Case Overview Patient Sam, 42 y/o male, was brought into the mental health unit after he threatened to hit his boss upon being fired. He has history of chronic alcohol consumption which affected his performances at work (causing him to be terminated) and at home (prompting his wife to abandon him). On admission, Sam had positive alcohol breath, had slurred speech, had poor judgment, was argumentative, and was irritable. The patient verbalized an average consumption of “three to four drinks” every night, which increased to half-a-bottle of whisky per night when his wife left him two weeks prior to admission.
His family history revealed that Sam’s father was also a chronic drinker who beat his wife and verbally abused his son. Consequently, Sam grew up insecure, fearful, and feeling worthless. Thus, drinking became his way of coping with the stress of his job and his past. DSM-IV Criteria for Substance Abuse Disorder According to the Diagnostic and Statistical Manual-IV (DSM-IV), Sam has a substance abuse disorder because he fits the following criteria (DSM-IV, 1994): 1.
Sam recurrently uses the substance, making him fail at work and at home. He was constantly late for work, unable to complete his allocated duties, always involved with verbal altercations with workmates and he was observed to sneak in alcohol and drink it during lunch time. 2. Sam continued alcohol use despite having unrelenting problems with social/occupational relations. Sam’s wife left him because he had increasing anger outbursts and increased physical threats.
Sam also has dependence on alcohol, evidenced by the presence of three criteria for substance dependence: a) need for increased amount of substance (from 3-4 drinks to half-bottle); b) compromised social and occupational activities due to substance use; and d) continued alcohol abuse despite persistent psychological problems. The Alcohol Situation of Australia In 2006, the Australian Institute on Health and Welfare (AIHW) reported that alcohol abuse ranked as 17th main cause of burden in Australia, and the second major cause of substance-related mortality and hospitalization (AIHW, 2006).
An Australian Bureau of Statistics (ABS) survey revealed that 62% of Australian adults drink, 13% of whom drink at a high/risky level (ABS, 2006). In general, more males drink than females (ABS, 2006). Individuals aged 18-24, are also most likely to drink riskily (AIHW, 2006). Smoking and diet are lifestyle-related risk factors for alcohol abuse (National Health and Medical Reasearch Center Council (NHMRC), 2005). Among drinkers, 40% males and 35% females smoke, while 64% males and 51% females don’t eat enough fruits (ABS, 2006).
Studies have related brain damage, dementia/cognitive problems, liver cirrhosis (NHMRC, 2005), and esophageal, throat, and oral cancers to drinking (AIHW, 2006). Alcohol is also related to breast cancer, hypertension, depression and injuries (ABS, 2006). Further, there were 31,132 alcohol-related deaths and around 500,000 alcohol-related hospitalizations from 1992 to 2001 (ABS, 2006). Finally, the approximated amount lost due to alcohol abuse nationally is around $7. 6 billion and rising (ABS, 2006). Psychodynamics of the Patient’s Alcohol Abuse
Sadly, Sam’s substance abuse is something that may have started early on in his life. Although he was not directly drinking, as a boy, he witnessed his father drink excessively. In the young boy’s mind, it was programmed that “drinking is good,” and that it is a means to relieve stress. This is evidenced by the patient’s statement that, “I’m like dad, we both love alcohol and there is nothing wrong in that. ” With his father as negative role model, Sam learned to adapt to stressful conditions in a similar method. Indeed, he verbalized that “he drinks alcohol to help him forget his painful past and cope with his stress at work.
” What’s more, offsprings of alcoholics are four times more at risk of developing alcohol dependence as compared to children of non-alcoholics (Docstoc, 2008). Thus, Sam was at a higher risk for alcoholism. Individuals suffering from alcohol dependence have remained fixed in a lower level of psychological development, more specifically in Freud’s oral stage of psychosexual development. People with oral fixation relieve stress by activities concerning the mouth, such as drinking (Straker, 2010). Individuals stuck in the oral stage tend to be needy, with dependency issues, and sensitive to rejection (Cherry, 2010).
This is supported by Sam’s revelation that he had been drinking heavily after his wife left him because he misses his wife and kids, and he felt lonely. In addition to these, alcohol-dependent people usually have a retarded ego and a weak superego (Docstoc, 2008). The ego functions in a person’s reality orientation, and makes the person capable of understanding the needs of others (Heffner Media Group Inc. , 2005). With Sam’s retarded ego, he tends to go to work late, sneak in alcohol at work, and verbally abuse his family and coworkers.
This retarded ego was eventually the reason that led to his unemployment and that pushed his wife to leave him. Furthermore, Sam’s underdeveloped ego makes him incapable of recognizing his addiction to alcohol, as confirmed by his denial of his drinking problem and his refusal to enter rehabilitation. On the other hand, the superego functions as a person’s conscience and moral compass, telling people what is right or wrong. The superego enforces rules and constantly strives for perfection (Structure of Mind: Freud’s Id, Ego, ; Superego, 2005).
