Substance Use Assessment: Ch. 6 Flashcards
What are the “illicit drugs”?
- Marijuana
- Cocaine
- Heroin
- Methamphetamine
- Hallucinogenics
- Inhalants
- Nonmedical use of psychotherapeutics (prescription pain relievers, tranquilizers, stimulants, and sedatives)
what are the drink/day range for men and women?
what are the chronic health risks?
- Women: >1 drink/ day
Men: >2drinks/ day - wait until they are sober to question
- Chronic: hypertension, heart disease, and stroke; the cancers listed earlier plus liver and colorectal cancer; mental illness such as depression and anxiety; learning and memory dysfunction
CAGE
- Cut down: ever wanted to cut down
- Annoyed: that friends/ family suggested you cut down
- Guilty
- Eye-opener: have you ever had a drink in the morning?
Yes to >2 questions signals possible abuse.
AUDIT
what is it
what does it assess
what is the score cut off= indicating hazardous drinking
A quantitative form has the advantage of letting you document a number for a response so it is not open to individual interpretation.
Assesses: alcohol consumption, drinking behavior or dependence, and adverse consequences from alcohol
A cut off point of ≥8 points for men or ≥4 points for women. Adolescents, and those older than 60 years indicates hazardous alcohol consumption.
what would a nurse say to Advise and Assist a patients who abuses alcohol?
“you are drinking more than is medically safe.”
“I strongly recommend that you cut down or quit, and I am willing to help.”
**Always document that you gave advice
SMAST-G
who is the test for
what score indicates an alcohol problem?
Questionnaire for older adults who report social or regular drinking of any amount of alcohol.
A score ≥2 points indicates an alcohol problem and a need for more in-depth assessment.
what time frame qualifies a patient to be in early remission:
Sober for >3 months but < 12 months
(with the exception that “Craving, or a strong desire or urge to use alcohol,” may still exist.
what time frame qualifies a patient to be in sustained remission:
Sober for > 12 months (with the exception that “Craving, or a strong desire or urge to use alcohol,” may still exist.
TWEAK
what does it stand for?
who is it made for?
Help ID at-risk drinking in pregnant women.
-Tolerance: How many drinks until you feel high? (≥3 drinks to feel high = Tolerance)
- Worry: Have close friends or relatives worried or complained about your drinking in the past year?
- Eye-opener: Do you sometimes take a drink in the morning when you first get up?
- Amnesia: Has a friend or family member ever told you about things you said or did that you could not remember?
- Kut down: Do you sometimes feel the need to cut down on your drinking?
A Scoring ≥2 points = a drinking problem
-Per the CDC “no amount of alcohol consumption has been determined safe in pregnancy”
Alcohol Withdrawal (objective data)
what are the symptoms?
what is the biggest risk?
The most dangerous substance to withdraw from b/c of the risk of seizures
Increased vital signs Tremors Delirium Hallucinations Poor attn. span Disorientation
Nystagmus
Eyes shake
CIWA
what does it measure?
Clinical Institute Withdrawal Assessment
-It is quantified to measure the progress of withdrawal
-Take the vital signs: blood pressure (BP), pulse, respirations, oxygen saturation. Assess and rate each of the 10 criteria of the CIWA scale
- Scores of 0 to 9 = absent or minimal withdrawal
- 10 to 19 = mild-to-moderate withdrawal
- ≥20 = severe withdrawal.
- If initial score is ≥8, take vital signs every hour for 8 hours.
- A score of 8 may trigger PRN medication.
- A score of ≥15 triggers scheduled medication.
-If all the scores are <8 for 72 hours, you can safely discontinue use of the CIWA assessment.
Opioid Withdrawal (objective data)
what are the symptoms
what are the risks
The most challenging substance to withdraw from.
flu-like symptoms Agitation Increased vital signs Dilated pupils Bradypnea
Death due to bradypnea (they just stop breathing)
