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Nursing Care Plan for
Client with SubstanceRelated Disorder
Dian Wahyuni
Mental Health Nursing II
Binawan Institute of Health Science
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Objectives
Discuss the Biologic, Psychologic, and
Sociocultural Context of Care
Understand the symptoms patterns
Develop nursing care plan for clients with
substance use
Understand treatment modalities
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Psychological Context
Depressed mood
Unmet dependency meet
Impulsive style Inability to contend with life stress
Unmet needs of power/attention
Low self-concept/self-esteem Inability to tolerate failure
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Sociocultural Context
Peer influence/pressure
Detrimental environment
Deteriorating neighborhood Alienating issues
Illegal behaviors
Drug trafficking
Dysfunctional family system
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Terms
Substance Dependence / addiction Continued to use despite substance-related problems, asevidence by physiologic, cognitive, and behavioral symptoms.
Tolerance: The need for greater amount of the substance toproduced the desire effect or when the same amount of thesubstance is used overtime the effect is decreased
Withdrawal : The physiologic, cognitive, and behavioralsymptoms (specific to the substance) that occur when heavy useof the substance for over long period is stopped and thedecrease level of the substance in blood/tissues.
Compulsive use pattern: the use pattern is longer than intendedand larger is needed, the individuals want to stop the habit but
always fail, more time devoted to gain, use and recovering fromthe drugs, the use of substance continues despite the physical,legal, occupational problems.
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Substance Abuse Failure to complete obligations in home, work or school
Continued use of substance despite danger
Legal problems related to substance use
Recurrent social or interpersonal problems
Substance intoxication A reversible substance-specific syndrome that occurs following
intake or exposure to the substance
Comorbidity / Dual Diagnosis Substance-related disorders that occur in association with other
Axis I mental disorders in DSM-IV-TR Other coexisting mental disorders with substance disorders are:
anxiety disorders, mood disorders, major depression, bipolardisorders, personality disorders.
Terms
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Klasifikasi Zat
1. Depresan SSP Alkohol
BArbiturat
Sedatif/ Hipnotik NonBarbiturat
Ansiolitik Inhalan
Opioid (analgesik narkotik )
Sintetis
2.Stimulan SSP Amfetamin Stimulan Non Amfetamin
Nikotin
Kafein
3. Halusinogen
•Fenisiklidin (PCP)
•Psilosisbin (dalam jamur psilocybe)
•Meskalin (dalam kaktus peyote)
• Asam lisergis
4. Kanabioid
•Kanabis (Mariyuana)
•Hasish (hash)
•Dronabinol (Marionol)
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Depresan SSP
Efek muncul karena neurotransmitor inhibitordistimulasi (GABA) atau mengubahneurotransmiter eksitasi (dopamin danepineprin)
Penggunaan kronis dapat mengurangi produksidan suplai neurotransmitor inhibitor
Neuro eksitasi terjadi bila konsumsi dihentikan
tiba-tiba. Stimulasi Norepineprin dan dopaminyang terjadi setelah penghentian menyebabkangejala putus zat.
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Stimulan SSP
Meningkatkan pelepasan norepineprin dari saraf
prasinaps dan mencegah pengambilannya
kembali
Blokade prasinaps menyebabkan deplesikatekolamin dan menyebabkan peningkatan
kebutuhan akan zat yang menstimulasi.
