Introduction to Medical-Surgical Nursing, 6th ed.
57
Lesson Plans for
Substance-Related and Addictive Disorders
CHAPTER LESSON PLANS & OBJECTIVES
Lesson 57.1:
2. Discuss prevention and treatment for substance-related and addictive disorders.
4. Describe the development, course, and outcomes of gambling addiction.
6. Describe the nursing diagnoses and interventions associated with substance-related and addictive
disorders.
7. Discuss populations who present special problems in relation to substance use and gambling
addiction.
CHAPTER TEACHING FOCUS
• In this chapter, the student will be introduced to topics related to substance-related disorders.
• The student will become acquainted with the etiology and risk factors of substance-related or addictive
disorders, components of a nursing assessment of a patient with substance–related or addictive
disorders, and disorders associated with substance abuse or addiction.
• Treatment, nursing diagnoses, and interventions will also be discussed.
CONCEPTS
The following conceptual themes and specific concepts match those presented in Giddens, J. R. (2013).
THEME: Maladaptive Behavior
• Concept: Addiction
• Exemplar: Alcohol and Alcoholism, p. 1312
• Box 57-1: Twelve Steps of Alcoholics Anonymous, p. 1314
• Box 57-2: Twelve Traditions of Alcoholics Anonymous, p. 1315
• Nursing Care Plan: Patient Who Is Abusing Alcohol, p. 1316
• Pharmacology Capsule: Disulfiram, p. 1317
• Pharmacology Capsule: Naltrexone, p. 1317
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CHAPTER PRETEST
Have the students answer these questions prior to covering this chapter to understand where they stand
in relation to the content.
1) A person exhibits behavior in which category when the person is unable to fulfill major role
obligations at work, school, or home?
a) Impaired control
b) Risky use
c) Pharmacologic risk
d) Social impairment
2) The theory that individuals possess certain personality traits that predispose them to alcohol or
substance abuse is the __________.
a) biologic theory
b) sociocultural theory
c) intrapersonal theory
d) behavioral theory
3) When planning care for a patient who is an alcoholic, one of the most important factors for the nurse
to consider is __________.
a) when the patient last had a drink
b) the patient’s past coping skills
c) the patient’s body weight
d) the patient’s history of previous treatment
4) An alcoholic patient states that he started drinking because it was the only way he could deal with the
loneliness after his wife died suddenly. This an example of which defense mechanism?
a) Projection
b) Rationalization
c) Denial
d) Intellectualization
5) A patient’s spouse who structures her life around covering up for her husband’s substance abuse
problems can be considered __________.
a) a conspirator
b) addicted
c) codependent
d) a scapegoat
6) A planned meeting used to confront an alcoholic about the effects of drinking on the lives of his family
is __________.
a) a confrontation
b) an ultimatum
c) an intervention
d) a 12-step program
7) A drug used to assist in blocking the effects of withdrawal symptoms in drug addicts is __________.
a) Narcan
b) Antabuse
c) Xanax
d) Catapres
8) What substance is most likely to be abused by an elderly patient?
a) Cocaine
b) Alcohol
c) Sleeping pills
d) Marijuana
9) When Narcan is given to a patient to treat an opiate overdose, what does the patient experience?
a) Acute withdrawal
b) Addiction
c) Depression
d) Respiratory distress
10) A patient diagnosed with both a psychiatric illness and substance–related disorder is considered to
have __________.
a) an addictive personality
b) a dual diagnosis
c) a risk for injury
d) a need for institutionalization
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Chapter Pretest Answers
CHAPTER BACKGROUND ASSESSMENT
Discuss these questions with your students prior to covering this chapter to understand where they stand
in relation to the content.
Question: What are three medical complications related to chronic alcoholism? Describe signs and
symptoms associated with each one.
Answer: Some medical complications associated with chronic alcoholism are cirrhosis of the liver,
Question: What are three defense mechanisms that substance abusers commonly use? Provide an
example of each.
Answer: Substance abusers often draw on several defense mechanisms to rationalize their addictive
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Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 57.1
Instructor Preparation
Textbook Objectives Covered
2. Discuss prevention and treatment for substance-related and addictive disorders.
4. Describe the development, course, and outcomes of gambling addiction.
6. Describe the nursing diagnoses and interventions associated with substance-related and
addictive disorders.
7. Discuss populations who present special problems in relation to substance use and gambling
addiction.
