Source: Ross et al., 2015.)

Types of Illicit Drug Use

There is a range of illicit substances on which the nurse needs to be educated, some of which they may be more familiar with than others. Alcohol, cannabis, and tobacco are among the most commonly used substances that the nurse will discuss with patients (Table 20.8). As a healthcare professional, the nurse may be familiar with over-the-counter and prescription medications, including painkillers, opiates, and benzodiazepines. Some illicit drugs are more well-known as “street drugs,” such as heroin, cocaine, and methamphetamine. Hallucinogens and synthetic drugs are also substances of which the nurse should be aware.

Drug Common Forms Common Ways Taken
Alcohol Liquid Various alcoholic drinks, including wine, beer, and spirits
Cannabis Greenish-gray mixture of dried, shredded leaves, stems, seeds, and/or flowers; resin (hashish); or sticky, black liquid (hash oil) Smoked, vaped, eaten (mixed in food or brewed as tea)
Benzodiazepines Pill, capsule, liquid Swallowed, injected, snorted
Cocaine White powder, whitish rock crystal Snorted, smoked, injected
Heroin White or brownish powder, or black sticky substance known as “black tar heroin” Injected, smoked, snorted
LSD Tablet; capsule; clear liquid; small, decorated squares of absorbent paper to which liquid has been added Swallowed, absorbed through mouth tissues (paper squares)
MDMA (ecstasy) Colorful tablets with imprinted logos, capsules, powder, liquid Swallowed, snorted
Methamphetamine (meth) White powder or pill; crystal meth looks like pieces of glass or shiny blue-white “rocks” of different sizes Swallowed, snorted, smoked, injected
PCP (angel dust) White or colored powder, tablet, or capsule; clear liquid Injected, snorted, swallowed, smoked (powder added to mint, parsley, oregano, or marijuana)
Prescription opioids Capsule; liquid; tablet; in some cases, suppository, sublingual tablets, film, buccal tablet Injected, smoked, snorted, rectally if suppository
Psilocybin (mushrooms) Fresh or dried mushrooms with long, slender stems topped by caps with dark gills Swallowed (eaten, brewed as tea, or added to other foods)
Rohypnol (roofies) Pill Swallowed, dissolved in a drink
Synthetic cannabinoids Dried, shredded plant material that looks like potpourri and is sometimes sold as “incense” Smoked, swallowed (brewed as tea)
Synthetic cathinones (bath salts) White or brown crystalline powder sold in small plastic or foil packages labeled “not for human consumption” and sometimes sold as jewelry cleaner; tablet; capsule; liquid Swallowed, snorted, injected
Tobacco/nicotine/vaping Cigarettes; vaping devices such as e-cigarettes; cigars; bidis; hookahs; kreteks; smokeless tobacco such as snuff, spit tobacco, chew Smoked, snorted, chewed, vaporized
Table 20.8 Commonly Used Drugs (Source: National Institute on Drug Abuse, 2020a.)

The nurse needs to be aware of not only the types of drugs patients may misuse but also the signs of abuse that can be specific to certain drugs. While there are some general patterns of behavior as well as physical and mental health symptoms that may broadly apply to substance use, each drug may also have its own “telltale” signs. The patient’s physical and emotional presentation during the assessment can provide the nurse with additional data, which will need to be considered in the context of the patient’s scores on screeners for drug use.

The tools used for substance use screening can help the nurse ascertain the patient’s level of awareness and understanding of specific drugs. If the patient is using substances, further questioning can help the nurse determine the patient’s level of insight into their drug use. For example, a patient may or may not think their substance use is a problem and may not be aware of (or in denial of) the risks and consequences associated with SUD.

Drug use can also contribute to health risks by altering a person’s judgment and rational thought. This includes the potential for addiction, driving under the influence, increased chances of catching an infectious disease, and adverse effects on pregnancy.

Illicit Drug Withdrawal

The nurse needs to use their clinical judgment, experience, and available tools to assess whether a patient who reports using substances is addicted to drugs. It’s important for the nurse to recall the differences between drug dependence and addiction and be equipped to recognize the behaviors that can separate these two patterns of substance use.

The nurse also needs to evaluate the patient for drug withdrawal (Table 20.9). While the patient may report symptoms of withdrawal, the nurse also needs to observe the patient for the signs and symptoms of drug withdrawal during the assessment.

