Care of Clients with Maladaptive Patterns of

Behavior, Acute and Chronic

INSTRUCTOR’S GUIDE BS NURSING / THIRD YEAR
Session # 22

LESSON TITLE: SUBSTANCE ABUSE Materials:

Textbook, Notebook, Bondpaper, Pen and Paper,
LEARNING OUTCOMES:
References
At the end of the lesson, the nursing student can:

1. Identify and differentiate the signs and symptoms of Videbeck, S. L. (2014). Mental and Psychiatric
substance abuse and dependence. Health Nursing. 6th Edition. Lippincott, Williams
2. Evaluate the short-term and long-term effects of substance and Wilkins. Philadelphia, PA.
abuse on physical and mental health
3. Demonstrate proficiency in using standardized screening Merk Manual (2021). Retrieved from
tools and assessments related to substance abuse [Link]
4. Create and implement individualized, evidence-based health-disorders /substance-related-
treatment plans for patients with substance abuse disorders disorders/substance-use-disorders

LESSON REVIEW / PREVIEW & HOOK ACTIVITY (15 minutes)

Instruction: On the spaces provided, write 3 key words that have earned your interest on Substance Abuse. Below each
word, provide a brief explanation.

1. _______________________

Explanation: ___________________________________________________

2. _______________________

Explanation: ___________________________________________________

3. _______________________

Explanation: ___________________________________________________

MAIN LESSON (1 hour)

Substance Abuse
➢ Using a drug in a way that is inconsistent with medical and social norms and despite negative consequences.
➢ Some substances can be obtained legally such as alcohol and prescription medications, others are illegal such as
illegal drugs.
➢ Denotes problems in social, vocational, or legal areas of the person’s life.

Important Terms
1. Polysubstance Abuse: abuse of more than one substance such as abuse of different kinds of illegal drugs or combining
abuse of prescription medications and illegal drugs

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2. Substance dependence: refers to the persistent use of alcohol or other psychoactive drugs despite problems caused by
such use. Involves compulsive use or addiction. Can cause significant withdrawal symptoms when drug use is reduced
or stopped completely.
3. Tolerance: decreased response to a drug that occurs with repeated use. A user who develops a tolerance to the rewarding
properties of the abused drug must take increasingly higher amounts to get the desired effect.
4. Withdrawal: an uncomfortable syndrome that occurs when tissue and blood levels of the abused substance heavily over
prolonged period. Withdrawal symptoms may abuse the person to resume taking the substance to relieve the symptoms,
thereby contributing to repeated drug use.
5. Intoxication: a reversible, substance-specific syndrome caused by ingestion of or exposure to that substance.
6. Detoxification: the process of safely withdrawing from a substance

Etiology/Risk Factors
1. Biologic Factors: children of alcoholic parents are at higher risk for developing alcoholism and drug dependence than
are children of non-alcoholic parents. Several studies of twins have shown a higher rate of concordance (when one twin
has it, the other twin gets it) among identical than fraternal twins.
2. Psychological Factors: children of alcoholics are four times as likely to develop alcoholism compared to the general
population. Some theorists believe that inconsistency in the parent’s behavior, poor role modeling, and lack of nurturing
pave the way for the child to adopt a similar style of maladaptive coping, stormy relationships, and substance abuse.
3. Social and Environmental Factors: cultural factors, social attitudes, peer behaviors, laws, cost, and availability all
influence initial and continued use of substances. In general, younger experimenters use substances that carry less
social disapproval such as alcohol and cannabis, whereas older people use drugs such as cocaine and opioids that are
more costly and rate higher disapproval.