Lesson Preparation Checklist
• Prepare lecture from TEACH lecture slides available on Evolve.
• Guest speaker: nurse skilled in the care of substance abuse patients
• Student performance evaluation of all entry-level skills required for student comprehension of
Materials and Supplies
• computer and PowerPoint
projector
• prize for winner of poster or
handout contest
Key Terms
• addiction (p. 1312)
• codependent (p. 1313)
• delirium tremens (p. 1310)
• 12-step program (p. 1314)
• withdrawal (p. 1305)
__________________________________________ Chapter 57Substance-Related and Addictive Disorders 5
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LESSON 57.1
Student Preparation
Assignments 2 hours
1
READ – Textbook (pp. 1305-1307)
REVIEW
• Figure 57-1: Overall risk for addiction (p. 1306)
ANSWER – Text
ANSWER – Study Guide
• Part IA: 1, 7 (p. 391)
2
READ – Textbook (pp. 1307-1308)
ANSWER – Text
• Review Questions for the NCLEX Examination: 7 (p. 1327)
3
READ – Textbook (pp. 1310-1323)
REVIEW
• Table 57-1: Common Mood-Altering Chemicals (pp. 1311-1312)
• Box 57-1: Twelve Steps of Alcoholics Anonymous (p. 1314)
• Box 57-2: Twelve Traditions of Alcoholics Anonymous (p. 1315)
ANSWER – Text
• Review Questions for the NCLEX Examination: 2, 5, 8 (pp. 1327-1328)
ANSWER – Study Guide
4
READ – Textbook (pp. 1308-1309)
5
READ – Textbook (pp. 1309-1310, 1323)
ANSWER – Text
• Review Questions for the NCLEX Examination: 3, 4 (p. 1327)
ANSWER – Study Guide
• Part IA: 6 (p. 391)
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LESSON 57.1
6
READ – Textbook (pp. 1323-1324)
ANSWER – Text
• Review Questions for the NCLEX Examination: 6 (p. 1327)
ANSWER – Study Guide
• Part IIIF: 3-5 (p. 395)
• Part IIIG: 1, 2, 4 (p. 396)
7
READ – Textbook (pp. 1324-1326)
ANSWER – Text
• Review Questions for the NCLEX Examination: 9, 10 (p. 1328)
ANSWER – Study Guide
SIMCHART
• Case Study: Daniel Miller: Overdose
50-Minute Lesson Plan
Lecture Outline 20 minutes
Slide 1
Chapter 57
Substance-Related and Addictive Disorders
1
Substance-Related Disorders
• Drug and alcohol abuse contribute to death of over 100,000 Americans annually
Slide 3
Substance-Related Disorders (cont.)
• Impaired control
• Social impairment
• Risky use
• Pharmacologic criteria
TALKING POINTS:
• What are characteristics of each category?
Biologic Theory
• Genetic factors account for 40-60% of individual’s vulnerability to addiction
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Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 57.1
Slide 5
Biologic Theory (cont.)
• Medical community considers drug dependency to be a physical illness, like those with
the following characteristics
• Incurability
• A genetic predisposition
• A potential to be treated effectively only by total abstinence from the substance that
the body cannot handle
Slide 6
Environmental Factors
• Home environment: children who live in a home where older adults abuse alcohol or
drugs, or engage in criminal behavior may be at increased risk for addiction
Slide 7
Environmental Factors (cont.)
• People who live in poverty or crime-ridden areas may use drugs to relieve stress
• People with strong religious values prohibiting excessive use of drugs have lower rates of
• In college, students may be exposed to alcohol and drugs
Slide 8
Other Factors
• Factors that increase addiction risk: early use, availability, costs, method of administration
• The earlier the individual begins to use substances, the more likely he/she is to develop
more serious abuse
• Smoking or injecting a substance intravenously increases its addictive potential; drug
enters brain within seconds
Slide 9
Comorbidity
• Many people who are addicted to drugs are also diagnosed with mental illnesses
• Individuals with mood or anxiety disorders are almost twice as likely to suffer from drug
abuse disorder and vice versa
Prescription Drugs
• Nonmedical use of prescription drugs is highest among young adults (opioid pain
2
Slide 11
Prevention
• Some children are addicted to drugs by age 12 or 13; adolescence is critical time for
preventing drug addiction
• Teenagers are still developing judgment, decision-making skills
• Alcohol use has decreased, but marijuana use has increased, especially among boys
Slide 12
Prevention (cont.)
