Alcoholism

Presented by-
Jasleen Kaur Brar

 Alcoholism is a chronic relapsing disease
characterized by denial and inability to
discontinue its use despite knowing its
adverse consequences.
 A person is considered to suffer from
chronic alcoholism if his use of alcohol is
upto such extent that it interferes with
successful physical and social functioning.

 The National Council on alcohol and drug dependency
and The American Society of Addiction Medicine define
alcoholism as "a primary, chronic disease characterized by
impaired control over drinking, preoccupation with the
drug alcohol, use of alcohol despite adverse consequences,
and distortions in thinking."

 The DSM-IV defines alcohol abuse as
repeated use despite recurrent adverse
consequences.
 It further defines alcohol dependence as
alcohol abuse combined with tolerance,
withdrawal, and an uncontrollable drive to
drink.

 Use refers to simple use of a substance. An
individual who drinks any alcoholic beverage
is using alcohol
 Moderate Use is defined as no more than two
alcoholic beverages per day for men and no
more than one alcoholic beverage per day for
women.

 Abuse is often used to refer to the illegal use
of any substance, use of prescription
medications in excess of the prescribed
dosage or use of a prescription drug without a
prescription, and sometimes refers to use that
results in long-term health problems.

Genetic factors – It runs in
families, children of alcoholics
consume 4 times more than the
children of non alcoholic.(Neumann,
2005). So if father is alcoholic,
children are having greater risk

 Psychological –
 Poor stress management skills,
loneliness, desire to escape from
reality, a sense of adventure,
pleasure seeking.
 Emotionally immature, need for
praise and appreciation.

 Low frustration tolerance , feelings of
inadequacy.
 Psychological trauma during childhood as
disturbed parent child relationship.
 Inferiority, low self esteem, poor impulse
control.
 Disorders like depression, anxiety, phobia are
prone to consume as an escape.

 Personality disorders – persons
who have harsh super ego and who
are self puncture turn to alcoholics to
diminish their stress.
Childhood history of antisocial
personality disorder.
Common in cyclothemic
personalities.

Social factors – over crowding,
influence of bad company, cinemas,
literature.
Peer pressure, urbanization, religious
reasons, unemployment.

 Poor social support, fashion- a sign
of modernity, social inadequacy,
isolation.
Some settings as colleges and
military settings where alcohol is
considered as a status symbol.

To forget miseries and problems of life.
Unhealthy environment, sudden loss in
property or closed ones.
Parental disharmony.

Occupational – heavy vehicle
drivers, labourers, manual workers,
Physical exhaustion or hard physical
labour.

 Economic causes :
 Poverty
 Unemployment
 Professions like poets, painters, waiters, journalists,
commercial, musicians, reporters are at greater risk.

 Others :
 Marital disharmony
 Easy availability
 Free time and boredom
 Loneliness.

Pre-alcoholic symptomatic phase :
In conventional social situations, an
individual starts drinking alcohol but
soon experiences tension relief.
Gradually tolerance for tension
decreases to such an extent that he
resorts to alcohol almost daily.

 Prodromal phase:
 Sudden onset of black outs, signs of
intoxication, loss of memory or events.
 Seek occasions to drink, unknown to others
with the fear that they will misjudge them.

 Worrying about whether there will be enough to drink
at a social gathering or not.
 Swallow the first two drinks very quickly.
 Guilt feelings about drinking behaviour.

 Crucial phase:
 Loss of control over drinking, increased
isolation, decrease in sexual drive, centering
the behaviour around alcohol.
 Improper nutrition, increased hostility
towards spouse, increased jealousy feelings,
suspicious nature.

 Chronic phase : marked impairment in
thinking process leading to alcoholic
psychosis, delirium tremors occurs, develops
rationalization and amenable to treatment.
- Casual to habitual drinker

ELLIOT and MERRILL has
described five stages through
which a person has to pass till he
became complete disorganized
personality-

1. Morning drinking- Person starts
drinking alcohol in morning and he feels it
is necessary to push him throughout the
day.
2. Escape drinking- It starts, when a
person is not able to face reality of
problems without the help of alcohol.