Types of Substances and Treatment

Substance Signs and Symptoms of Intoxication Treatment – Withdrawal and Detoxification
and Overdose
Alcohol Slurred speech, unsteady gait, lack of • Withdrawal symptoms begin 4-12 hours after
coordination, impaired attention, stopping or marked reduction of alcohol intake
concentration, memory and judgment, (tremors, sweating, elevated pulse and BP,
aggressive or inappropriate sexual insomnia, anxiety, hallucinations, delirium,
behaviors, vomiting, unconsciousness seizures – peaks in 2 days, ends in 5 days)
and respiratory depression • Detoxification is under medical supervision – safe
withdrawal is accomplished with medications:
Benzodiazepines (Lorazepam, Diazepam) to
suppress withdrawal symptoms

Sedatives, Hypnotics, Slurred speech, lack of coordination, • The onset of withdrawal symptoms depends on
Anxiolytics unsteady gait, labile mood, lethargic, the half-life of the drug. Medications, such as
confused, impaired attention or lorazepam, whose actions typically last about 10
memory, and even stupor and coma. hours produce withdrawal symptoms in 6 to 8
hours; longer acting medications such as
diazepam may not produce withdrawal symptoms
for 1 week. The withdrawal syndrome is
characterized by symptoms that are the opposite
of the acute effects of the drug: increased pulse,
blood pressure, respirations, and temperature,
hand tremor, insomnia, anxiety, nausea, and
psychomotor agitation. Seizures and
hallucinations occur only rarely in severe
benzodiazepine withdrawal
• Detoxification from sedatives, hypnotics, and
anxiolytics is often managed medically by tapering
the amount of the drug the client receives over a
period of days or weeks, depending on the drug
and the amount the client had been using.

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 • Tapering: administering decreasing doses of a
medication, is essential with barbiturates to
prevent coma and death that will occur if the drug
is stopped abruptly.

Stimulants (Cocaine, High or euphoric feeling, hyperactivity, • Withdrawal from stimulants occurs within a few
Amphetamines, hypervigilance, talkativeness, anxiety, hours to several days after cessation of the drug
Others) grandiosity, hallucinations, stereotypic and is not life threatening. Marked dysphoria is
or repetitive behavior, anger, fighting, the primary symptom and is accompanied by
and impaired judgment, tachycardia, fatigue, vivid and unpleasant dreams, insomnia
elevated blood pressure, dilated pupils, or hypersomnia, increased appetite, and
perspiration or chills, nausea, chest psychomotor retardation or agitation.
pain, confusion, and cardiac • Marked withdrawal symptoms are referred to as
dysrhythmias, seizure, coma “crashing;” the person may experience
depressive symptoms including suicidal ideation
for several days. Stimulant withdrawal is not
treated pharmacologically.
Cannabis (Marijuana) High feeling similar to that with alcohol, • Some people have reported withdrawal
lowered inhibitions, relaxation, symptoms of muscle aches, sweating, anxiety,
euphoria, and increased appetite, and tremors, no clinically significant withdrawal
impaired motor coordination, syndrome is identified
inappropriate laughter, impaired
judgment and short-term memory, and
distortions of time and perception;
anxiety, dysphoria, and social
withdrawal may occur in some users.
Opioids (Morphine, Apathy, lethargy, listlessness, impaired • Naloxone (Narcan) is treatment of choice for
Heroin) judgment, psychomotor retardation or opioid toxicity
agitation, constricted pupils, • Opioid withdrawal develops when drug intake
drowsiness, slurred speech, and ceases or decreases markedly, or it can be
impaired attention and memory, precipitated by the administration of an opioid
respiratory depression, pupillary antagonist. Initial symptoms are anxiety,
constriction, unconsciousness, and restlessness, aching back and legs, and
cravings for more opioids. Symptoms that
death.
develop as withdrawal progresses include
nausea, vomiting, dysphoria, lacrimation,
rhinorrhea, sweating, diarrhea, yawning, fever,
and insomnia.
• Methadone can be used as a replacement for the
opioid, and the dosage is then decreased over 2
weeks. Substitution of methadone during
detoxification reduces symptoms to no worse
than a mild case of flu. Withdrawal symptoms
such as anxiety, insomnia, dysphoria,
anhedonia, and drug craving may persist for
weeks or months.

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Hallucinogens (Ecstasy, Anxiety, depression, paranoid • No withdrawal syndrome has been identified for
LSD) ideation, ideas of reference, fear of hallucinogens, although some people have
losing one’s mind, and potentially reported a craving for the drug. Hallucinogens
dangerous behavior such as can produce flashbacks, which are transient
jumping out a window in the belief recurrences of perceptual disturbances like those
that one can fly, sweating, experienced with hallucinogen use. These
tachycardia, palpitations, blurred episodes occur even after all traces of the
vision, tremors, and lack of hallucinogen are gone and may persist for a few
coordination, belligerence, months up to 5 years.
aggression, impulsivity, and
unpredictable behavior.