Bila dihentikan secara tiba-tiba, neurotransmiter
eksitasi akan sangat deplesi dan menyebabkan
depresi serta disforia yang parah
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Opioid
Adalah depresan SSP dan analgesik yang
sangat kuat
Menghambat pelepasan zat p dan
menempel pada reseptor endorfin untuk
meredakan nyeri
Bila dihentikan mendadak, akan terjadi
pelepasan norepineprin yang sangat
banyak
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Halusionogen
Menstimulasi reseptor prasinaps danmenyebabkan gangguan penglihatan danpersepsi
PCP melepaskan dopamin, norepineprin,serotonin dan menghambat GABA
Penghentian mendadak menyebabkan
ketidakseimbangan neurotransmiter danmenyebabkan kecemasan, insomnia danpanik
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Kanabioid
Mirip dengan halusinogen dan depresan
SSP
Menyebabkan sulit konsentrasi, euforia,
hilangnya memori jangka pendek
Penghentian yang tiba-tiba membuat efek
stimulasi berlebihan karena sifat depresan
dihentika
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Inhalan
Bekerja sebagai depresan SSP, dapat
menembus sawar darah otak
Dosisnya tidak dapat dikendalikan, sangat
berbahaya
Bila dihentikan tiba-tiba, tidak
menimbulkan gejala
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Assessment
Multiaxial Assessment (DSM IV TR)
Axis I: Clinical dysfunction
Axis II: Personality Disorders and Mental
Retardation
Axis III: Psychosocial and Environmental
Problems
Axis IV: Global Assessment of Functioning(GAF)
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Assessment
Autoanamnesis (client) and aloanamnesis(parents, caregiver or any significant person)
Physical Assessment
Psychiatric Assessment Laboratory Assessment
Fluoroscopy Assessment
Electrophysiology assessment
Psychology test
Social evaluation
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Autoanamnesis
Firstly build trust relationship with client then ask
client related to substance use
If trust relationship has not been established:
Identify areas where client needs professional help(problem at school, problems with parents, problems
in client working place, etc)
How long the problem has existed?
What efforts have been done?
Demographic data
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Ask client related to what, when, why and how the client use
the substance. Ask client related to medical complication related to drug use
Ask client related to other complication such as: insomnia,lack of concentration, agitated, lost of appetite, etc.
Ask client related to mental disturbance: hallucination,
delusion, panic, depression Why the client want to stop using right now? Why now?
How client use his/her leisure time?
Are there any problems with client psychosocial relationship?
How is client education, marriage and work history?
Is client have been admitted to hospital or rehabilitationcenter?
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Aloanamnesis
Client growth and development history
Educational, marriage, and work history
Typical behavior of client before the substance
consumption What are behaviors changes occurred?
Are tools used for substance use found inclient’s room? Or family found the substance in
client’s property? Was family members often lost their valuables?
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Physical examination
(not only limited to these signs and symptoms)
Examination Sign and Symptoms Details
Consciousness Somnolent
Stupor-coma
Delirium
Opioid intoxication, sedatif-hipnotic, alcohol,
inhalant. Amphetamines and cocaine
withdrawal.
Any substance overdose
Sedatif – hipnotik or alcohol withdrawl,
amphetamine or PCP intoxicationPulse Rapid
Slow
LSD or amphetamine intoxication,
opioid withdrawal
Opioid; sedatif-hipnotik; alcohol;
inhalant intoxication
Body temperatureHigh
Low
LSD intoxication; amphetamineintoxication. Alcohol, sedatif-hipnotic,
opioid withdrawal, infection disease
Opioid intoxication
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Examination Sign and Symptoms Details
Respiratory rate Slow