3. Increasing consumption : Consumption of
alcohol increases in amount leading to
personal disorganization and decreased
social value and feels that he cannot survive
without alcohol.
4. Drinking and social functions: Drinking
becomes absolute necessity in social
gathering.

5. Extreme behaviour : drinks excessively and
behave indiscriminately, eg. Fighting, abusing,
throwing away things, beating wife and children,
absurd and dangerous behaviour etc.

 MODERATE : Moderately consuming
alcohol and does not cause much
problem.
 PROBLEM : Drinking will impair
health, affects peace of mind, family
disruption, loss of reputation and
drinking becomes the routine.

 EXPERIMENTAL: Due to peer pressure and
curiousity, individual starts consuming alcohol.
 RECREATIONAL : Gradually the frequency of
alcohol consumption will increase as an enjoyment.

 RELAXATIONAL : During weekends or on
holiday, it may work out to release the tension
,relax mind and to sedate the brain from
painful emotions and promotes a sense of
well being and pleasure.
 COMPULSIVE: Person becomes addict to
overcome the discomfort of withdrawal
symptoms.

 Red palms and red nose
 Improper gait
 Decreased sensation and
weakness in legs and feet.
 Disorientation
 Ring like opacity of cornea

 PHYSICAL SIGNS :
 Indigestion- anorexia
 Sweating
 Unsteady gait
 Malaise and tremors
 Weakness in feet and legs
 Pain in upper abdomen

 PSYCHOLOGICAL SIGNS :
 Blackouts- amnesia of events
 Loss of self control
 Outburst of aggressive behaviour
 Insomnia

A .Medical :
a.Gastro-intestinal Tract
 Gastritis
 Dyspepsia
 Vomiting
 Peptic ulcer
 Cancer

 Reflex esophagitis
 Carcinoma of stomach and oesophagus, larynx,
liver, colon
 Fatty degeneration of the liver, interferes with
absorption of vitamin B-complex
 Cirrhosis of liver
 Hepatitis, Jaundice
 Liver cell carcinoma
 Acute and chronic
 pancreatitis

b. Cardiovascular System :
 Cardiomyopathy
 Hypertension
 Heart failure or stroke
 High risk for myocardial infarction.
c. Blood :
 Folic acid deficiency anaemia
 Decreased WBC production causes infections

d. Nervous System :
 Confusion, numbness of hands, feet,
disordered thinking
 Depression, depresses vital centers of the
brain
 Peripheral Neuropathy,
 Dementia
 Epilepsy
 Head injury
 Cerebellar degeneration
 Wernicke’s encephalopathy coma

e. Hormonal :
 Hypoglycemia
f. Muscle :
 Peripheral muscle weakness
 Wasting of muscles
g. Bones :
 Interferes with the production of bones
 Thinning of bones, osteoporosis
 Fractures

I. Reproductive System :
 Sexual dysfunction in male
 Failure of ovulation in female
 Interruption in menstruation
j. Nutritional Deficiency Diseases :
 PEM
 B complex deficiency-Pellagra, Beriberi

k. Pregnancy :
 Fetal abnormalities
 Developmental disabilities- Mental
retardation, Growth retardation
 Low birth weight
 Still birth
 Birth defects
 Foetal alcohol syndrome

Social Complications :
 Domestic abuse, divorce, poor performance in
school and at work.
 Prone for motor vehicle accidents, susceptible for
accidental injuries, violence acts,e.g. murder,
reduced productivity.

Any rapid decrease in the amount of alcohol
content in the blood will produce withdrawal
symptoms.
1 Simple Withdrawal Syndrome :
 Mild tremors
 Nausea and vomiting
 Weakness
 Irritability
 Insomnia

 Insomnia
 Anxiety
 Tachycardia
 Hypertension
 Impaired attention

2 Delirium Tremors :
 The term means ‘trembling madness’. It
occurs within 2-4 days of complete or
significant abstinence from heavy alcohol
drinking.
 Definiton.
 ‘A severe form of withdrawal that involves
sudden and severe mental or neurological
changes.

