MK Lecture 2: Alcoholism, Psychodynamics, Drug Abuse, and Aminoglycosides

Psychological Aspects of Alcoholism and Abuse

• The Number One Problem: The primary psychological problem in alcoholism, and indeed in any and all abusive situations (including child abuse, gambling, cocaine abuse, spouse abuse, and elder abuse), is denial.

  • Function of Denial: It allows the abuser to continue the behavior without having to answer for it by refusing to recognize the problem.
  • Definition: Denial is the refusal to accept the reality of a problem.
  • Treatment of Denial: The strategy is to confront it.
    • Confrontation Strategy: Point out the difference between what the person says and what they actually do.
    • Examples of Confrontation:
      • A patient says they are not an alcoholic, but they have finished a six-pack by $10:00$ in the morning.
      • A patient says they are not a spouse abuser, but there is a restraining order against them.
      • A patient says they are not a child abuser, but Protective Services has taken their children.
      • A patient claims to have a thyroid issue, but they are $5$‑foot‑$1$ and weigh $400~\text{pounds}$.
  • Aggression vs. Confrontation: Aggression attacks the person (e.g., "You are an alcoholic jerk; admit it!"). Confrontation attacks the problem by stating observations without judgment of right or wrong.
  • Interacting with Staff/Physicians:
    • Use "I" statements rather than "You" statements.
    • Bad: "Why don't you like me?" or "You wrote the order incorrectly."
    • Good: "I seem to be having a problem," or "I am having a difficult time interpreting exactly what you want."

• Denial in Loss and Grief:

  • DABDA Stages: Denial, Anger, Bargaining, Depression, Acceptance.
  • Approach: Unlike abuse, denial in loss and grief is a healthy, normal first reaction. You should support it rather than confront it.
  • The Farmer Example: A farmer loses his hand in a baler accident. The next morning, he says he cannot wait to go home and play the piano. Since this is loss, you support the denial by asking about his piano playing or favorite music rather than pointing out he only has one hand.

Dependency, Codependency, and Manipulation

• Dependency: This occurs when the abuser gets a significant other to do things for them or make decisions for them (e.g., "Call my boss and tell him I am sick").

  • The Abuser: Is the dependent party.

• Codependency: This occurs when the significant other derives positive self-esteem from making decisions for or doing things for the abuser.

  • Pathology: It is a symbiotic relationship where the abuser avoids responsibility and the significant other feels good about themselves for being "the only one who can handle" the abuser.
  • Treatment:
    1. Set limits and enforce them (saying "No").
    2. Work on the self-esteem of the codependent person.
  • Outcome: Frequently, treating codependency successfully leads to the loss of the relationship because the codependent person realizes they do not need the abuser for self-esteem.

• Manipulation:

  • Definition: The abuser gets a significant other to do things that are NOT in the best interest of the significant other.
  • Distinction: If the act requested is neutral (no harm, no foul), it is dependency. If the act is inherently harmful, dangerous, or illegal, it is manipulation.
  • Example (Dependency vs. Manipulation):
    • Dependency: A $49$‑year‑old asks a $50$‑year‑old spouse to buy alcohol.
    • Manipulation: A $49$‑year‑old asks a $17$‑year‑old daughter to buy alcohol (it is illegal for the minor).
  • Treatment: Set limits and enforce them. Manipulation is easier to treat than codependency because no one likes being manipulated; there is no positive self-esteem involved.

• Patient Count Summary:

  • Denial: $1$ patient.
  • Dependency/Codependency: $2$ patients (must treat both).
  • Manipulation: $1$ patient.

Wernicke’s and Korsakoff’s Syndrome

• Nature:

  • Wernicke’s: Encephalopathy.
  • Korsakoff’s: Psychosis.
  • Combined: A thiamine (Vitamin $B_1$) deficiency-induced psychosis that results in a loss of touch with reality.

• Primary Symptoms: Amnesia with confabulation (making up stories to fill memory gaps).

  • The patient believes the lies as if they were reality.
  • Example: A man with a third-grade education believes he was Ronald Reagan’s National Security Adviser and can provide dates and meeting details.

• Management:

  • Rule: Do not confront or present reality, as the patient has brain damage and cannot learn it.
  • Strategy: Redirect the patient into something they can do (e.g., if they think they have a cabinet meeting, suggest they shower first and then watch CNN for news from Washington D.C.).

• Characteristics:

  • Preventable: By taking Vitamin $B_1$. Vitamin $B_1$ is a coenzyme necessary for the metabolism of alcohol. Without it, alcohol goes to the brain and destroys cells.
  • Arrestable: You can stop it from getting worse by taking $B_1$. The patient does not necessarily have to stop drinking to stop the progression.
  • Irreversible: Approximately $70\%$ of cases are permanent.

Alcoholism Medications: Antabuse and Revia

• Generic Name: Disulfiram.
• Aversion Therapy: Designed to create a gut-level hatred for alcohol. If the patient drinks, the chemical interaction in their blood makes them deathly ill.
• Onset and Duration: It takes $2~\text{weeks}$ of taking the drug to reach therapeutic levels and $2~\text{weeks}$ of being off the drug before it is safe to drink again.
• Patient Teaching (Avoidance List):
  • Mouthwash (even if spat out).
  • Aftershaves, perfumes, and colognes (topical absorption causes nausea).
  • Insect repellents (mosquito sprays containing alcohol).
  • Elixirs (over-the-counter liquid medications like NyQuil, DayQuil, Tylenol PM, etc.).
  • Alcohol-based hand sanitizers.
  • Uncooked/No-bake icings (containing vanilla extract).
  • Note: Patients can have red wine vinaigrette (it does not contain enough alcohol to trigger the reaction).

