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Paper Abstract: Its use for an alcoholic coming to a medical clinic. Symptoms of nusea and vomiting. Examines components of the protocol: assessment, diagnosis, treatment planning, case management, teaching the patient how to manage the condition outside the clinical setting. Evaluation instruments (CAGE questionnaire), Alcohol Clinical Index (ACI), AUDIT, NIAAA Guidelines. Nurse-patient collaboration. Paper Introduction: This research sets forth a case-study protocol for an alcoholic coming to a medical clinic with increased nausea and vomiting. The following components of the protocol will be examined: assessment, diagnosis, treatment planning, case management, and teaching the patient how to manage the condition outside the clinical setting. For each component, appropriate evaluation instruments will be identified, and appropriate reference to relevant literature will be made. Assessment Because the case study assumes the patient presents with increased nausea and vomiting, it may seem reasonable to presume that the patient has already been identified as alcoholic, hence subject to a range of symptoms of which nausea and vomiting may be typical and a candidate for acute intervention. Dayer-Beren Text of the Paper: The entire text of the paper is shown below. However, the text is somewhat scrambled. We want to give you as much information as we possibly can about our papers and essays, but we cannot give them away for free. In the text below you will find that while disordered, many of the phrases are essentially intact. From this text you will be able to get a solid sense of the writing style, the concepts addressed, and the sources used in the research paper. (1995). Dayer-Berenson, L. (1996). Retrieved from the World Wide Web 1 February 2 2, athttp://www.niaaa.nih.gov/publications/instable.htm. American Journal of Psychiatry,131, 1121-1123. In this case, the comorbidity of nausea andvomiting, consistent with the last bulleted item above, suggests that thebest plan is to abstain from alcohol. Clinic nurses: Confronting campus alcoholuse on the frontline. RN, 5 , 46-5 . Teaching the patient how to manage the condition Heinemann and Hofmann (1989) explain that nurses are at the forefrontof delivering much primary care to patients and their families and serve apedagogic role more fully than a physician. Archives of General Psychiatry,53, 217-224. Alcoholism Treatment Assessment Instruments.Retrieved from the World Wide Web 1 February 2 2, athttp://www.niaaa.nih.gov/publications/instable.htm. National Institute on Alcohol Abuse and Alcoholism. Behavior Therapy,25, 533-58 . Executive summary: Improving thedelivery of alcohol treatment and prevention services a national plan foralcohol health services research. Have people annoyed you by criticizing your drinking? (1995). (2 1f, December).Drinking expectancy questionnaire. InternationalJournal of Addiction, 26, 1173-1185. This research sets forth a case-study protocol for an alcoholic comingto a medical clinic with increased nausea and vomiting. Pharmacological as well as behavioral treatments for alcohol use haveemerged in recent years, and research has showed the complementary utilityof drug-based and behavior-based treatments (O'Malley, et al., 1996).However, drug therapy candidates must be identified in the screening andassessment stage, and drug therapy is not recommended as a substitute forbehavioral intervention (NASADAD, 2 1). What isessential about planning is being specific about drinking patterns and"related health risks." Additionally, it is important to ask the patient:"How to you feel about your drinking?" (NIAAA, 1995). The key to the effectiveness of CAGE as an assessment tool is said tobe its nonconfrontationalism (NIAAA, 2 1a). National Institute on Alcohol Abuse and Alcoholism. Moreover,the ADS yields a measure of the severity of dependence that is importantfor treatment planning, especially with respect to the intensity oftreatment" (NIAAA, 2 1c). (1987). Department of Health and Human Services,Public Health Service, National Institutes of Health. Like ACI, AUDIT can be combined with a clinical examinationcalled the Clinical Screening Procedure, during which questions that do notrefer specifically to alcohol use may nevertheless elicit case-relevantinformation. Planning The specificity of ADS with regard to patient behavior, history ofalcohol use, and attitudes toward alcohol's role in one's life has beenfound to have implications for the structure of treatment planning. It can also be used to plantreatment." References Addiction Resource Guide (2 2). Sullivan(1994) offers specific suggestions for