Manifestations :
 Mental status changes: Mood changes,
confusion, disorientation in the time and
place, psychomotor agitation, restlessness,
excitement, decreased attention span,
irritability,
 Disorderly behaviour, clouding of
consciousness, altered sensorium.

3.ALCOHOLIC PARANOID : It occurs in chronic
alcoholics, characterized by suspicious nature,
decreased sexual potency and other paranoid
features.
 Treatment is symptomatic.

4.ALCOHOLIC HALLUCINATIONS It
develops after an attack of delerium
tremors, auditory and visual
hallucinations, delusions of persecutory
and reference are common.
 Capacity for social adjustment is
retained.
 Full recovery takes place in 3-4 weeks.

5. DEMENTIA : It develops slowly.
 Signs include tremors, indistinct speech, mild
euphoria etc.
 No specific treatment is recommended. Usually it
resolves by itself.

6.Wernicke encephalopathy : It is a
syndrome characterised by ataxia,
ophthalmoplegia, confusion, and
impairment of short-term memory.
 Treatment begins with IV or IM
injection of thiamine, followed by
assessment of central nervous system
and metabolic conditions.

7.Korsakoff's syndrome: (amnesic-confabulatory
syndrome)is a brain disorder caused by the lack of
thiamine (vitamin B1) in the brain

 There are six major symptoms of it:
 Anterograde amnesia
 Retrograde amnesia, severe memory loss
 Confabulation, that is, invented memories
which are then taken as true due to gaps in
memory
 Unrelevant content in conversation
 Lack of insight
 Apathy - the patients lose interest in things
quickly and generally appear indifferent to
change.

 Treatment involves the replacement or
supplementation of thiamine by IV or IM
injection, together with proper nutrition
and hydration. However, the amnesia
and brain damage caused by the disease
does not always respond to thiamine
replacement therapy. So in some cases,
drug therapy is recommended

 CAGE questionnaire : named for its four
questions, is used to screen patients.
 Two "yes" responses indicate that the respondent
should be investigated further. The questionnaire
asks the following questions:

 Have you ever felt you needed to Cut down
on your drinking?
 Have people Annoyed you by criticizing your
drinking?
 Have you ever felt Guilty about drinking?
 Have you ever felt you needed a drink first
thing in the morning (Eye-opener) to steady
your nerves or to get rid of a hangover?

OTHER SCREENING TEST AVAILABLE :
 Alcohol Dependence Data Questionnaire
 Michigan Alcohol Screening Test
 Alcohol Use Disorders Identification Test
(AUDIT)
 Paddington Alcohol Test (PAT)

 According to the DSM-IV, an alcohol
dependence diagnosis is:
 Maladaptive alcohol use with clinically
significant impairment as manifested by at
least three of the following within any one-
year period:
 Tolerance
 Withdrawal
 Taken in greater amounts or over longer time
course than intended

 Desire or unsuccessful attempts to cut down
or control use.
 Great deal of time spent obtaining, using, or
recovering from use.
 Social, occupational, or recreational activities
given up or reduced; continued use despite
knowledge of physical or psychological
sequeale.

Urine and blood tests :
 One common test being that of blood alcohol
content (BAC).

 Detoxification :
 Alcohol detoxification or 'detox' for alcoholics
is an abrupt stop of alcohol drinking coupled
with the substitution of drugs that have similar
effects to prevent alcohol withdrawal.
 It treats the physical effects of prolonged use
of alcohol, but does not actually treat
alcoholism. After detox is complete, relapse is
likely without further treatment.

 Drugs used for this are :
 Benzodiazepines – chlordiazep 80-
200mg/day.
 Diazepam 40-80 mg/day
 Thiamine 100 mg IM for 3-5 days followed
by vitamin b administration 100 mg OD
for atleast 6 months.
 Anticonvulsants can be given if
necessary.