Fast and shallow
Sedatif-hipnotic, alcohol, or
opioid use
High dose sedatif hipnotic
intoxication
Blood pressure High
Low
Amphetamin, cocaine, LSD
and Canabis use
Alcohol withdrawl. Opioid
withdrwl (BP usually high at
the beginning)
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Examination Sign and Symptoms Details
Eye Palpebra is half closed
Conjunctiva :
Red
Pale
Sclera icteric
Pupil:
Pin pointDilatation and reactive
Dilatation and nonreactive
Eye movement:
Lateral nistagmus
Vertical or horizontalnistagmus
Lacrimation
Diplopia
Increase blinking reflect
Opioid intoxication
Canabis intoxicationLong consumption of
amphetamine and cocain
Substance use induced hepatic
disease
Opioid intoxication
Amphetamine and LSDintoxication
Anticolinergic drugs
Sedatif-hipnotic intoxication,
canabis intoxication
PCP intoxication
Opioid withdrawl
Sedatif-hipnotik intoxication
Sedatif-hipnotik withdrawl
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Examination Sign and Symptoms Details
Nose Rinore (wet)
Ulcus or Nasal Septum
perforation
Opioid withdrawl
Inhalant cocain use
Mouth Bad breath/ dry chemical
substance
Frequent yawning
Inhalant use
Amphetamine, cocaine or hallucinogen
intoxication, opioid withdrawl
Lung Bronchitis
Tuberculosis
Fibrosis
Cancer
Tobaco and canabis use
Heavy psychoactive drug user
Psychoactive drug user (parenteral
use)
Tobacco smoker
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Examination Sign and Symptoms Details
Heart Tachycardia
Arrhythmia
Amphetamin, cocain,
hallucinogen intoxication;
opioid, sedative-hypnotic,
alcohol withdrawal
Inhalant intoxication;
sedative-hipnotic withdrawl
Stomach Gastritis Alcohol use
Liver Cirrhosis hepatic
Fatty liver
B/C hepatitis
Heavy alcohol use
Overdose alcohol use
Parenteral/intravena opioid
use
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Examination Sign and Symptoms Details
Stomach wall Spasme Opioid or sedatif-hipnotic
withdrawlSkin Blushing
Sianosis
Over perspiration
Gooseflesh
Pruritus
Dry
Needle trackPopping scar
Paronikia, tinea, skabies, pedikulosis
Alcohol, amphetamine,
hallucinogen, and opioid use
Opioid, amphetamine,
cocaine and hallucinogen use
Amphetamine intoxication,
cocaine and opioidwithdrawal
Opioid withdrawl
Opioid use
Colinergic drug use
Intravena route of opioid,
amphetamine or barbiturate
Swallowing injection site,
usually because of opioid use
Psychotic user who doesn’t
pay attention in their self care
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Examination Sign and Symptoms Details
Nervi Craniales Diplopia, dismetria, dan disartri Sedatif-hipnotik, alcohol, opioid
and inhalant intoxication.
Motor nerve Ataxia
Light tremor
Major tremor
Sedatif-hipnotik, alcohol,
inhalant, opioid intoxication. Amfetamin, cocain, hallucinogen,
opioid withdrawl.
Sedatif-hipnotic withdrawl
Reflects Hyperreflexion
Hypo-/a-reflection
Amphetamin, cocaine, LSD use
Sedative –hypnotic, alcohol or
inhalant heavy intoxication
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Psychiatric Assessment Comorbidity/dual diagnosis
Anxiety, depression, dissocial personality disorders, hyperactivity are some mental disordersthat could lead to substance abuse
Substance abuse lead to several mental disorders: panic (cannabis user), psychosis (amphetamine or cocaine users), dementia (alcohol), depression (amphetamine and cocainewithdrawal) delirium (alcohol or sedative-hypnotic withdrawal)
Emotional disorders: Agitative: amphetamine, cocaine, cafeine, PCP intoxication
Aggressive: amphetamine, cocaine, PCP intoxication
Depression: Amphetamine, cocain, segdative-hypnotic, alcoholwithdrawal
Disforia/: cocaine or opioid beginners
Euforia: All psychoactive drugs intoxication
Nervous: Amphetamine, cocaine, hallucinogen, cafeine, PCP, cannabisuse. Opioid, sedative hipnotic, alcohol and nicotiine withdrawal
Impulsive: PCP intoxication Irritabel : Alcohol intoxication, sedatif-hypnotic, inhalant intoxication.
Alcohol, sedative hypnotic, nicotine withdrawal
Labil : Sedative-hypnotic, alcohol, PCP intoxication.