• Preventing alcohol use among children
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LESSON 57.1
Slide 13
Prevention (cont.)
• Talk to children about dangers of early alcohol use; discuss during annual physicals
• Share literature about preventing alcohol abuse with the community
• Support recreational alternatives to drinking
• Encourage parents to learn about their responsibilities regarding alcohol access and
serving alcohol to minors in their homes
• Talk to teachers, counselors, school administrators about school prevention programs
• Contact elected and appointed officials to inform them about alcohol abuse
Slide 14
Treatment
• Addiction is complex but treatable disease; no single treatment is appropriate for
everyone
• Treatment attends to needs of the individual, requires an adequate period of time in
treatment
• Counseling and behavioral therapies are most commonly used form of therapy;
medications are an important treatment for many patients
• Treatment plan must be assessed continually, modified as necessary
• Treatment should assess for presence of other diseases
Treatment (cont.)
4
Slide 16
concealing the extent of involvement with gambling
• Only about 10% of those with gambling addiction seek treatment
Gambling Disorder
• Persistent and recurrent problematic gambling behavior leading to clinically significant
impairment or distress
• Involves risking something of value in hopes of gaining something of greater value;
causes disruptions in personal, family, and/or vocational pursuits
• Individual gambles with increasing amounts of money to achieve the desired excitement,
5
Slide 17
Health History
• Interview with patient, family members, significant others; a social assessment; medical
records; school or military records
TALKING POINTS:
• A nonjudgmental and matter–of-fact manner is the least likely to alienate an already
defensive patient.
• Why is it important to know when the patient last ingested the drug and how much?
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LESSON 57.1
Slide 18
Health History (cont.)
• Patterns and consequences of abuse
• Abuser describes typical patterns of behavior and a combination of physical or
psychologic withdrawal symptoms
• Many have erratic and unprovoked mood swings
TALKING POINTS:
• A few patients may not experience any physical withdrawal symptoms despite a history of
prolonged, frequent, and heavy abuse, even of some substances that usually are
physically addicting.
• What are blackouts?
Slide 19
Health History (cont.)
• Defense mechanisms employed
• Denial: patients state that they do not have a problem with drug use despite evidence
to the contrary
• Rationalization: abusers attempt to justify the reasons for their abuse of substances
TALKING POINTS:
• What are examples of each type of defense mechanism?
Physical Examination
• Many substance abusers appear malnourished and poorly cared for
• Evidence of physical trauma: falls, abrasions, or fights
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LESSON 57.1
Slide 21
Diagnostic Tests
• May have abnormal liver function tests, electrolytes, nutritional status, and gastric function
tests
• May have hepatitis B and C, syphilis, HIV
• Blood alcohol study
• Most accurate test available to measure the degree of intoxication on initiation of
treatment for alcohol abuse
• Urine drug screening
TALKING POINTS:
• A blood alcohol level above 0.3% requires treatment for overdose; at concentrations of
over 0.4%, death is likely.
• Legal intoxication is determined when a person’s blood alcohol level reaches what level?
• Drugs that are most likely to be identified with a urine drug screen include amphetamines,
barbiturates, benzodiazepines, cocaine, “crack,” opiates, marijuana, PCP, LSD, opioid
analgesics, sedatives, and stimulants.
• Depending on the length of the hair, substance use can be detected for up to 1 year after
only 2 or 3 days of use.
3
Slide 22
Alcohol
• Most commonly abused drug in the United States
• According to the American Society of Addiction Medicine, alcoholism is “a primary,
chronic disease with psychosocial and environmental factors influencing its development
TALKING POINTS:
• Simple intoxication from alcohol usually lasts less than 12 hours and is followed by the
unpleasant experience of a hangover beginning about 4 to 6 hours after the last drink.
• What are typical symptoms of alcohol intoxication?
Slide 23
Alcoholism
• Chronic use involves the regular daily ingestion of large quantities of alcohol, regular
heavy drinking only on weekends, or binges of heavy drinking followed by long periods of
abstinence
• Physical addiction occurs when alcohol becomes integrated into physiologic processes at
__________________________________________ Chapter 57Substance-Related and Addictive Disorders 11
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LESSON 57.1
Slide 24
Alcohol Withdrawal Syndrome
• Involves physiologic and behavioral symptoms that begin when the individual’s blood
alcohol level drops
Slide 25
Alcohol Withdrawal Syndrome: Stages
• First stage: early withdrawal
• Occurs within 6 to 12 hours after the last drink
• Symptoms: anxiety, agitation, then irritability
Slide 26
Alcohol Withdrawal Syndrome: Stages (cont.)