 Used for over 30 years.
 Works on principle of classical
conditioning.
 300-600 mg of drug mixed in
alcohol is given to the client for 6-8
times in a week.

 Soon after the ingestion of drug, adverse
reaction starts appearing and may last for 30-
120 minutes. Reaction consists of :
 Facial flushing
 Sweating
 Throbbing headache
 Neck pain
 Tachycardia

 Respiratory distress
 Potentially serious drop in B.P.
 Nausea and vomiting.
 In severe disulfram reaction,
diphenhydramine hydrochloride 50 mg IM or
IV is given.

 It must be taken daily atleast for 6-8 days,
period can last for upto 2 weeks.
 Alcohol containing substances (hidden
alcohol) can trigger the side effects, so these
should be avoided. These are :
 Foods as soups, apple ciders, anything made
with wine vinegar as pickles, flavour extracts
used in cooking.

 Medicines include cold and cough syrups, mouth
washes, vitamin and mineral tonics.
 Skin preparations include alcohol rubs, after shave
lotions, transdermal patches.
 Avoid inhaling fumes, substances that contain
alcohol as paints.

 It is an opoid antagonist which is now approved for
treatment of alcoholism. Unlike disulfram, it
decreases the pleasant and reinforcing effects of
alcohol without making the user ill.

MOTIVATIONAL INTERVIEWING :
 Explaining the complications and personal
risks of consuming alcohol
 Availability of treatment options to change
their behaviour related to alcohol
consumption.

 INDIVIDUAL PSYCHOTHERAPY :
 Educate about the effects of alcohol
consumption and the coping strategies to
overcome the habit.
 Precautionary measures, diversional
activities.
 Methods to prevent occurrence of
complications.

 GROUP THERAPY :
 Observe the problems of alcoholic
 Provide oppurtunities to observe
other problems and discuss with
each other.
 Explain them the better ways of
coping with problems.

 COUNSELLING :
 To find out the problems and to solve them.
 To guide about various methods to relax mind
and engaging themselves in productive
activities.

 AVERSIVE COUNSELLING :
 Based on principle of classical conditioning.
 Explain the behaviour pattern which are
pleasurable, pros and cons of alcoholism,
maladaptive behaviour.
 Explain about the complications
of alcoholism and family complications.

 Client is exposed to adverse effects of
excessive alcohol consumption like
chemical induced vomiting, shock etc.
thereby develops aversion towards the
evil habbits.

 COGNITIVE THERAPY :
 Help the client to identify the maladaptive
thinking patterns; evil effects of alcoholism.
 To guide the individual to slowly reduce the
dose of alcohol intake and by understanding
the evil effects of alcohol.

 RELAPSE PREVENTION TECHNIQUE :
 It helps the client :
 Identify high risk relapse factors and develop
strategies to deal with them.
 Learn the methods to cope up with cognitive
distortions.

 CUE EXPOSURE TECHNIQUE :
Repeated exposures to desensitise the clients to the
effects of alcohol and thus improve their ability to
remain abstinent.

 SUPPORTIVE PSYCHOTHERAPY :
Symtomatic treatment along with educating
the individual about preventive measures
against complications.

 BEHAVIOUR MODIFICATION TECHNIQUES:
 Systematic desensitization
 Relaxation techniques
 Operant conditioning

 FAMILY THERAPY :
 If the head of family develops
alcoholism, family will be affected with
economic crisis,maladjustment. Thus the
family need to be educated about
various cpoing strategies, evil effects of
alcoholism to ahildren and preventive
measures to adopt.

 Al-Anon and Alateen are international
organizations jointly known as Al-Anon
Family Groups with a membership of over
half a million men, women and teens,
providing a twelve-step program of recovery
for friends and family members of alcoholics.
 Al-Anon is for adults within the program
whereas Alateen is for young people (ages 12
to 20).