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Communication disorders:
Lots of talking: alcohol intoxication
Thought disorders: Delusions: Amphetamine, cocaine, hallucinogen, cannabis intoxication;
alcohol withdrawal
Depersonalization: Hallucinogen, PCP intoxication
Perception disorders: Hallucination: amphetamine, hallucinogen intoxication; alcohol
withdrawal
Illusion: hallucinogen intoxication
Sinestesi: Hallucinogen intoxication
Memory and Attention disturbance
Amnesia: alcohol, sedative-hypnotic withdrawal Dementia: long time use of alcohol
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Tingkah laku klien pengguna zat sedatif hipnotik
a. Menurunnya sifat menahan dirib. Jalan tidak stabil, koordinasi motorik kurang
c. Bicara cadel, bertele-tele
d. Sering datang ke dokter untuk minta resep
e. Kurang perhatianf. Sangat gembira, berdiam, (depresi), dan kadang
bersikap bermusuhan
g. Gangguan dalam daya pertimbangan
h. Dalam keadaan yang over dosis, kesadaran menurun,
koma dan dapat menimbulkan kematian.i. Meningkatkan rasa percaya diri
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Observasi perilaku pasien
Mekanisme pertahanan diri yang biasa digunakan:
denial dari masalah
proyeksi merupakan tingkah laku untuk melepaskan diri dari tanggung jawab
Disosiasi merupakan proses dari penggunaan zat adiktif
Data khusus jumlah dan kemurnian zat yang digunakan
Sering menggunakan
Metode penggunaan (dirokok, intravena, Oral)
Dosis terakhir digunakan
Cara memperoleh zat (dokter, mencuri, dll)
Dampak bila tidak menggunakan Jika over dosis, berapa beratnya
Stressor dalam hidupnya
Sistem dukungan (keluarga, social, finansial)
tingkat harga diri klien, persepsi klien terhadap zat adiktif
Tingkah laku manipulatif
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Tingkah laku klien pengguna opioda :
a. Terkantuk-kantuk
b. Bicara cadel
c. Koordinasi motorik terganggud. Acuh terhadap lingkungan, kurang perhatian
e. Perilaku manipulatif, untuk mendapatkan zat adiktif
f. Kontrol diri kurang
Tingkah laku klien pengguna kokain :
a. Hiperaktif
b. Euphoria, agitasi, dan sampai agitasi
c. Iritabilitas
d. Halusinasi dan wahame. Kewaspadaan yang berlebihan
f. Sangat tegang
g. Gelisah, insomnia
h. Tampak membesar – besarkan sesuatu
i. Dalam keadaan over dosis: kejang, delirium, dan paranoid
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Observasi perilaku pasien
Mekanisme pertahanan diri yang biasa digunakan:
denial dari masalah
proyeksi merupakan tingkah laku untuk melepaskan diri dari tanggung jawab
Disosiasi merupakan proses dari penggunaan zat adiktif
Data khusus jumlah dan kemurnian zat yang digunakan
Sering menggunakan
Metode penggunaan (dirokok, intravena, Oral)
Dosis terakhir digunakan
Cara memperoleh zat (dokter, mencuri, dll)
Dampak bila tidak menggunakan Jika over dosis, berapa beratnya
Stressor dalam hidupnya
Sistem dukungan (keluarga, social, finansial)
tingkat harga diri klien, persepsi klien terhadap zat adiktif
Tingkah laku manipulatif
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The Treatment
Detoxification:
Medical treatment to overcome overdose
Opioid Withdrawal:
Abrupt withdrawal
Symptomatic treatment withdrawal
Gradual withdrawal
Non Opioid substitute (clonididne)
Rapid detoxification
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Long Term Medical Management
Disulfiram (Antabuse alcohol)
Naltrexon (opioid antagonis)
Methadone maintenance program (forheroin user)
Buprenorfin maintenance program (opioid
user)
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Therapeutic Community
Same with Milieu therapy The leader is an ex user
The professionals act as consultant or advisor
Four principles:
• Democratization• Permissive behaviors
• Communality
• Reality confrontation
Phase I: orientation
Phase II: therapy (everyday therapy or seminars)
Phase III: Community relationship
Phase IV: TC in once a week
Graduation
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Treatment modalities Abstinence VS Controlled use
Behavioral, cognitive, Traditional psychotherapy
Self-help group
Alcoholic Anonymous (AA)
• 12 steps of AA Al-Anon; Naranon; Cocanon
Narcotics Anonymous (NA)
Cocaine Anonymous CA)
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1. Ancaman kehidupan
a. Gangguan keseimbangan cairan: mual, muntah berhubungandengan pemutusan zat opioda
b. Resiko terhadap amuk berhubungan dengan intoksikasisedatif hipnotik
c. Resiko cidera diri berhubungan dengan intoksikasi aklkohol,sedatif, hipnotik
d. Panik berhubungan dengan putus zat alkohol
2. Intoksikasia. Cemas berhubungan dengan intoksikasi ganja
b. Kerusakan komunikasi verbal berhubungan denganintoksikasi sedatif hipnotik, alcohol, opioda
DIAGNOSA KEPERAWATAN
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Resiko tinggi terhadap cedera: jatuh berhubungan dengan kesulitan
keseimbangan
Perubahan nutrisi: kurang dari kebutuhan tubuh berhubungan
dengan asupan makanan yang kurang
Gangguan pola tidur berhubungan dengan sensori sistem sarafpusat
pola tidur berhubungan dengan hipersensitifitas
Kerusakan pertukaran gas: pola nafas tidak efektif berhubungan
dengan penurunan ekspansi paru.
