MODULE 22: CONCEPT OF ADDICTION

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MODULE 22: CONCEPT OF ADDICTION

Case Study: Parts 1, 2, & 3

Case Study, Part 1 Paul is the 19-year-old son of Mark and Susan John. The Johns have been married for 20 years. Mrs. Johns is a full-time stay-at-home mom. Paul’s dad is a corporate attorney who has always been somewhat demanding of his wife and children. He drinks alcohol daily, but has always been employed and has maintained a middle-class lifestyle for his family. Paul has two younger sisters: Mara, the younger of the two, has been treated for anorexia since the age of

• His 15-year-old sister, Jess, is doing well in high school. Paul did well in high school,

where he played varsity soccer and did fairly well academically.Paul has just returned home from his first full year at college. His mother is concerned because he doesn’t seem like his old self; he shows no interest in his old friends or in getting a summer job. On the other hand, he seems secretive and has left the house on many occasions claiming that he has new friends who “get it.” He is very short tempered with his sisters, constantly irritable and discontent. He is very evasive when asked about his grades or any college activities. He has noticeable weight loss and appears unkempt. His father is intolerant of his behavior. His mother is concerned and has arranged to accompany him on a visit to his primary care provider. She is hoping to find out what his problem is so it can be treated before his father becomes angrier with him and his behavior. You are the nurse who is assessing Paul.Question 1 Describe the elements of the interview/assessment environment that you should consider before beginning Paul’s patient assessment.Answer 1

• The physical environment should be calm, quiet, and private.
• Confidentiality is essential; you will need to explain to Paul’s mother that you need to

spend some time alone with Paul to get some information and get to know him.

• Plan for enough time to establish rapport with Paul.
• Review the steps of beginning a therapeutic relationship.

Question 2 What questions would be appropriate in assessing Paul’s physiologic, emotional, and psychologic status?Answer 2

• After establishing rapport, provide Paul broad openings by asking questions such as:
• “Tell me why you are seeing the (primary care provider) today?”
• “How have you been feeling lately?”
• “Are you having any physical problems?”
• “Any changes since you went away to college?”
• Use therapeutic communication to convey interest and elicit more information:
• “You say your parents are worried about you. Why do you think they’re

worried?”

• “What do you think is contributing to your trouble sleeping?”

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• “You seem angry. Can you tell me how you’re feeling?”
• “I notice you look a little disheveled today.”

Question 3 What elements of the family history might indicate a potential for substance use or abuse in Paul?Answer 3

• Paul’s dad drinks alcohol daily.
• There is evidence of ineffective or maladaptive coping in the home; for example, his

father’s anger and his sister’s eating disorder.

• His mom demonstrates codependent behaviors.

Question 4 If substance abuse is suspected, how should you proceed to address any ego defense mechanisms displayed?Answer 4 Confront the observations calmly, clearly, and without blame. For example, denial is common.If Paul denies that there is anything wrong, concretely point out his amount of weight loss and indications of his lack of hygiene.Question 5 What diagnostic measures might be needed based on your assessment?Answer 5

• A complete history and physical examination to assess state of health.
• Ask about use of all substances, legal and illegal. If alcohol abuse is suspected, use the

CAGE questionnaire.

• Complete family history related to any history of addiction. Include all forms of substance

addictions including drugs, alcohol, caffeine, and nicotine. Explore family history of eating disorders, including obesity, and history of process addictions such as sex, gambling, shopping, and work.

• Laboratory studies include routine CBC, blood chemistry, and urinalysis. Appropriate

toxicology studies and serum blood levels may be ordered. Urine, saliva, and serum testing may be orders to identify some metabolites. Hair testing may also be ordered to assess the for specific substance use in the past 90 days.Question 6 If depression is suspected, what further assessments would you perform?Answer 6

• The nurse should ask specific questions related to mood and affect. Ask how Paul has been

feeling at home, at school, with friends, with specific family members.

• Ask specific questions about substance use at school and home. Use the CAGE

questionnaire. 2 / 4

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• The nurse should always perform a lethality screening during the initial interview if the

patient is suspected to be a danger to himself or others. A simple question such as, “Have you thought about hurting yourself?” can start the process.