Drug Overdose and Withdrawal

Step 1: Identify Upper vs. Downer

• Uppers: Caffeine, Cocaine, PCP/LSD, Methamphetamines, and Adderall.
  • Signs/Symptoms: Everything goes up—Euphoria, tachycardia, restlessness, irritability, borborygmi, diarrhea, spasticity, and hyperreflexia (reflexes of $3+$ or $4+$). Seizures are the primary risk.
• Downers: Everything else (Morphine, Heroin, Valium, Xanax, Ativan, Alcohol, etc.).
  • Signs/Symptoms: Everything goes down—Lethargy, bradycardia, respiratory depression/arrest.

Step 2: Determine Overdose vs. Withdrawal

• Overdose (Intoxication): Too much of the drug.

  • Upper Overdose: Everything goes UP.
  • Downer Overdose: Everything goes DOWN.

• Withdrawal: Not enough of the drug.

  • Upper Withdrawal: Everything goes DOWN (looks like Downer Overdose).
  • Downer Withdrawal: Everything goes UP (looks like Upper Overdose).

• Critical Nursing Actions:

  • Highest priority for respiratory arrest: Downer Overdose and Upper Withdrawal.
  • Highest priority for seizure: Upper Overdose and Downer Withdrawal.

Drug Addiction in the Newborn

• Assessment Rules:
  • At birth and within the first $24~\text{hours}$, always assume intoxication.
  • After $24~\text{hours}$ of life, assume withdrawal.
• Example Case: A baby born to a Quaalude-addicted mother $24~\text{hours}$ ago.
  • Quaaludes are downers.
  • $24~\text{hours}$ signifies withdrawal.
  • Withdrawal from a downer means everything goes UP.
  • Symptoms: Difficult to console, exaggerated startle reflex, seizure risk, shrill high-pitched cry.

Alcohol Withdrawal Syndrome (AWS) vs. Delirium Tremens (DTs)

• AWS: Occurs in every alcoholic within $24~\text{hours}$ after stopping. It is not life-threatening and the patient is not dangerous.
• DTs: Occurs in a minority ($< 20\%$) of alcoholics exactly $72~\text{hours}$ after stopping. It is life-threatening and the patient is dangerous (unstable).

• Restraint Protocols:
  • $2$-point locked leathers involve one arm and the opposite leg.
  • Rotate extremities every $2~\text{hours}$. Check frequently.
• Medications for Both:
  • Antihypertensives: Because everything is going up (withdrawal from a downer).
  • Tranquilizers: Same reason.
  • Multivitamin with $B_1$: To prevent Wernicke-Korsakoff syndrome ("No $B_1$, you become one").

Aminoglycosides: "Mean Old Mycins"

• Usage: The "big guns" for serious, resistant, life-threatening, Gram-negative infections (e.g., septic peritonitis, fulminating pyelonephritis).
• Suffix Rule: All aminoglycosides end in -mycin.
  • The Exception: If the drug has "thro" in it, it is not an aminoglycoside (e.g., Erythromycin, Clarithromycin, Azithromycin). "Thro it off the list."
• Toxicities:
  1. Ototoxicity: Think of ears (mice ears). Monitor hearing, tinnitus, and vertigo.
  2. Nephrotoxicity: The ear is shaped like a kidney. Monitor creatinine (24-hour creatinine clearance is best; serum creatinine is second best).
• Administration: Every $8~\text{hours}$. Damages Cranial Nerve $8$.
• Routes:
  • IM or IV: For systemic infections.
  • PO: Only in two cases for "bowel sterilization" because it is not absorbed into the bloodstream.
    1. Hepatic encephalopathy (to kill $E.\text{coli}$ and lower ammonia levels).
    2. Pre-op bowel surgery.
• Oral Bowel Sterilizers: Neomycin and Kanamycin. Remember the cadence: "Who can sterilize my bowel? Neo-Can!"

Troughs and Peaks (TAP Levels)

• Purpose: Used for drugs with a "narrow therapeutic window" (a small difference between therapeutic and toxic doses).
• Troughs (All Routes): Always draw $30~\text{minutes}$ prior to the next dose.
• Peaks (Route Dependent):
  • Sublingual: $5‑10~\text{minutes}$ after drug dissolves.
  • IV: $15‑30~\text{minutes}$ after the bag is finished.
  • IM: $30‑60~\text{minutes}$.
  • Subcutaneous: See diabetes/insulins (variable).
  • PO: Not tested (too variable).
• Selection Rule: If two answers fall within the correct range (e.g., $15$ and $30~\text{minutes}$ for IV), pick the highest without going over ($30~\text{minutes}$). This rule applies broadly to NCLEX questions (e.g., antidepressants taking $2‑4~\text{weeks}$, or nighttime potty training occurring between $3‑5~\text{years}$).