Pharmacologic Treatment
• Alcohol withdrawal usually is managed with a benzodiazepine anxiolytic agent, which is used to suppress the
symptoms of abstinence.
• Disulfiram (Antabuse) may be prescribed to help to deter clients from drinking. If a client taking disulfiram drinks
alcohol, a severe adverse reaction occurs with flushing, a throbbing headache, dizziness, sweating, nausea, and
vomiting.
• Methadone, a potent synthetic opiate, is used as a substitute for heroin in some maintenance programs. The client
takes one daily dose of methadone, which meets the physical need for opiates but does not produce cravings for
more.
• Levomethadyl is a narcotic analgesic whose only purpose is the treatment of opiate dependence. It is used in the
same manner as methadone.
• Naltrexone (ReVia) is an opioid antagonist often used to treat overdose. It blocks the effects of any opioids that
might be ingested, thereby negating the effects of using more opioids.
• Clonidine (Catapres) is an alpha-2-adrenergic agonist used to treat hypertension. It is given to clients with opiate
dependence to suppress some effects of withdrawal or abstinence.

Support Groups for Substance Abusers

1. Al-Anon Family Groups: Support services for adults who abuse alcohol, adults who grew up with an alcoholic,
and teens affected by someone else's problematic use of alcohol.
2. Alcoholics Anonymous: International fellowship of people with a drinking problem that pioneered the 12-step
approach to help its members overcome their addiction to alcohol and help others to do the same.
3. Dual [Link]: Access to resources for people with mental illness and problems with substance abuse,
including a list of treatment facilities that offer integrated care, information on research, and publications.
4. Hazelden Betty Ford Foundation: Nonprofit treatment provider for alcohol and drug addiction with information on
treatment options, recovery advocacy programs, and educational opportunities in addiction counseling.
5. LifeRing: Support for people with drug and alcohol use problems by facilitating sharing of practical experiences
and sobriety support as an alternative to traditional 12-step programs.
6. National Alliance on Mental Illness (NAMI): A national mental health organization that provides advocacy,
education, support, and public awareness programs and services.
7. Narcotics Anonymous World Services: Helps people combat addiction, regardless of the substance that caused
it, through a 12-step program similar to that used by Alcoholics Anonymous.

Health Teaching to Client and Family

1. Substance abuse is an illness.
2. Dispel myths about substance abuse.
3. Abstinence from substances is not a matter of willpower.
4. Any alcohol, whether beer, wine, or liquor, can be an abused substance.
5. Prescribed medication can be an abused substance.
6. Feedback from family about a return to previous maladaptive coping mechanisms is vital.
7. Continued participation in an aftercare program is important.

Nursing Interventions
1. Health teaching for the client and family
2. Dispel myths surrounding substance abuse

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 3. Decrease co - dependent behaviors among family members
4. Make appropriate referrals for family members
5. Promote coping skills
6. Role-play potentially difficult situations
7. Focus on the here-and-now with clients
8. Set realistic goals such as staying sober today

CASELET: Alcohol Withdrawal

Background

In the harmonious city of Bacolod, a 40-year-old man named Ramon seeks treatment at a local hospital due to severe
alcohol withdrawal symptoms. Ramon, a former overseas Filipino worker (OFW), has returned to the Philippines after 15
years abroad and is struggling to readjust to life back home.

The Case of Ramon

Ramon's experience with Alcohol Withdrawal is influenced by several unique factors:

1. Overseas Filipino Worker (OFW) Experience: Ramon worked as a construction worker in the Middle East for 15
years, sending money back to his family in the Philippines. His return has been met with mixed emotions, including
feelings of displacement and difficulty reconnecting with his family.
2. Cultural Beliefs and Social Pressures: Filipino culture has a strong drinking culture, especially in social
gatherings and celebrations. As an OFW, Ramon often felt pressure to drink with colleagues and friends as a way
to bond and cope with stress.
3. Economic Stress: Despite years of work abroad, Ramon faces financial challenges and struggles to find stable
employment in the Philippines. This stress has exacerbated his alcohol use as a way to cope with uncertainty and
anxiety.
4. Family Expectations: Ramon's family has high expectations of him due to his years of working abroad. He feels
pressure to provide financial support and live up to their expectations, which has contributed to his stress and
drinking habits.
5. Social Stigma: Alcoholism and mental health issues are often stigmatized in Filipino culture, making it challenging
for individuals like Ramon to seek help or talk openly about their struggles.