Diagnosa keperawatan lain yang mungkin muncul
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Nursing Diagnosis
Growth and development, altered
Infection, risk for Injury, risk for
Nutrition, altered
Self-care deficit
Sensory/Perceptual Alteration
Sexual dysfunction
Sleep pattern disturbance
Knowledge deficit Management therapeutic regimen, individuals or families: ineffective
Noncompliance
Anxiety
Communication, impaired verbal
Family process, altered
Social isolation Self-esteem disturbance
Violence, risk for
Powerlessness
Spiritual distress
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RENCANA KEPERAWATAN
1. Kondisi overdosis
Tujuan : Klien tidak mengalami ancaman kehidupan
Rencana tindakan:
- Oservasi tanda – tanda vital, kesadaran pada 15 menit pada 3 jam pertama, 30 menit pada 3 jam kedua tiap 1 jam pada 24 jamberikutnya
- Bekerja sama dengan dokter untuk pemberian obat
- Observasi keseimbangan cairan
- Menjaga keselamatan diri klien
- Menemani klien- Fiksasi bila perlu
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3. Kondisi withdrawl
a. Observasi tanda- tanda kejang
b. Berikan kompres hangat bila terdapat kejang pada perut
c. Memberikan perawatan pada klien waham, halusinasi: terutama
untuk menuunkan perasaa yang disebabkan masalah ini: takut,curiga, cemas, gembira berlebihan, benarkan persepsi yang salah
d. Bekerja sama dengan dokter dalam memberikan obat anti nyeri
4. Kondisi detoksikasi
a. Melatih konsentrasi: mengadakan kelompok diskusi pagi
b. Memberikan konseling untuk merubah moral dan spiritual klienselama ini yang menyimpang, ditujukan agar klien menjadi manusiayang bertanggung jawab, sehat mental, rasa bersyukur, dan optimis
c. Mempersiapkan klien untuk kembali ke masyarakat, dengan bekerjasama dengan pekerja social, psikolog.
RENCANA KEPERAWATAN
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INTERVENSI KEPERAWATAN
Dx: Resiko tinggi terhadap cedera: jatuh berhubungan dengan kesulitankeseimbangan
Kriteria hasil:
- mendemonstrasikan hilangnya efek-efek penarikan diri yang memburuk
- tidak mengalami cedera fisik
Intervensi:
Mandiri
1.Identifikasi tingkat gejala putus alkohol, misalnya tahap I diasosiasikandengan tanda/gejala hiperaktivitas (misalnya tremor, tidak dapatberistirahat, mual/muntah, diaforesis, takhikardi, hipertensi); tahap IIdimanifestasikan dengan peningkatan hiperaktivitas ditambah denganhalusinogen; tingkat III gejala meliputi DTs dan hiperaktifitas autonomikyang berlebihan dengan kekacauan mental berat, ansietas, insomnia,demam.
2.Pantau aktivitas kejang. Pertahankan ketepatan aliran udara. Berikankeamanan lingkungan misalnya bantalan pada pagar tempat tidur.
3.Periksa refleks tenton dalam. Kaji cara berjalan, jika memungkinkan
4.Bantu dengan ambulasi dan aktivitas perawatan diri sesuai kebutuhan
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Kolaborasi
5. Berikan cairan IV/PO dengan hati-hati sesuai petunjuk
6. Berikan obat-obat sesuai petunjuk: benzodiazepin, oksazepam,fenobarbital, magnesium sulfat.
Rasional:
1. Pengenalan dan intervensi yang tepat dapat menghalangi terjadinyagejala-gejala dan mempercepat kesembuhan. Selain itu perkembangangejala mengindikasikan perlunya perubahan pada terapi obat-obatanyang lebih intensif untuk mencegah kematian.