Substance Withdrawal Symptoms
Alcohol Restlessness, sweating, tachycardia, vomiting, irritability, seizures, headache, disorientation
Cannabis Irritability, trouble sleeping, decreased appetite, anxiety
Benzodiazepines Must be discussed with a healthcare provider; barbiturate withdrawal can cause severe abstinence syndrome that may even include seizures.
Cocaine Depression, fatigue, increased appetite, insomnia, vivid and unpleasant dreams, slowed thinking and movement, restlessness
Heroin Restlessness, muscle and bone pain, insomnia, diarrhea, vomiting, cold flashes with goose bumps
LSD It is unknown if LSD withdrawal includes any symptoms.
MDMA (ecstasy) Fatigue, loss of appetite, depression, trouble concentrating
Methamphetamine (meth) Depression, anxiety, fatigue
Opioids (heroin, fentanyl, morphine, codeine, Vicodin, Norco, oxycodone) Restlessness, muscle and bone pain, insomnia, diarrhea, vomiting, cold flashes with goose bumps, and leg movements
PCP (angel dust) Headaches, increased appetite, sleepiness, depression
Psilocybin mushrooms) It is unknown if psilocybin withdrawal includes any symptoms.
Rohypnol (roofies) Headache; muscle pain; extreme anxiety, tension, restlessness, confusion, irritability; numbness and tingling of hands or feet; hallucinations, delirium, convulsions, seizures, or shock
Synthetic cannabinoids Headaches, anxiety, depression, irritability
Synthetic cathinones (bath salts) Depression, anxiety
Tobacco/nicotine/vaping Irritability, attention and sleep problems, depression, increased appetite
Table 20.9 Substances and Their Associated Withdrawal Symptoms (Source: National Institute on Drug Abuse, 2020a.)

The Nurse’s Role in Managing Substance Misuse

The nursing process functions as a systematic approach to patient-centered care. The five steps of the nursing process include assessment, diagnosis, planning, implementation, and evaluation. This section applies the nursing process to care for a hospitalized patient with a substance use disorder (SUD) who receives withdrawal treatment.

Nursing Assessment

When assessing a patient for drug and alcohol misuse, the nurse should begin with a thorough history. The nurse should establish if the patient has any history of substance abuse, a history of withdrawal symptoms they have experienced in previous attempts to quit using, their treatment history, their mental health and social history, and any medical history of new physical symptoms they are experiencing.

In addition to the history, the patient’s lab values can provide much information about their current state of health. When evaluating a patient for substance or alcohol use disorder (AUD), there are certain labs that should be assessed (Table 20.10).

Lab Assessment
Complete blood count (CBC) Anemia, infections
Glucose Hyper/hypoglycemia
Serum electrolytes Potassium, magnesium, and phosphate abnormalities, particularly with severe dehydration
Creatinine Kidney function
Liver function Liver damage
Amylase and lipase Pancreatitis
Urine drug testing Current/recent use of specific substances, including benzodiazepines, cocaine, opioids
Blood alcohol levels Intoxication levels, abuse
Urine hCG Pregnancy (in patients of reproductive age)
ECG Cardiac function, complications (indicated for patients over age 50)
Table 20.10 Lab Assessments for SUD

Nursing Diagnosis

A nursing diagnosis is made by gathering and analyzing patient data, then using that data to construct a path forward for managing the patient’s current or potential symptoms. Through assessment, the nurse elicits subjective details from the patient about their substance use and observes objective information to create a full picture of the patient’s present state. In analysis, the nurse identifies risk and protective factors, behaviors, and other influences on the patient’s substance use.

There are a few common clinical scenarios the nurse may encounter when formulating a nursing diagnosis for a patient who is abusing substances. One example would be impaired coping, which is both a factor that contributes to the development of and a barrier to overcoming substance use. By identifying the patient’s need for more effective coping skills in the nursing diagnosis, the nurse starts putting together an action plan with interventions that will support the patient in developing healthy coping skills, reducing their reliance on substances, and preventing relapse. For example, the nurse may discuss coping skills and stress-management techniques with the patient, encourage them to take part in community resources such as support groups, and connect them with other healthcare providers such as therapists.

Outcome Identification

The nurse then considers the intended end result for the patient, or their future goal. An appropriately written goal is specific, measurable, attainable, realistic, and has a time/deadline (SMART). An example of a broad goal related to withdrawal would be that the patient will stabilize and remain free from injury. There are also some additional goals that the nurse may consider for the patient:

  • The patient’s vital signs will remain within normal ranges during treatment. The nurse regularly assesses the patient’s vitals to determine the response to treatment and quickly identify any signs of possible complications, such as hemodynamic instability.
  • The patient’s electrolyte levels will remain within normal ranges during treatment. As there can be electrolyte disturbances from various factors during withdrawal, such as dehydration, the nurse needs to monitor the patient carefully for signs of electrolyte abnormalities.
  • The patient will participate in planning a post-withdrawal treatment program before discharge. By actively engaging the patient in developing a post-hospital plan, the nurse is able to continue to assess the patient’s insight into substance use and their ability and willingness to comply with treatment. Involving the patient also gives them some agency in the decision-making process, which can help motivate them to meet their long-term goals (e.g., maintaining sobriety).