• Second stage: major withdrawal
• Begins with seizures and hallucinations; can advance to life-threatening delirium
tremens (or DTs)
• Occurs after about 3 days (sometimes less) without alcohol and can be predicted from
TALKING POINTS:
• Alcohol withdrawal is the most life-threatening withdrawal syndrome in comparison to
those associated with other types of commonly abused drugs, even heroin.
• What advice should the nurse give an alcoholic who wants to quit drinking?
Slide 27
Medical Complications
• Cirrhosis of the liver, pancreatitis, gastrointestinal bleeding, Wernicke encephalopathy,
Korsakoff psychosis, and fetal alcohol syndrome
• Wernicke encephalopathy
• Due to vitamin B1 (thiamine) deficiency
Medical Complications (cont.)
Slide 29
Medical Complications (cont.)
• Fetal alcohol syndrome
• A medical complication of great concern
• If woman drinks to excess throughout pregnancy, unborn child at risk for low birth
weight, mental retardation, growth deficiencies, heart defects, facial malformations,
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LESSON 57.1
Slide 30
Treatment for Alcohol Abuse
• Active family involvement in the treatment of alcohol abuse is critical to the effectiveness
of treatment outcomes
• Alcoholism affects everyone in the family system
Slide 31
Treatment for Alcohol Abuse (cont.)
• Family and peer pressure and confrontation critical in inducing alcoholic to seek treatment
• Through participation in a 12-step self-help support group for the significant others of
substance abusers, called Al-Anon and Al-Ateen, spouses, children, friends, and
coworkers can learn how to cope with issues and avoid enabling the alcoholic so it
becomes harder for him/her to continue a destructive pattern of drinking
Slide 32
Treatment for Alcohol Abuse (cont.)
• Intervention
• A planned, structured meeting by family and friends to confront the alcoholic, who is
brought into the meeting without prior notification about the intervention
• Led by a specially trained interventionist who helps those involved in the process to
TALKING POINTS:
• The use of this strategy has come under criticism because the user confronted in this way
often feels coerced into treatment.
• How do proponents of the use of intervention justify the consequences it may have?
Slide 33
Treatment for Alcohol Abuse (cont.)
• Detoxification
• Usually in an inpatient hospital
• Vital signs are monitored frequently
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Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 57.1
Slide 34
Treatment for Alcohol Abuse (cont.)
• Rehabilitation
• Once medically stable, patient referred to inpatient or outpatient program, depending
on needs and resources
• Inpatient program lasts about 28 days; includes highly structured scheduling of
Treatment for Alcohol Abuse (cont.)
• Alcoholics Anonymous
• Nonprofit, worldwide organization of alcoholics who meet anonymously in small
TALKING POINTS:
• What are the 12 steps of the program?
Slide 36
Treatment for Alcohol Abuse (cont.)
• Rehabilitation
• Trend is toward using more nontraditional treatment approaches
• The teaching of stress management; social skills training; behavioral approaches
TALKING POINTS:
• Cost-containment has stimulated the development of many new types of outpatient
programs for the treatment of alcoholism.
• What treatment programs may an alcoholic be referred to?
14 Chapter 57Substance-Related and Addictive Disorders ___________________________________________
LESSON 57.1
Slide 37
Treatment for Alcohol Abuse (cont.)
• Relapse prevention
• Assists patients to identify triggers of substance use
• Person then actively avoids these people and places
• Other coping strategies also developed that can be used if the person encounters a
trigger
• Aftercare and recovery
TALKING POINTS:
• Relapse prevention is a key component in the treatment of persons with substance abuse
or addictive disorders.
• What services are provided by Adult Children of Alcoholics and Codependents
Anonymous?
Slide 38
Treatment for Alcohol Abuse (cont.)
• Medications
• Disulfiram (Antabuse)
• Metronidazole (Flagyl)
• Naltrexone hydrochloride (Trexan)
• Antidepressants
• Amitriptyline (Elavil)
TALKING POINTS:
• The treatment team may recommend the use of disulfiram (Antabuse) to assist the
alcoholic who is highly motivated to remain sober but recognizes that poor impulse control
may increase the odds of relapse.
• Inhibits the metabolism of alcohol in the body, producing an uncomfortable, potentially