effective patient education,including developing a "repertoire of resources" for treating patients:"Such resources include a certified addictions nurse or other substanceabuse expert, local chapters of Alcoholics Anonymous, State agencies foralcohol and drug abuse, and the National Council on Alcohol and DrugDependence." Sullivan (1994) stresses the need for nurse-patient collaboration.Assessment, planning, and treatment must be undertaken in partnership withthe patient, to prepare the ground for meaningful teaching. The CAGEinstrument makes use of four questions with key words in the questionsspelling out cage. Retrieved from the World Wide Web 1February 2 2, athttp://hstat.nlm.nih.gov/hq/Hquest/fws/T/db/local.ppip.ppipc/screen/ Geller, A., Day, N.L., Crane, S.C., Hersh, A.S., Holder, H., Manning,W., Mayas, J., Morse, R.M., Schuckit, M.A., Steinwachs, D., Suchinsky,R.T., Wallack, S. Hays, J.T., & Spickard, W.A. a. Beers, &A.B. What the ARG calls freestanding inpatientrehabilitation (e.g., Betty Ford Clinic) would be out of the financialreach of most inpatients. Alcoholism TreatmentAssessment Instruments. Effective education may also mandate a nurse's adjustment of attitudes(Sullivan, 1994). Merck manual of medical information. Clinicalversus laboratory detection of alcohol abuse: The Alcohol Clinical Index.British Medical Journal, 292, 17 3-17 8. Physicians are advised to ask for periodic updates fromtreatment specialists; to monitor symptoms of depression and anxiety thatmay accompany abstinence; and to monitor compliance by testing forelevations in serum gamma-glutamyltransferase (GGT), which indicatesexcessive drinking. 1. (2 1c, December).Alcohol dependence scale. Alcoholism: Early diagnosis andintervention. Alcoholism Treatment AssessmentInstruments. Alcoholic patients, she explains, "often present with a medicalor psychological problem that appears to be totally unrelated to alcohol."That is why appropriate assessment is so important. R. Berkow, M.H. Nausea and vomiting are notsolely a consequence of alcohol use. Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover (eye-opener)? O'Malley, S.S., Jaffe, A.J., Chang, G., Rose, S., Schottenfeld, R.,Meyer, R.E., & Rounsaville, B. Fact File. In addition to hospital rehab, there is long-term residential rehab,for persons who "lack the impulse control and sober habits to successfullymaintain a recovery in their community" (ARG, 2 2). Retrieved from the World Wide Web 1 February 2 2, athttp://www.niaaa.nih.gov/publications/instable.htm. B. Dayer-Berenson (2 2) cautions against failing to addressalcohol addiction as the underlying cause of another clinic-admittingdiagnosis. C., Toneatto, T., Sobell, M. Naegle (1994) also connectssuccessful patient teaching to successful assessment procedures. Skinner, H.A., Holt, S., Sheu, W.J., and Israel, Y. Journal of American College Health, 45, 2 5-8. (1997). (1994, Spring). (1998, April). If the known alcoholicpatient's nausea and vomiting are increasing, intervention may become morecritical to avoid further deterioration and health-care costs (Sobell,Toneatto, & Sobell, 1995). Have you ever felt bad or guilty about your drinking? (2 1a, December).CAGE questionnaire. Retrieved from the World Wide Web 1 February 2 2, athttp://www.alcoholics-anonymous.org/. The higherthe score, the more alcohol dependence the subject reveals. A variety of psychometric instruments can bemarshaled into identifying the specifics of a case. (1993). The CAGE questionnaire:Validation of a new alcoholism instrument. Have you ever felt you ought to cut down on your drinking? 2nd Ed.Washington, D.C.: U.S. Outpatient treatment programs include educationand counseling, group bonding, work on denial of drinking problems, andsupport in maintaining abstinence (ARG, 2 2). Department of Health and Human Services, PublicHealth Service, Office of Public Health and Science, Office of DiseasePrevention and Health Promotion. ARG cautions thatin hospitals that have only detox units, follow-up rehabilitation isusually indicated. Physicians'guide to helping patients with alcohol problems. Health-care counseling couldbe pursued in conjunction with such programs as Alcoholics Anonymous. National Association of State Alcohol and Drug Abuse Directors. Nurse educators look atalcohol education for the profession. (1987, December). (2 1a, December).Chemical dependency assessment profile. TheAlcohol Dependence Scale (ADS) has been identified as a diagnosticinstrument (NIAAA, 2 1c). Diagnosis Assessment, or screening, is to be distinguished from diagnosis inthat the latter should elicit additional information that can be morespecifically quantified than the general drinking-related