CASE PRESENTATION

ON SUBSTANCE USE
DISORDER
PRESENTED BY
ASMITA SUBEDI
ROLLNO 4
SARADHA KHANAL
ROLLNO.
PBBN 3RD YEAR
NORVIC INSTITUTE OF NURSING EDUCATION
 CONTENT
• OBJECTIVE
• HISTORY TAKING
• FAMILY TREE
• PHYSICAL EXAMINATION
• MENTAL STATUS EXAMINATION
• DEVELOPMENTAL TASK
• DISEASE PORTION
• DRUGS USE IN MY PATIENT
 CONT……
• INVESTIGATION
• APPLICATION OF NURSING THEORY
• NURSING CARE PLAN
• PROGRESS REPORT
• DIVERSIONAL THERAPY
• HEALTH TEACHING
• SUMMARIZATION
• REFERENCE
 OBJECTIVES OF CASE STUDY

• GENERAL OBJECTIVE

• SPECIFIC OBJECTIVES
 GENERAL OBJECTIVES
• To acquire complete knowledge about the
disease condition and be able to carry out
necessary intervention when in need as well
as to be able to explain about its experience to
others.
 SPECIFIC OBJECTIVES
• To be able to provide nursing care to the
individual with different mental disorders.
• To be able to identify the physical and
psychological problems of the client.
.To be able to interpret the significant findings
of mental status examination.
• To be able to formulate appropriate nursing
management according to nursing process
including application of theory.
PHYSICAL EXAMINATION
 MENTAL STATUS EXAMINATION(S)
• General appearance and behavior:
• Built: normal
• Facial expression: calm
• Age group: appropriate for his age, looked above 40yrs
• Grooming: well groomed
• Hygiene: maintained
• Level of cooperation: cooperative
• Level of communication: average
• Psychomotor activity: signs of restlessness, tremors.
 Continue...
• Talk or speech:
• Spontaneous, normal reaction time, slow
pitch, normal understandable tone, volume
decrease.
• Mood:
• The subjective and objective mood was
congruent.
• Thought
• Stem of thought: normal
• Form and production: normal
• Content of thought: normal
 Continue..
• Perception:
• No signs of illusion or hallucinations

• Attention and concentration:

• The attention and concentration level is
normal.
• Memory:
• Immediate memory: intact ( 12 months
question was answered immediately)
• Recent memory: intact
• Q: aja bihana tarkari k khanu vayo?
• Remote memory: intact
• Q: tapai ko chori kaile janminu bhako?
• Orientation:
• Time: oriented
• Place: oriented
• Person: oriented

• Intelligence:
• Her intellegence level was of average level
• Judgment:
• His judgment was good.
• General knowledge:
• His general knowledge is average

• Insight:
• Insight present
 DEVELOPMENTAL TASK
ACCORING TO Havighurst’(s)
Middle Age – 36 – 60 years
• Maintaining economic standard of living
• Performing civic and social responsibilities
• Relating to spouse as a person
• Adjusting to physiological changes
 DEVELOPMENTAL TASK
DEVELOPMENTAL TASK PRESENT ABSENT
The young adult achieved independent from PRESENT
parental control

They begain to control strong friendship and PRESENT

intimate relationship outside the family.