 Nursing Assessment
 History
 Collect brief history of the client
 Developemental aspects-milestones
pattern, educational status ,scholastic
environment and any problems associated
with it .

 Employment history and details about
stressors in working environment , work load
 Marital history: Marital life pattern ,any history
of conflicts between life partners/couple,
deprivation ,disparities
 Sexual history : Satisfactory
pattern/dissatisfactory life/difficulties in sexual
life

 Transitional periods in life- any life events
influencing alcoholism or drug abuse
 Any positive family history-history of
alcoholics or drug addicts among parents and
relatives
 Social history : social environment-peer group
influence , influence of western culture, social
gathering, broken family, deprivation of love,
school environment, life style pattern.

 Psychological factors, e.g.feeling of
aloofness, isolation, exposed to extreme
stress in life, e.g.death of loved one;
separation /divorce, failure in life.
 Forensic history: Previuos court cases, any
imprisonment, or pending court case.

 Physical Examination
 Inspection or observation: General
appearance, behaviour pattern, evidence of
malnutrition,tremors , etc.
 Percussion:Tenderness-epigastric region
 Palpation:Hepatomegaly, splenomegaly,
cardiomegaly
 Auscultation: Look for cardiac murmurs,
respiratory sounds.

 Mental status Examination
 General appearance and behaviour
 Psychomotor activity
 Thought, content, mood ,perception
 Cognitive function : orientation ,memory,
intelligence, abstractility, jugdement insight.
 General information

 Psychosocial Assessment
 Family: Environment, Interaction and
relationship. pattern ,bondage,
healthy/unhealthy living pattern
 Work environment: Regularity in job,
performance ,responsibilities,
workload,change of job, relationship with
superior and colleagues.

 Social environment-peer group, social
relationship, social functions, accidents,
friends and relatives influence
 Crime:History of committing criminal acts and
violence
 Religion , caste,cultural functions, social
gatherings, motivating or stimulating factors.

1.Nursing Diagnosis
 Alteration in sleep pattern r/t post drinking agitation
evidenced by improper sleep.
 Goal: To enhance adequate sleeping pattern.

 Interventions and rationale :
 Provide a calm and quiet environment, will
help the client to sleep better.
 Advice the family members to stay along with
the client to promote comfort and security.

 Never leave the client alone as leaving the
client alone will divert his mind, and it also
promote the sense of being cared and loved.
 Observe the sleeping pattern, to check for the
factors that hinders good sleep for the client.

 Ask the client to cultivate the habit of taking
bath before going to bed, will promote the
sleep.
 Provide dim light ,soft music, if the client is
having the habit of reading books, allow him
to do so.
 Administer the medications as per doctors
prescription.

2.Nursing Diagnosis
Potential for self injury and injury to others
r/t alcohol withdrawal, seizures etc. as
evidenced by confusion and agitated
behaviour.
 Goal : To protect the client from self injury
and injury to others.

 Provide safe environment, if the client exhibits
violent or withdrawal behaviour, to prevent
self and injury to others.
 Administer medications as per prescriptions,
helps in improving physical and mental
stability.
 Assist for self care activities and ambulation,
will provide diversion and improves
confidence.

 Observe and document ,if the client is having
seizures, to maintain records.
 Observe the gait and assist ,to give help to
the client.
 Assess the emotions of the client, e.g.:
depression, violence; counsel the client
,utilize behavior modification techniques,
cognitive, assertiveness techniques, will help
in early recovery.

3.Alteration in physical health r/t adverse
efftects of alcoholism as evidenced by poor
health
 Goal :To promote and maintain good physical
health.

 Observe and record vital signs, physical
complaints, will provide baseline data to
intervene.
 Provide symptomatic care and needed
assistance ,to cope with the existing
problems.

 Provide care to the client during and after
seizures,if any. This will help to prevent injury
to the client.
 If the client is too calm during withdrawal
period ,observe or check for any possession
of alcohol, to asess the remission at earliest.