2. Kejang grand mal paling umum terjadi dan dihubungkan denganpenurunana kadar Mg, hipoglikemia, peningkatan alkohol darah atauriwayat kejang.
3. Refleksi tertekan, hilang, atau hiperaktif. Nauropati perifer umumterjadi terutama pada pasien neuropati
4. mencegah jatuh dengan cedera
5. mungkin dibutuhkan pada waktu ekuilibrium, terjadinya masalahkoordinasi tangan/mata.
6. Penggantian yang berhati-hati akan memperbaiki dehidrasi danmeningkatkan pembersihan renal dari toksin sambil mengurangi resikokelebihan hidrasi.
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PERAN PERAWAT
Perawat harus mengetahui masalah yangberkaitan dengan penggunaan NAPZA agardapat memberikan perawatan kepada kliensecara efektif.
Perawat harus memahami perasaan seseorangtentang alkohol sehingga perawat dapat bekerjasecara efektif. Perawat jiwa juga membantudalam mendampingi klien NAPZA dan keluarga
dalam melaksanakan terapi. Serta memberikanpendidikan kesehatan agar klien bisaberkomunikasi efektif dan berpersepsi positif
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Laboratory Assessment
Urine analysis
Should be done before 48 hours after the
last use
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Ineffective individual coping
Expected outcomes: The patient will abstain from using all mood-altering chemicals
Short-term goals: The patient will substitute healthy coping responses for
substance abusing behaviors
The patient will assume responsibility for behaviors The patient will identify and use social support system
Intervention: Build trust relationship with the patient
Help the patient to identify the substance abuse problem
Involve the patient in describing situations that lead tosubstance-abusing behaviors
Consistently offer support and the expectation hat the patienthas the strength to overcome the problem
I t ti (C t )
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Intervention (Cont.)
Encourage the patient to participate in a treatment
program Develop with the patient a written contract for behavioral
changes that is signed by the nurse and patient
Help the patient to identify and adopt healthier copingresponses.
Identify and assess social support systems that areavailable to the patients
Provide support to significant others
Educate the patient and significant others about thesubstance abuse problem and available resources
Refer the patient to appropriate resource and providesupport until the patient is involved in the program
M ti ti l h
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Motivational approaches
(Stuart&Laraia, 2001, p.513)
Principles Express emphaty trough reflective listening
Develop discrepancy between patients’ goal or values and their currentbehaviors
Avoid arguments and direct confortation
Roll with resistance
Support self-efficacy
FRAMES approach
Feedback
Responsibility for change
Advice; nonjudgmental Menus of self-directed change
Emphatic Counseling
Self-efficacy; optimistic empowerment
Decisional balance grid
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The Treatment
Detoxification:
Medical treatment to overcome overdose
Opioid Withdrawal:
Abrupt withdrawal
Symptomatic treatment withdrawal
Gradual withdrawal
Non Opioid substitute (clonididne)
Rapid detoxification
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Long Term Medical Management
Disulfiram (Antabuse alcohol)
Naltrexon (opioid antagonis)
Methadone maintenance program (for
heroin user)
Buprenorfin maintenance program (opioid
user)
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Therapeutic Community
Same with Milieu therapy The leader is an ex user
The professionals act as consultant or advisor
Four principles:• Democratization
• Permissive behaviors
• Communality
• Reality confrontation
Phase I: orientation
Phase II: therapy (everyday therapy or seminars)
Phase III: Community relationship
Phase IV: TC in once a week
Graduation
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Treatment modalities Abstinence VS Controlled use
Behavioral, cognitive, Traditional psychotherapy
Self-help group
Alcoholic Anonymous (AA)
• 12 steps of AA Al-Anon; Naranon; Cocanon
Narcotics Anonymous (NA)
Cocaine Anonymous CA)