They establish personal set of values PRESENT

They prepare for life work and develop the PRESENT

capacity for intimacy.
 SUBSTANCE USE DISORDER
 CANNABIS
OPOID
• COCAINE- STIMULANTS
• HALLUCINOGENS
• NICOTINE
• CAFFEINE
 ICD CODE FOR SUBSTANCE USE
(F10 – F19)
• F10 = mental and behavioral disorder due to
use of alcohol
• F11 = Due to use of opioids
• F12 = Due to use of cannabinoids
• F13 = due to use of sedatives
• F14 = Due to use of cocaine
• F15 = Due to use of other stimulants
• F16 = Due to use of hallucinogens
 CONTINUE…
• F17 = Due to use of tobacco
• F18 = Due to use of volatile solvents
• F19 = Due to use of multipale drugs use
CANNABIS USE DISORDER
CANNABIS
 INTRODUCTION
• Cannabis is weed like species.
• It contains psychoactive chemical like
THC(TETRA HYDRO CANNABINAL)
• It is derived from Greek word Kannabis
• It has different name in Nepal ( i.e ganja,
chares, bhang, marijuana)
• It is some time used at certain religious
ceremonies.
 Cont..
• Ganja is an indigenous form of cannabis,
which has been used traditionally in Nepal
from centuries.
• Shiva sect of Hindu religion allows taking
ganja, which is very classical.
• It is regulated by social norms and does not
create social problem in traditional social
structure of Nepal.
 CONT……..
• The history of modern drugs use begain in
1960s, when the hippies from the western
world introduced them in Nepal. Then the
types of drugs gradually shifted from cannabis
to synthetic opiates and sedatives- hypnotic
and their mode of administration also
changed from smoking or ingesting to
injecting.
 DEFINATION
Cannabis is the genetic name for various
preparations of hemp plant.
The flowering tops of the cannabis plant
secrete a sticky resin that contain the active
ingredient of marijuana known as delta-9 tetra
hydro cannabinal.
 BHANG
 It is derived from the cut tops of uncultivated
plants and has low resin content.
 GHANJA
The second grade is obtained from the
flowering tops and leaves of carefully selected
cultivated plants and it has a higher quality
and quantity of resin than bhang.
 CHARES
The third highest grade is largely made from
the resin itself, obtain from the tops of mature
plants, only this version is properly called
hashish.
 MARIJUANA
It is made up of flowering tops and
leaves(secrete a sticky resin).

NOTES:
ROUTE: SMOKING OR INGESTION( CHEWING
OR EATING)
 MECHANISM OF ACTION
THC, the main active ingredient in marijuana ,
binds to and activate specific receptors
,known as cannabinoid receptors.
There are many of these receptors in parts of
the brain that control memory , thought,
concentration, time and depth perception and
coordinated movement.
 Cont….
By activating these receptor ,THC interferes
with their normal functioning.
The high lipid-solubility of cannabinoids result
in their persisting in the body for long periods
of time. Even after a single administration of
THC, detectable level of THC can be found in
the body for a week or longer.
 DRUG DEPENDANCE
Drugs dependence refers to a state when the
person is habituated to take the drugs so
frequently that interferes his bodily, social and
occupational functioning.
 OPIOID DEPENDANCE
• Opioids are drugs that act on the nervous system
to relieve pain. Continued use and abuse can lead
to physical dependance, psychological
dependance and withdrawal symptoms. They
come in tablets, capsules or liquid. These can be
bought illegally or prescribed

• Opioids include substances such

as morphine, heroin, codeine and oxycodone.
 Epidemiology
• The lifetime prevalence for heroin use is about 1
percent (DSM-IV-TR)

• Age: 18 to 25 years

• – Methods of administration: injecting, smoking,

snorting

• – The male-to-female ratio: 3 to 1.

 Identification of drug dependance
• Lack of interest in studies
• Loss of interest in hobbies , games and sports
• Withdrawal from family
• Social isolation
• Blank expression, irresponsible and aggressive
behavior
 continue..
• Irregular eating and sleeping habit
• Longs hours in bathroom
• Lying and stealing
• Lack of energy and motivation
• Low productivity
• Impaired judgment
 Opioids use pattern
• 1. Acute intoxication
• 2. Withdrawal State
• 3. Dependence syndrome
• 4. Harmful Use
 Opioids Intoxication
• Euphoria, psychomotor↑or↓, impaired
judgment, attention, memory or impaired
social or occupational functioning.
• Pupillary constriction, or dilation
• Drowsiness, Slurred speech
• Slow respiration, Respiratory depression,
Death due to respiratory failure
 Opioids Withdrawal
• Onset within 6-12 hours, reaches its’ peak
within 48 hours and subsides over a period of
5-7 days, and persist persist for more than 14
days.
 Tolerance and Dependence