4.Negligence in meeting physical needs
related to depression, insecurity as evidenced
by poor personal hygiene.
 Goal : To calm-up the mind and maintain
good personal hygiene.

 Promote a sense of well-being to the client
,helps in motivation towards good hygiene
habbits.
 Motivate the client to be self sufficient and
independent, helps in improving confidence.

 Make the client to understand about
importance of maintenance of good personal
hygiene and insist on hygienic habits and
maintaining it, will help in improving the
hygiene of client.
 Assist the client for self care activities, if the
client is in depressive mood, will help in
gaining trust and mutual confidence.

5.Knowledge deficit related to adverse effects
of alcoholism and methods to overcome the
problems.
 Goal : To make the client to adopt the normal
life without alcohol, slowly and gain
knowledge over the adverse effects of
alcoholism.

Interventions and rationale :
 Educate the client on adverse effects of
alcoholism; show the case, who are suffering
with complications of alcoholism, how their
families are affected due to this problem ,will
help the client to understand complications
and adverse effects in a better way.

 Counsel the client to utilize behavior
modification techniques to get aversion
towards alcoholism.
 Motivate the client to have change in life style,
social group gathering pattern to improve
socialization and to promote self confidence.

6.Altered sensory perception related to
disturbances like hallucinations &altered
consciousness as evidenced by fear,
psychomotor retardation etc.
 Goal : Reduction in fear, anxiety,
hallucinations and depression.

 Intervention
 Maintain good emotional status and improved
sensory perception pattern to promote a
sense of well being.
 Assess the level of consciousness and
behavioral responses to have baseline data to
intervene.

 Accept the client’s emotions pattern and
altered levels to promote emotional support
and comfort of client.
 Note onset and pattern of hallucination and
document it to check the efficacy of the
treatment modalities.

 Provide emotional/moral support; counsel the
client, explore the stressors and teach the
strategies to overcome the problems
 Provide calm and quiet environment to
promote comfort to the client.
 Be non judgemental; observe the client’s
behaviour, helps in gaining trust and
improving confidence.

 Motivate the client to talk about his feelings
openly without any inhibitions , will help to
ventilate.
 Never leave the client alone, always motivate
someone who is close to him will improve the
sense of being loved.

 Provide stress free environment to promote
physical and emotional comfort.
 Protect the client from self-injury as agitated
clients may harm themselves.
 Explain to the relatives, not to show their
emotional disturbances to the client, on
bedside to prevent further demotivation.

 Parents :
 Provide the child with a secure, stable home
environment (lack of love is a cause of taking
alcohol)
 Keep the child occupied .Provide opportunities for
sports, hobbies and other useful activities that could
stand him away from evil outlets.
 Keep the children informed about hazards of alcohol
addiction and how to stay away from people and
places that can influence him.

 Promote a well knit family feeling of inter
dependence .It will lead to feeling of being
wanted and loved.
 Parents should build a relationship of mutual
truth and understanding. A healthy loving
parent child relationship can be a great help
to avoid alcohol addiction.
 Individualisation :to establish mutual respect,
parents should began respecting the child as
human being in his own right.

 Taking time for recreation: Parents should
spend time with children in regard to their
hobbies and interests.
 Encouragement: Family and friends need to
know the child’s strength and help him to
accept his weakness in order to cope with the
realities of life
 Communicating love :Children should be
dealt with love, sympathy, security and sense
of well being.

 Encountering alcohol abuse: Family should
not over react when they come to know about
the chemical dependence of the person .
 They should keep all lines of communication
open. Family should speak to his friends
,inform his teacher and should consult for
professional evaluation.

 Accepting the fact: The professionals should
let the person recognize his alcohol
depending and that he is suffering with a
disease and needs to be controlled
.Recognizing their reality means half their
battle won.

 Confrontation: If the person does
not accept the disease ,then
confront him. Family should talk
honestly and without anger, should
describe their anger only when the
person can understand it and
should be specific while talking to
the client.

Alcoholism

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