questions of thescreening phase and thereby point to a program of intervention options. The Brown-Peterson Recovery ProgressInventory (B-PRPI) measures a patient's "current functioning level in'working' a '12-step' (Alcoholics Anonymous)-oriented recovery program"(NIAAA, 2 1f). Retrieved from the World Wide Web 1 February 2 2, athttp://www.niaaa.nih.gov/publications/instable.htm. (1991). According to the 1997 National Longitudinal Alcohol EpidemiologicalSurvey of the National Institute on Alcohol Abuse and Alcoholism, as littleas 1 % of those in need of treatment for alcohol problems have actuallygotten it. 2. Alcoholism Treatment AssessmentInstruments. Thus such tests as a blood count,urinalysis, and ultrasound readings of pancreas, stomach, intestine, andgall bladder may be indicated (Merck, 1997). How much is toomuch? Citing results of a survey of nurses who dislike treatingcertain kinds of patients, including alcoholics, Collins (1987) notes thatsome nurses express anger or "strongly held opinions" of disapproval ofpatients who are deemed to be responsible for their condition. According to the Addiction Resource Guide (2 2), determining whetherto make an outpatient referral depends on two factors: willingness andability to attend sessions regularly and abstinence for 48 hours at a time,with support. Retrieved from theWorld Wide Web 1 February 2 2, athttp://www.niaaa.nih.gov/publications/physicn.htm. McLeod, G., & Hall, P. National Institute on Alcohol Abuse and Alcoholism. Various abstinence-treatment options and philosophies exist:inpatient, outpatient, and self-help. National Institute on Alcohol Abuse and Alcoholism. NIH Publication No. However,at least one study indicates that, on its own, CAGE is less sensitive toearly problem drinking (Hays & Spickard, 1987), of which onset of increasednausea is an aspect. New York: Pocket Books. Retrieved from the World Wide Web 1 February2 2, at http://nsweb.nursingspectrum.com/ce/ce84.htm. This gap may be the result of various factors: barriers to accessing alcohol services, including financial, geographic, and cultural barriers; denial that treatment is needed; concern about the stigma of alcoholism; or the lack of pressure from family, friends, and employers to seek treatment (Geller, et al., 2 ). By extension, the patient's status can be an index of theeffectiveness of a given program. Alcohol Health & Research World, 13,48-51. The AUDIT consists of1 questions designed to identify the extent of the patient's involvementwith alcohol. Early-stage alcoholism has been associated with gastrointestinalcomplaints, including nausea, vomiting, indigestion, esophageal reflux(indicating accumulated acid in stomach and/or inflamed stomach lining,consistent with nausea, vomiting) right-abdominal pain, and irritable bowelsyndrome, as well as ulcers (Hill & Kugelmas, 1998). Bethesda, Md.: National Institute onAlcohol Abuse and Alcoholism. Alcoholism Treatment Assessment Instruments. Thefact that the alcoholic of the case study is undergoing an increase innausea and vomiting, and not just onset thereof, provides a clue that itmay be too late for earliest-stage intervention treatment and that a moreintensive intervention is called for. Advising patients about safe levels of alcohol consumption. Skinner, H.A., Holt, S., Sheu, W.J., & Israel, Y. Rehab is alsoroutinely associated with 12-step treatment modalities. Alcoholics Anonymous. No b. This is a potential problem in the instant case becauseof the possibility that detoxification could eliminate the alcoholic's GIcomorbidity and demotivate him to continue with treatment (ARG, 2 2). This procedure is deemed useful especially if patients aredefensive about alcohol use (Fox, 1998; NIAAA, 2 1b). Retrieved from the World Wide Web 1 February 2 2, athttp://www.niaaa.nih.gov/publications/instable.htm. 4. (2 , October). Clinicalversus laboratory detection of alcohol abuse: The Alcohol Clinical Index.British Medical Journal, 292, 7 3-17 8. Psychometric instruments are available that may enable nurses to trackthe efficacy of intervention and education alike. (1998). Washington, D.C.: National Association of StateAlcohol and Drug Abuse Directors. Fox, C. The questions are keyed as follows: 1. Assessment guidelines promulgated by the National Institute on AlcoholAbuse and Alcoholism (NIAAA, 1995) are reduced to two majorrecommendations: Ask about typical drinking patterns, and ask aboutpersonal and family history. The ADS isconsidered a strong predictor "with respect to a DSM diagnosis. (2 1b, December).Alcohol use disorders identification test. Retrieved from the World Wide Web 1 February 2 2, athttp://www.niaaa.nih.gov/publications/instable.htm. Effectiveeducation