• Tolerance: high that a hundred fold

increases in dose is required to produce
the original effect.
 Harmful effect
• Central Nervous System
• Gastrointestinal Effects
• Cardiovascular Effects
• Dermatological Effect
• Respiratory Effect
• Muscular Effect
OPOID WITHDRAWAL
 SIGN AND AYMPTOMS OF OPIOID
WITHDRAWAL(s)
ACCORDING TO BOOK ACCORDING TO PATIENT
1) Anorexia and nausea -ABSENT
2) Bone, joint and muscle pain -MUSCLE PAIN
3) Insomnia and disturbed sleep -PRESENT
4) Intense craving -PRESENT
5) Dilated pupils -ABSENT
6) hypertension -ABSENT
7) lacrimation -PRESENT
8) sweating -PRESENT
9) fever -ABSENT
10)hypothermia/ hyperthermia -ABSENT
11) Tremor -PRESENT
 HARMFUL EFFECT
• • Central Nervous System
• • Gastrointestinal Effects
• • Cardiovascular Effects
• • Dermatological Effect
• • Respiratory Effect
• . Muscular Effect
 SIGN AND SYMPTOMS OF
INTOXICATION(m)
ACCORDING TO BOOK ACCORDING TO PATIENT
Mild euphoria( sense of pleasant feeling Present
and optimistic)
Altered sense of perception Absent
Impaired attention/ judgment Absent
Red eyes Absent
tremor Present
photophobia Absent
relaxation Absent
Sense of floaters in air Present
Light headaches Present
Lacrimation Absent
Dry mouth Present
EFFECT OF CANNABIS
 WITHDRAWAL SYMPTOMS
(MOSTLY FOUND IN1st 72-96hrs)
ACCORDING TO BOOK IN MY PATIENT
Sleep disturbance present
Irritability present
Loss of appetite present
Nervousness present
Sweating absent
Tremor of hand present
Anxiety present
Craving present
 COMPLICATION
Transient or short lasting psychiatric disorder
as acute anxiety, paranoid psychosis, hysterical
states, hypomania, schizophrenia like state.
Amotivational syndrome
Memory impairement
 TREATMENT
(supportive and symptomatic
treatment)
ACCORDING TO BOOK IN MY PATIENT

Reassurance Done

Antipsychotic Given

Antianxiolytic Given

Psychotherapy( family therapy and individual Individual therapy

therapy)
 DRUGS USE IN MY PATIENT
• TAB PANTOP 40mg P/O
• TAB OLENZAPINE (OZE) 20mg P/O (HS)
• TAB LOREE 2mg P/O(HS)
• TAB BENZEE PLUS 1TAB P/O(HS)
 DRUGS USE IN MY PATIENT(s)
• TAB TORVATE 300 mg
• TAB OZE 2.5 mg
• TAB LOREE 2mg
• TAB METFORMIN 1000mg
 INVESTIGATION
ACCORDING TO BOOK ACCORDING TO PATIENT