Nursing Interventions

When planning interventions for SUD, the nurse needs to approach it from a patient-centered view. Each patient will need an individualized plan, and there will be specific factors, barriers, and goals for each patient. Key considerations during the planning stage are the severity of the patient’s substance use, any other medical or mental health conditions they have, their level of support (social, financial), and how ready and able they are to commit to change.

The approach that the nurse takes to planning, as well as the interventions they select, will depend on these patient factors, as well as available resources. For example, a patient who demonstrates willingness to try to make changes but is hesitant may benefit from a more phased approach that “meets them where they are” in their current stage and gradually guides them to their long-term goal. The order in which the nurse plans interventions will, to some degree, be dictated by the acuity of the patient’s condition. In some circumstances, such as managing a patient who has more urgent needs related to drug overdose or self-harm, the nurse needs a more immediate action plan to ensure the patient’s safety.

The nurse needs to take an interdisciplinary and collaborative approach to planning that involves the patient’s support system, other healthcare providers, and community resources. This could include referrals for psychotherapy, connecting with local support groups, and following up with their primary care physician.

The specific interventions that the nurse includes will also depend on how feasible they are for a particular patient. For example, even if a patient is willing, there might be practical (such as transportation) or financial (such as healthcare) barriers to participating in community-based therapy that the nurse will need to consider. Another patient may have multiple medical conditions that need to be managed at the same time as they are working toward their goal of sobriety. Some patients may not have support from their family and friends, which presents challenges to their long-term goal of abstaining from substances. If a patient has loved ones who are still using substances, this can present a risk factor for relapse that the nurse needs to proactively plan to prevent.

Clinical Judgment Measurement Model

Analyze Cues: Determining Patient Needs

A 42-year-old male patient with a history of excesssive alcohol use is brought to the unit after being found unresponsive at home by his neighbor. The nurse’s first task is to determine the patient’s immediate needs by assessing vital signs, checking labs, and reviewing the EHR for medical and social history.

Based on the patient’s presentation (tachycardia, tremors), history (chronic alcohol use with previous attempts to stop drinking), and lab results (elevated blood alcohol level on admission), the nurse understands that the patient is in symptomatic alcohol withdrawal.

The nurse formulates the next steps in providing care based on the patient’s immediate needs for safety and symptom management.

Nursing interventions provide a supportive environment while the patient undergoes withdrawal treatment. Vital signs are monitored closely because increases in temperature, pulse, and blood pressure are signs of withdrawal. After ensuring that an individual’s physiological needs of airway, breathing, and circulation are met, safety measures receive top priority. Safety measures during withdrawal treatment may include interventions such as fall precautions, seizure precautions, or implementing restraints as needed to maintain the safety of the individual or those around them.

Clinical Safety and Procedures (QSEN)

QSEN Competency: Applying an Extremity Restraint

See the competency checklist for Applying an Extremity Restraint. You can find the checklists on the Student resources tab of your book page on openstax.org.

Evaluation

Evaluation involves assessing the individualized outcomes related to the effectiveness of symptom management and the withdrawal treatment plan. In the evaluation stage, the nurse looks at the patient’s goal and uses the details and timeline to assess whether the goal has been met. The nurse needs to ask questions such as, “Did the patient do the activity or meet the specific guidelines? Were they able to do them within the timeline?”

For example, if the goal was for the patient to have vital signs within normal limits while in the hospital, the nurse investigates whether the patient’s vital signs every day that they were in the hospital had been within normal range. If the measurements were all normal, then the goal was met. If the measurements were abnormal, then the goal was not met. If the goal was met, no further action is needed. If the goal was not met, the nurse must revise the interventions and make a new goal for the patient.

Patient Education

Patient education is a vital step in the nursing process that involves providing patients with the information they need to make informed decisions about their health. The goal of patient education is to assist patients in understanding their medical conditions, treatment options, and important self-care measures they can employ to promote better health outcomes. Throughout this process, patients are empowered to take an active role in managing their health (Paterick et al., 2017).

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