Given that the patient’s superego is weak, he has difficulty staying away from excessive alcohol and all its moral implications. Finally, the substance-dependent person displays characteristics of short tolerance for stress or frustration, low self esteem, and poor impulse control (Docstoc, 2008). This is manifested in Sam’s reports that owing to his impaired relationship with his father, he had always felt worthless, insecure, afraid, guilty, depressed and threatened, most especially after he lost his job. These ego and superego problems have developed due to the parents’ failure to satisfy Sam’s need for love and belonging.
When parents fail to meet a child’s need for attention, the child grows up dependent on others, trying to find support from entities outside the family. And more often than not, this search brings with it a dependence on alcohol, drugs and other substances (Susic, 2008). Mental Health Issues The patient has multiple mental health problems, including problems with ego integrity, changes in affect and mood, depression, and problems with perception and thought processes (Docstoc, 2008). However, only the following nursing diagnoses will be addressed: 1. VIOLENCE, Risk for self-directed
Indicator/Risk Factor: unemployment, depression, low self-esteem and verbal cue of: “I am a failure. I wish I was dead. ” 2. SENSORY PERCEPTION, Disturbed (potential) Indicator/Risk Factor: biochemical imbalance; expected withdrawal symptoms. 3. DENIAL, Ineffective Related factor: lack of control in life and lack of effective defense mechanisms. Nursing Interventions Risk for Self-Directed Violence This was defined by the North American Nursing Diagnosis Association (NANDA) as “behaviors in which an individual demonstrates that he or she can be physically, emotionally, and/or sexually harmful to self (Doenges, Moorhouse, ; Murr, 2008).
” Risk factors found in the patient includes negative role model, low self-esteem, fixation in earlier level of development, lack of support system, depression, and suicidal ideation (he mentioned that “he wished he was dead”) (Townsend, 2006). With these, interventions should include: a) thorough assessment; b) no-suicide contract; c) means restriction; d) suicide watch; e) calm and nonjudgmental attitude; and f) use of restraints, physical/chemical, as ordered. Disturbed Sensory Perception This is a potential diagnosis since it is yet to occur.
Once Sam goes into withdrawal, he can experience Delirium Tremens, a life-threatening condition coupled by delusions and hallucinations (Black ; Hawks, 2006). Intervention should then focus on: a) decreased stimuli in room; b) reorientation to reality; c) correction of misconceptions on withdrawal symptoms; d) provision of safety from injury; e) reduction of anxiety; and f) administration of anxiolytics (Valium, Librium, etc. ). Ineffective Denial Ineffective denial involves the rejection of the knowledge or implications of a certain condition (Allnurses. com, 2009).
In Sam, denial is evident in his inability to admit the impact of drinking in his life. He also delayed seeking medical help, even with the threat of job termination. Also, he claims that “he does not have a drinking problem. ” Therefore, intervention should include: a) identifying current problem/stressor and exploring client’s feelings; b) identifying ineffective coping; c) using therapeutic communication skills; d) encouraging the patient to verbalize feelings e) encouraging contact with significant others; and f) providing simple tasks the patient can complete.
Rationale for Nursing Interventions Risk for Self-Directed Violence Thorough assessment gives perspective on how care should be rendered (Gulanick et al. , 2010). A no-suicide contract helps ensure that a patient cannot harm himself, reducing the risk for self-directed violence (Caruso, 2005). Means restriction is useful in keeping the environment safe and free of materials that can be used to harm one’s self (British Columbia, 2009). Next, suicide watch, or staying with the patient for a period of time, makes the lonely person feel that he is not alone, and it also delays possible suicide plan.
A nonjudgmental attitude increases the patient’s feeling of acceptance, making it easier for him to accept his problem (Doenges, Moorhouse, ; Murr, 2008). Finally, physical/chemical restraints are needed to keep the patient from harming himself (Nursingcareplan, 2007). Disturbed Sensory Perception Firstly, decreasing stimuli in a patient’s room also decreases the possibility of forming incorrect sensory perceptions (F. A. Davis Company, 2005). Secondly, reorientation to reality assists the patient in differentiating what is a sensory problem to reality (Alcohol: Acute Withdrawal, 2008).
Additionally, correction of misconceptions relieves the patient’s anxiety and allows him to participate more in his plan of care, thereby interfering with his abilities to respond to hallucinations (Townsend, 2006). Provision of safety is also a priority nursing responsibility, and reducing the patient’s anxiety provides a feeling of security (Townsend, 2006). Finally, the administration of anxiolytics help prevent the occurrence of Delirium Tremens (Black ; Hawks, 2006). Ineffective Denial
Identifying current stressors provide a direction for nursing care and exploring the client’s feelings about these stressors can help him in getting to accept the facts that he denies. (Doenges, Moorhouse, ; Murr, 2008). Additionally, recognizing ineffective coping mechanisms allows the nurse to assist the patient in developing new and more effective ones (Doenges, Moorhouse, ; Murr, 2008). The utilization of therapeutic communication skills makes possible the development of a therapeutic nurse-patient relationship, a vital factor in the success of nursing care.
