NCP Stimulants Amphetamines, cocaine, caffeine, and nicotine and Inhalant Related Disorders

DSM-IV

AMPHETAMINE-INDUCED DISORDERS

292.81 Intoxication delirium

292.89 Amphetamine intoxication

292.0 Amphetamine withdrawal

292.11 Psychotic disorders with delusions

292.12 Psychotic disorders with hallucinations

CAFFEINE-INDUCED DISORDERS

305.90 Caffeine intoxication

292.89 Caffeine-induced anxiety disorder

292.89 Caffeine-induced sleep disorder

COCAINE-INDUCED DISORDERS

292.89 Cocaine intoxication

292.0 Cocaine withdrawal

292.81 Intoxication delirium

INHALANT-INDUCED DISORDERS

292.89 Inhalant intoxication

292.81 Inhalant intoxication delirium

292.84 Inhalant-induced mood disorder

292.89 Inhalant-induced anxiety disorder

NICOTINE-INDUCED DISORDER

292.0 Nicotine withdrawal

(For additional listings, consult DSM-IV.)

Stimulants are natural and manufactured drugs that speed up the nervous system. They can be swallowed, injected, inhaled, or smoked. These substances are identified by the behavioral stimulation and psychomotor agitation that they induce. They differ widely in their molecular structures and in their mechanisms of action. The most prevalent and widely used stimulants are caffeine and nicotine. Caffeine is readily available as a common ingredient in coffee, tea, colas, and chocolate. Nicotine is a primary substance in tobacco products. These are generally accepted as a part of our culture, are not usually seen in overdose situations, and are included here for information only. Other more potent stimulants (e.g., cocaine, amphetamines, and nonamphetamine stimulants) are regulated by the Controlled Substance Act. They are available for therapeutic purposes by prescription but are also widely available on the illicit drug market. The potential for overdose and even death is high.

Inhalant substances such as gasoline, glue, paint/paint thinners, spray paints, cleaning compounds, and correction fluid, to name a few, are not classified as stimulants; however, the intoxicating effects of these products and their therapeutic interventions are similar and therefore addressed here.

This plan of care addresses acute intoxication/withdrawal and is to be used in conjunction with CP: Substance Dependence/Abuse Rehabilitation.

ETIOLOGICAL THEORIES

Psychodynamics

Individuals who abuse substances fail to complete tasks of separation-individuation, resulting in underdeveloped egos. The person retains a highly dependent nature, with characteristics of poor impulse control, low frustration tolerance, and low self-esteem, low social conformity, neurotocism, and introversion. The superego is weak, resulting in absence of guilt feelings for behavior. Underlying psychiatric status must be assessed, as these individuals may use stimulants for varying self-medication reasons (dual diagnosis).

Biological

An apparent genetic link is involved in the development of substance use disorders. However, the statistics are currently inconclusive regarding abuse of stimulant drugs.

Family Dynamics

Predisposition to substance use disorders occurs in a dysfunctional family system. There is often one parent who is absent or who is an overpowering tyrant and/or one parent who is weak and ineffectual. Substance abuse may be evident as the primary method of relieving stress. The child has negative role models and learns to respond to stressful situations in like manner.

CLIENT ASSESSMENT DATA BASE

The client may present with intoxication or in various stages of withdrawal, affecting data gathered. Data depend on stage of withdrawal, concurrent use of alcohol/other drugs, or contaminants in drug “cut.”

Activity/Rest

Insomnia; hypersomnia; nightmares

Anxiety

Hyperactivity, increased alertness, or falling asleep during activities; lethargy (inhalants)

Inability to tolerate or to correct chronic fatigue (depression and/or loneliness may be a factor)

General muscle weakness, incoordination, unsteady gait (inhalants)

Circulation

BP usually elevated; may be hypotensive

Tachycardia, irregular pulse

Diaphoresis

Ego Integrity

Need to feel elated, sociable, happy with self, desire to prove self-worth, improve
self-concept; craving for excitement

Compulsion regarding substance use, or denial of powerlessness over the substance (use of drug for celebration or crisis, believing drug can be used in regulated quantities, often resulting in binge use); may think of recovery process as notion of willpower, subject to impulse control

Absence of guilt feelings for behavior

Underdeveloped ego; highly dependent nature, with characteristics of poor impulse control, low frustration tolerance, and low self-esteem; reckless/rebellious behavior, weak superego