of an alcoholic patient involves rapport and people skills--working with rather than "talking at" the patient to define the problem andencourage cooperation. Alcoholics Anonymous (AA) is a self-help group known for its 12-stepprogram of permanent abstinence from alcohol: "Sobriety--freedom fromalcohol--through the teaching and practice of the Twelve Steps, is the solepurpose of an A.A. Retrieved from the World Wide Web 1 February2 2, at http://www.niaaa.nih.gov/publications/exsum.htm#intro. Inaddition, ACI gives a list of clinical signs to note during clinicalexamination, including evidence of abnormal vascular formation (Fox, 1998).The condition known as "caput Medusa," be relevant to a GI examination,refers to dilation of veins under the skin of the abdomen around the navel.This condition is a sign that liver vessels for filtering toxins out of thebody are blocked and that compensating, or collateral, blood vessels havebeen formed (Skinner, et al., 1986). NIAAA(2 1g) says that the DEQ is indicated as useful during treatment as wellas follow-up and that it "can discriminate between problem drinkers and canbe used to follow progress in therapy. The need for alcohol abuse-relatededucation in nursing curricula. Mayfield, D. National Institute on Alcohol Abuse and Alcoholism. Closed AA meetings, whichare limited to alcoholics, "provide an opportunity for members to sharewith one another on problems related to drinking patterns and attempts toachieve stable sobriety" (AA, 2 2). Bradley, K.A., Donovan, D.M., & Larson, E.B. 1: Current alcohol research in the use ofmedications as an adjunct to alcohol treatment and implications for statealcohol treatment systems. Whether the alcoholicin this case would be a candidate for long-term rehab would depend on anaccurate assessment of willingness to cooperate. Alcohol Health &Research World, 18, 158-61. Hill D. Sobell, L. Retrievedfrom the World Wide Web 1 February 2 2, athttp://www.addictionresourceguide.com/. B., & Kugelmas, M. One of the most popular and widely cited in the literature is the so-called CAGE questionnaire (based on Mayfield, et al., 1974). These options may overlap andconverge to some extent. Clinician's handbook of preventive services. E. (2 1d, December).Composite international diagnostic interview. The twelve steps of alcoholics anonymous.A.A. For example: Do you get physically sick (e.g., vomit, stomach cramps)as a result of drinking? Of special note is theDrinking Expectancy Questionnaire (DEQ), which uses 43 questions to measuresix factors of alcohol involvement: assertion, affective change, sexualenhancement, cognitive change, tension reduction, and dependence. Alcohol Health & Research World, 18, 154-57. Journal of General Internal Medicine, 2, 2 -427 Heinemann, M.E., & Hofmann, A.L. National Institute on Alcohol Abuse and Alcoholism. Addiction resource guide: Acomprenensive directory of addiction treatment facilities online. Identifying alcoholism in the hospitalizedpatient. However, many hospitals have rehab and/or detoxunits, both of which are typically covered by insurance. Management NIAAA (1995) provides specific recommendations for follow-through inmanaging a case. Retrieved from the World Wide Web 1 February 2 2,at http://www.niaaa.nih.gov/publications/instable.htm. The followingcomponents of the protocol will be examined: assessment, diagnosis,treatment planning, case management, and teaching the patient how to managethe condition outside the clinical setting. The importance of rapport withalcoholic patients is a point driven home repeatedly in the literature, andit must begin at the earliest stage of clinical contact. The simplicity ofCAGE is another benefit, and the originator of the questionnaire says thatit predicts that patients who answer yes to two questions are in early-stage alcoholism, with yes answers to more indicating more severe cases.This assertion appears to have been confirmed by various studies. (2 2). 3. (1986). (1997, March). Nursing Spectrum. Alcoholic liver disease.Postgraduate Medicine, 1 3, 261-275. Miller, J.B. Role ofnurses in primary care: managing alcohol-abusing patients. For each component, appropriateevaluation instruments will be identified, and appropriate reference torelevant literature will be made. Providingfeedback on the symptomatic evidence of a drinking problem plus informationabout the role of alcohol in the current medical problem is the first step.This would include providing information about such documented risk factorsas family history of alcohol abuse, alternatives to alcohol use such asstress management and recreation, and the disease of alcoholism. It is to treatmentplanning that we now turn. (NIAAA, 2 1a). Almost every time I drink (NIAAA, 2 1c) ADS answers are scored such that a = , b = 1, c = 2, etc. Fletcher (Eds.). ACI's inventors (Skinner,et al., 1986) provide more detailed questions about individual and familyhistory of alcohol use over the past 12 months and over the last month. (2 2). (1994, Spring). National Institute on Alcohol Abuse and Alcoholism. Patients who do not fit with those factors are candidates forinpatient treatment (rehab). 