Also, encouraging the patient to verbalize feelings gives the patient the sense that he can confide in you without being judged. Further, encouraging contact with significant others reduces the isolation of the patient. Finally, providing tasks the patient can complete gives him a sense of control and self worth (Doenges, Moorhouse, ; Murr, 2008). References Alcohol: Acute Withdrawal. (2008). Retrieved July 29, 2010, from slideshare. net: http://www. slideshare. net/thinkrn/alcohol-acute-withdrawal-nursing-care-plan Allnurses. com. (2009, May).
Psychosocial Problems and Care Plans. Retrieved July 29, 2010, from Allnurses. com: http://allnurses. com/nursing-student-assistance/psychosocial-problems-care-388766. html Australian Bureau of Statistics (ABS). (2006). National Health Survey: Summary fo Results, Australia, 2004-05. Canberra: ABS. Australian Institute on Health and Welfare (AIHW). (2006). Acohol COnsumption in Australia. Australian Bureau of Statistics. Black, J. , ; Hawks, J. (2006). Medical-Surgical Nursing: Clinical Management for Positive OUtcomes. Singapore: Elsevier Saunders PTE LTD.
British Columbia. (2009). Means Restriction. Retrieved July 28, 2010, from mcf. gov: http://www. mcf. gov. bc. ca/suicide_prevention/means. htm Caruso, K. (2005). Suicide. Retrieved July 28, 2010, from suicide. org: http://www. suicide. org/suicide-causes Cherry, K. (2010, June). Stages of Psychosexual Development. Retrieved July 29, 2010, from About. com: psychology: http://psychology. about. com/od/theoriesofpersonality/ss/psychosexualdev_2. htm Docstoc. (2008).
Alcohol-Related Disorders DSM-IV Alcohol-Induced Disorders. Retrieved July 29, 2010, from Docstoc.com: http://www. docstoc. com/docs/8100889/alcohol-disorders Doenges, M. , Moorhouse, M. , ; Murr, A. (2008). Nurse’s Pocket Guide. Philadelphia: E. A. Davis Company. DSM-IV, Diagnostic and Statistical Manual of Mental Disorders (4th ed. ). (1994). Washingyon DC: American Psychiatric Association (AMA). F. A. Davis Company. (2005). Disturbed Sensory Perception. Retrieved July 29, 2010, from fadavis. com: http://www. fadavis. com/townsend4e/additionalnursingcareplans. htm Gulanick et al.. (2010). Nursing Care Plans: Nursing Diagnosis and Intervention.
Retrieved July 29, 2010, from elsevierhealth. com: http://www1. us. elsevierhealth. com/MERLIN/Gulanick/Constructor/index. cfm? plan=27 Heffner Media Group Inc. (2005, March). Psychology 101. Retrieved July 29, 2010, from allpsych. com: http://allpsych. com/psychology101/ego. html National Health and Medical Reasearch Center Council (NHMRC). (2005). Australian Alcohol Guidelines: Health Risks and Benefits. Canberra: NHMRC. Nursingcareplan. (2007, June). NCP Substance Dependence Abuse Rehabilitation.
Retrieved July 29, 2010, from Nursingcareplan: http://nursingcareplan.blogspot. com/2007/05/ncp-substance-dependence-abuse. html Straker, D. (2010, May). Freud’s Psychosexual Stage Theory. Retrieved July 29, 2010, from chaningminds. ogs: http://changingminds. org/about. htm Structure of Mind: Freud’s Id, Ego, & Superego. (2005). Retrieved July 29, 2010, from wilderdom. com: http://www. wilderdom. com/personality/L8-4StructureMindIdEgoSuperego. html Susic, P. (2008, January). Substance Abuse From the Freudian View.
Retrieved July 29, 2010, from Psychtreatment. com: http://www. psychtreatment.com/substance_abuse_from_the_freudian_view. htm Townsend, M. (2006). Psychiatric/Mental Health Nursing: Concepts of Care. F. A. Davis Company **Word Count summary (exclusive of reference list) Case Overview (144 words) DSM-IV Criteria for Substance Abuse Disorder (142 words) The Alcohol Situation of Australia (188 words) Psychodynamics of the Patient’s Alcohol Abuse (523 words) Mental Health Issues (88 words) Nursing Interventions (283 words) Rationale for Nursing Interventions (374 words) TOTAL 1742 words