May be seen or view self as susceptible to influence by others, having an inability to say “no”

Feelings of helplessness, hopelessness, powerlessness

Emotional status: Anxious, evasive, irritable, may be angry/hostile, belligerent

Food/Fluid

Nausea/vomiting, anorexia

Weight loss; thin, cachectic appearance

Compulsiveness with food (especially sugars)

Neurosensory

Emotional/psychological symptoms (e.g., elation, grandiosity, loquacity [excessive talkativeness], hypervigilance)

Numbness in hands and feet

Twitching, jerking in face, neck, arms, hands (dyskinesias; dystonias)

Dizziness

Pupillary dilation with slowed reaction to light; blurred vision or diplopia; nystagmus, lack of convergence (inhalants)

Tremors, convulsions, coma

Delirium with tactile and olfactory hallucinations, as well as hallucinations of insects or vermin crawling in/under the skin (formication); labile affect, violent or aggressive behavior, symptoms of a paranoid delusional disorder (amphetamine or similarly acting substances)

Fixed delusional system of a persecutory nature, lasting weeks to a year or more

Psychosis (can occur with a 1-time high dose of amphetamine [especially with IV administration] or with long-term use at moderate or high dose)

Ideas of reference

Aggressiveness, hostility, violence, quick response to anger; psychomotor agitation/hyperactivity

Hypersensitive to sound, light, touch

Stereotyped compulsive motor behavior (e.g., sorting, taking things apart and putting them back together, moving mouth from side to side)

Psychomotor retardation, depressed reflexes, unsteady gait (inhalants)

Anxiety; impaired judgment and perception

Apathy, stupor, coma, or euphoria (inhalants)

Pain/Discomfort

Bone/chest pan

Respiration

Tachypnea, coughing

Nasal rhinitis (chronic cocaine use)

Chronic/recurrent bronchiolitis; pneumonia

Pulmonary hemorrhage

Safety

History of accidents; exposure to STDs, including HIV

Acute allergic/anaphylactic reaction (response to contaminants in drug cut)

Elevated temperature; fever/chills, diaphoresis

Evidence of trauma (e.g., bruises, lacerations, burns); nasal damage (if drug is snorted)

Assaultive behavior (inhalants)

Sexuality

Diminished/enhanced sexual desire; disinhibition regarding sexual behavior (promiscuity/prostitution)

Increased likelihood of pregnancy/abortion

Social Interactions

Impairment in relationship, social, or occupational functioning; encounters with the legal system; expulsion from school

Dysfunctional family system (family of origin)

Teaching/Learning

Predominant age range of 21 to 44 years (stimulants), teenage population (inhalants)

Learning difficulties (e.g., attention-deficit hyperactivity disorder)

Family history of substance abuse (especially alcohol)

Concurrent use of alcohol/other drugs (compounds symptoms/reactions)

Pattern of habitual use of the particular drug or pathological abuse, with inability to reduce or to stop use, occurring for at least 1 month

Intoxication throughout the day, sometimes with daily involvement

During-Period of Abstinence: Drug hunger, delayed reemergence of withdrawal symptoms (reemergence may occur at 3 months, between 9 and 12 months, and perhaps as late as 18 months after abstinence)

Previous hospitalizations or having been in residential treatment program for substance use/dual diagnosis

Health beliefs about use of drugs (e.g., “Diet pills are OK to use to lose weight.”)

Attendance at recovery groups (e.g., Narcotics/Alcoholics Anonymous or other drug-specific recovery groups)

DIAGNOSTIC STUDIES

Blood and Urine Drug Screens: To identify presence/type of drug(s) being used

Tests for Hepatitis and HIV: May be routine in known IV drug users or when client has identified risk factors.

Other Screening Studies: Depend on general condition, individual risk factors, and care setting.

Addiction Severity Index (ASI): Produces a “problem severity profile,” which indicates areas of treatment needs.

NURSING PRIORITIES

1. Maintain physiological stability.

2. Promote safety and security.

3. Prevent complications.

4. Support client’s acceptance of reality of situation.

5. Promote family involvement in Intervention/treatment process.

DISCHARGE GOALS

1. Homeostasis maintained.

2. Complications prevented/resolved.

3. Client is dealing with situation realistically/planning for the future.

4. Abstinence from drug(s) maintained on a day-to-day basis.

5. Attending rehabilitation program/therapy group.

6. Plan in place to meet needs after discharge.