HISTORY TAKING DONE

MENTAL STATUS EXAMINATION DONE

BLOOD TEST CBC,LFT,HBSAG, UREA,CREATININE,SUGAR

FASTING

URINE ROUTINE DONE

DRUG URINE ANALYSIS THC = DETECTED

OPI = DETECTED
COC = NOT DETECTED
AMP , BZO = NOT DETECTED
PROBLEM OF DRUG DEPENDENCE
Depression, frustration , anxiety.
 relapse of drugs abuse
Drugs overdose
Bacterial endocarditic, cellulities, hepatitis,
thrombophlebitis, pulmonary embolism,
septicemia caused by intravenous drug abuse.
Infection with HIV through shared needles.
 Cont…..
Drugs induced lose of inhibitions may lead to
unsafe sexual practices, which may result in
unwanted pregnancies, sexual practices, which
may result sexually transmitted diseases, HIV or
hepatitis.
Increase in various cancer rates: for example
lungs and pharynx cancer associated with
nicotine use, mouth and stomach cancer are
associated with alcohol abuse and dependence.
 Cont…
Behavioural problem: lying, stealing, cheating,
irregular at work, false yet convincing excuses
etc.
Problem with memory and concentration are
seen with hallucinogen use including
marijuana.
Problem with law: criminality
 PREVENTION
PARENTS:
 Provide the child with a secure stable home
environment.
Keep the child occupied, provide opportunity
for sports activities.
Talk to your children about the risks of drug
use and abuse and how to stay away from
people and places that influence him.
 Cont……
Be a good listener when your children talk
about peer pressure and be supportive of
their efforts to resist it.
Set a good example: don’t abuse alcohol or
addictive drugs.
Good interpersonal relationship between
parents and children.
Treatment of family member who may be
contributing to the drug abuse.
 COMMUNITY
 Prohibition of smoking in school and other
places.
 Prohibition of cigarette advertisement.
 Education of target groups and the general public
through T.V, radio, postures to create awareness
of the problem.
 Health education to school, college student and
the youth about the danger of drugs abuse
through the curriculum and mass media.
 Cont……
Teachers in school should allocate a certain
period in a week for talking to students on the
hazards of drugs addiction.
Treatment of family members who may be
contributing to the drug abuse.
Addictive drink during festivals should be
avoided.
 GOVERNMENTAL ROLE
Adopting certain legal regulations; for
controlling the import and export of narcotic
drugs.
Regulating the production and distribution of
drugs.
Establishing penalties for illegal possession or
sale of dangerous drugs.
 Cont…..
The provision of program including:
Treatment
Rehabilitation
Research and education
 Other……
Reduction of over prescribing by
doctors(especially benzodiazepines and other
anxiolytic drugs).
Integration of substance use related problem
with general health system.
Lower, restrict or eliminate availability of
drugs(supply reduction).
 RELAPSE
• About 80% of the addicts resume their habit
within 6 months. The main causes of relapse
are:
Presence of overt or latent psychiatric illness.
Poor follow up.
Poor rehabilitation services.
Easy availability of the drugs.
 Cont…..
Continues peer pressure
Out door method of treatment.
 TREATMENT
1.Identification of drugs addicts:
 What type of drugs is he/she using?
 How much and how often?
 What is the pattern of use?(e.g each day,
each weekend etc)
 What is the effect on his behavior his study
or work and his relationship.
 Cont…
2. Motivating the patient for treatment.
3.Detoxification(required hospitalization). Treat
the withdrawal symptoms of drugs.
 NURSING INTERVENTION
Encourage patient to participate as the treatment
plan.
Place the patient in room near to the nursing
station or where the staff can observe the patient
closely, inform physician when necessary.
Administer medications as prescribed by
physician. Encourage the patient to take
medication which will help to reduce symptoms
associated with drug abuse.
 Cont…
Encourage him to verbalize the reason of
anxiety.
Monitor the patients health status.
Encourage the patient to take adequate diet
and plenty of fluids and fluid replacement if
patient has severe vomiting. Give small
frequent feeding.
Help the patient to feed if tremors.
 Cont……
Record intake and output.
Encourage him to maintain personal hygiene.
Decrease environmental stimuli( bright lights,
television, visitors) when the client is restless
and irritable.
Observe the patient for any interruption of
sleep and use sleep promote measures.
 Cont………
Assist the patient in self care activities,
provide complete care depending on the
severity of the patient.
Encourage the patient to express his views on
obtaining the drugs.
Explain the relative not to feel emotionally
upset.
 APPLICATION OF NURSING THEORY
PEPLAUS THEORY(THEORY OF
INTERPERSONAL RELATIONSHIP)

• IT HAS 4 PHASES.
Orientation phase
Identification phase
Exploitation phase
Resolution phase
 THEORIES OF INTERPERSONAL
RELATIONSHIP
I applied 7 nurses role:
1. Stranger role
2. Resources role
3. Teaching role
4. Counseling role
5. Surrogate role
6. Active leadership
7. Technical expert role
 ADDITIONAL ROLE
Consultant
Health teacher
Tutor
Safety agent
Mediator
Researcher
administrator
NURSING DIAGNOSIS
PROGRESS REPORT
 DIVERSIONAL THERAPY
• Diversonal therapy include:
Talked to him about about his family, hobbies
so that he can engaged in gossip.
Tried to involve him in morning exercise
Encourage him to share his feeling with other
client and even with the counsellor.
I always accompany him during day time so
that he can express his feeling as much as
possible.
 Cont…..
Involving him in journal writing, board game
 HEALTH TEACHING
• Stress management technique
• Nutrition
• Personal hygiene
• Medication
• After discharge follow up
ANY QUARIES
 REFERENCE
• Budathoki .S, Prajapati. P, A textbook of Mental and
Psychiatric Nursing, first edition page no 147.
• Mosby's Nursing drug reference 28th edition.

• Neupuane .N, Shrestha. R, Behavioral Science Mental

Health Nursing Makalu Publication, 4th Edition, 2014

• Rai .L, Nursing Concept Theories and Principles 3rd

Edition, page no 207.
 CONT...
• Sharma .C, Sharma .P, Essentials of Psychiatric
and Mental Health nursing 2nd edition page
317.
• Subedi . D, Mental Health and Psychiatric
Nursing, Makalu publication,2nd edition , pg no
172.