• Information obtained on initial assessment should be promptly discussed with the

primary care provider and addressed in the treatment plan.

• Most college campuses offer free counseling to students. Encourage Paul to seek

counseling at school or at home.Case Study, Part 2 Paul is admitted to the emergency department (ED) at 2 a.m. on a Sunday morning in August as the result of a motor vehicle crash. His speech is slurred and his gate is ataxic. He is bleeding from a laceration on his left forehead and he is complaining that his left arm is extremely painful and “falling off.” A decision is made to admit Paul to the trauma unit. His father, as next of kin, is notified of the admission. His father states, “I knew this would happen.Let him rot.” Paul becomes combative as you attempt to assess his state of consciousness and physical injuries.Question 1 You suspect substance use. What are your immediate concerns?Answer 1 Although the nurse will want to address Paul’s injuries and evidence of intoxication, the immediate safety of the patient and the staff is of high priority when a patient becomes combative or aggressive. After ensuring the safety of Paul and the staff, prioritize physiologic needs and then psychologic needs.Question 2 How will you promote Paul’s cooperation with your assessment and eventual treatment?Answer 2

• Control the therapeutic milieu. Move to a location where noise and confusion can be

minimized.

• Approach Paul in an unhurried and nonjudgmental manner. Speak calmly and clearly.
• Introduce yourself. Call him by name. Use short, concrete statements.
• Decrease his anxiety. Reassure him he is safe.

Question 3 What specific diagnostic tests will be appropriate related to both his suspected substance use and his physical injuries?Answer 3

• Blood alcohol levels and serum levels specific to any specific drug use.
• Skull, left arm, and shoulder x-rays.
• A CAT scan or MRI of the head may be ordered.

Question 4 Refer to Module 49, Legal Issues: Are you able to begin assessment and treatment of Paul without consent from next-of-kin? What are the legal implications in this situation? 3 / 4

Nursing: A Concept-Based Approach to Learning, 4e Copyright © 2023 by Pearson Education, Inc. All rights reserved.Answer 4

• Paul is 19 years of age. He is able to consent to treatment if he is believed to be

cognitively intact.

• You may begin treatment and intervention on an emergency basis without consent.

Question 5 Paul’s mother arrives in the ED. She is very upset and demanding to see him. Will you involve Paul’s mother in his care? Why or why not?Answer 5

• Tell Paul, calmly, that his mother is in the ED and asking to see him. If he agrees to see

her, you should provide emotional support to her and escort her to see Paul.

• Paul is an adult patient, and he has the right to decide who his medical information may

be shared with.

• Paul must consent to having his medical information shared with his mother. If he

consents verbally, you may include her in Paul’s care. You should get Paul’s written consent to release information to his mother as soon as possible.Case Study, Part 3 It is 36 hours post-ED admission and Paul is being transferred from the trauma unit to a semiprivate room on a general medical-surgical unit. The scalp laceration is healing; there is no evidence of further head injury. Paul’s right humerus was fractured in the crash and a cast applied following a closed reduction. Laboratory studies revealed a blood alcohol level of 0.28 on admission. Paul now appears mildly anxious, and has a mild visible tremor of his hands.He is being prepared for discharge tomorrow. Admission to a substance abuse treatment program is being considered.Question 1 List at least three nursing diagnoses that would apply to Paul.Answer 1

• Potential alteration in safety related to alcohol withdrawal.
• Alteration in family relationships related to physical and emotional consequences of

substance abuse.

• Self-care deficit related to cast on right arm.

Question 2 What members of the interprofessional (IP) healthcare team should be involved in Paul’s care and discharge planning? Delineate the role of each team member.Answer 2

• Primary Care RN: Overall nursing and care coordination of inpatient treatment

activities.

• Primary Care Provider: Management and coordination of Paul’s overall treatment,

including the treatment team, discharge, and follow-up plans.

• Registered Dietician/Nutritionist: Working with Paul and his family to improve

nutritional status.

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