Questions

1. How can psychiatric nurses assess and diagnose Alcohol Withdrawal in a culturally sensitive manner?
2. What nursing interventions can be done to help Ramon manage his alcohol withdrawal symptoms?
3. How can nurses collaborate with Ramon's family to address his Alcohol Withdrawal?

CHECK FOR UNDERSTANDING (10 minutes)

You will answer and rationalize this by yourself. This will be recorded as your quiz. One (1) point will be given to the correct
answer and another one (1) point for the correct rationale. Superimpositions or erasures in your answer/rationale are not
allowed. You are given 10 minutes for this activity:

Multiple Choice

1. Nurse Alvin has observed a co-worker arriving to work drunk at least three times in the past month. Which action by
Nurse Alvin would best ensure client safety and obtain necessary assistance for the co-worker?
A. Ignore the co- worker’s behavior, and frequently assess the clients assigned to the co-worker.
B. Make general statements about safety issues at the next staff meeting.
C. Report the coworker’s behavior to the appropriate supervisor.
D. Warn the co-worker that this practice is unsafe.

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ANSWER: _____
RATIONALE: ______________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

2. Nurse Aly is teaching a client about Disulfiram (Antabuse), which the client is taking to deter his use of alcohol. She
explains that using alcohol when taking this medication can result in:
A. Abdominal cramps and diarrhea.
B. Drowsiness and decreased respiration.
C. Flushing, vomiting, and dizziness.
D. Increased pulse and blood pressure.
ANSWER: _____
RATIONALE: ______________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

3. The community nurse practicing primary prevention of alcohol abuse would target which groups for educational efforts?
A. Adolescents in their late teens and young adults in their early twenties
B. Elderly men who live in retirement communities
C. Women working in careers outside the home
D. Women working in the home
ANSWER: _____
RATIONALE: ______________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

4. Which medication is commonly used in treatment programs for heroin abusers to produce a non-euphoric state and to
replace heroin use?
A. Diazepam
B. Carbamazepine
C. Clonidine
D. Methadone
ANSWER: _____
RATIONALE: ______________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

5. Nurse Niko recommends that the family of a client with substance-related disorder attend a support group. The purpose
of these groups is to help family members understand the problem and to:
A. Change the problem behaviors of the abuser.
B. Learn how to assist the abuser in getting help.
C. Maintain focus on changing their own behaviors.
D. Prevent substance problems in vulnerable family members.
ANSWER: _____
RATIONALE: ______________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

RATIONALIZATION ACTIVITY (THIS WILL BE DONE DURING THE FACE-TO-FACE INTERACTION)

The instructor will now rationalize the answers to the students. You can now ask questions and debate among yourselves.
Write the correct answer and correct/additional ratio in the space provided.

1. ANSWER: _____
RATIONALE: __________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________

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2. ANSWER: _____
RATIONALE: __________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________

3. ANSWER: _____
RATIONALE: __________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________

4. ANSWER: _____
RATIONALE: __________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________

5. ANSWER: _____
RATIONALE: __________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________

LESSON WRAP-UP (30 minutes)

You will now mark (encircle) the session you have finished today in the tracker below. This is simply a visual to help you
track how much work you have accomplished and how much work there is left to do.

You are done with the session! Let’s track your progress.

AL Strategy: SUBSTANCE ABUSE – NURSING CARE PLAN

Instructions:
1. You are to create 1 nursing care plan each for client with the following abused substances: (1) Alcohol, (2)
Amphetamines using the format below:
Assessment Nursing Diagnosis Goal/Plan of Care Nursing Interventions
Subjective: Short – Term: Independent:

Objective: Long – Term: Collaborative:

 Give at least 10
interventions

Source:
2. The care plan must be written in a short bondpaper (for each type of abuse) using the required format provided
above. The output will then be attached to the Student Activity Sheets.

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