2. 4. CAGE is, however, flexible. National Institute on Alcohol Abuse and Alcoholism. Both CAGE questions and ACI are meantto be collapsed into the general medical history. Alcoholism Treatment AssessmentInstruments. Psychometric instruments have also been developed formonitoring a patient's progress. Alcoholism Treatment AssessmentInstruments. The patients your colleagues hate tonurse. NIAAA guidelines say that the next step is a patient referral foradditional diagnosis and treatment, under these conditions: involving thepatient in the referral decision; discussing alcohol-treatment servicesthat are available; scheduling a referral appointment with the patientstill in the office (NIAAA, 1995). Naegle, M.A. Although AA membership is famous for protecting the confidentiality ofmembers, the GGT test is a simple method of tracking the somatic effects ofabstinence (or not) irrespective of self-reports of the results of behaviorinterventions. Six-month follow-up of naltrexoneand psychotherapy for alcohol dependence. Sullivan, E.J., Handley, S.M., & Connors, H. 95-3769. Assessment Because the case study assumes the patient presents with increasednausea and vomiting, it may seem reasonable to presume that the patient hasalready been identified as alcoholic, hence subject to a range of symptomsof which nausea and vomiting may be typical and a candidate for acuteintervention. group," according to AA literature. State issue brief no. This would be consistent with both inpatient andoutpatient treatment protocols. 3. Retrievedfrom the World Wide Web 1 February 2 2, athttp://www.niaaa.nih.gov/publications/instable.htm. NIAAA guidelines say that patients should be advised to abstainaltogether from alcohol under these conditions: < evidence of alcohol dependence < history of repeated failed attempts to cut down < pregnant or trying to conceive < contraindicated medical condition or medicationPatients should be advised to cut down drinking if they are drinking aboverecommended low-risk amounts and "there is no evidence of alcoholdependence" (NIAAA, 1995). While AA and other treatment programs may help physically eliminatethe factor of alcohol from the patient's life, there remains the need toaddress symptoms of comorbidity intrinsically. (2 1f, December).Brown-Peterson recovery progress inventory. (1989, Winter). Alcoholism Treatment AssessmentInstruments. The Composite International Diagnostic Interview "serves thediagnostic criteria of DSM-III-R and ICD-1 for alcohol abuse, harmful use,and dependence," as well as onset of some symptoms (NIAAA, 2 1d). (1986). (1974). Washington, D.C.: U.S. CIDI isdependent on computer scoring, and administration of the test takes 7 minutes, which may make it impractical to use in nonspecialized clinicalsettings. Sometimes c. (2 1f, December).Drinker inventory of consequences. Another early screening/assessment instrument is known as AUDIT, whichstands for Alcohol Use Disorders Identification Test. Behavioral assessmentand treatment planning for alcohol, tobacco and other drug problems:Current status with an emphasis on clinical applications. National Institute on Alcohol Abuse and Alcoholism. 5. It is incorporated into The AlcoholClinical Index (ACI), an assessment tool that also uses the results ofclinical examination, plus medical history, evidence of alcohol use, andpatient issues regarding alcohol use. Archivesof Internal Medicine, 153, 2734-274 Collins, H.L. It consists of 25 multiple-choice questionsdealing with drinking behavior, self-awareness of a drinking compulsion andfeeling that drinking is out of one's control, increased physical alcoholtolerance, and symptoms of withdrawal. The Alcohol UseDisorders Identification Test (AUDIT) in a college sample. A more salient instrument may be the Chemical DependencyAssessment Profile (CDAP), which is similar to ADS in that it is considered"useful in evaluating response to intervention, treatment matching, outcomeevaluation, and program evaluation" (NIAAA, 2 1e). Fleming, M.F., Barry, K.L., & MacDonald, R. (2 1,December). The Twelve Steps topersonal recovery are anchored in spiritual terms, but AA definesalcoholism as a "progressive illness, that [] cannot be cured in theordinary sense of the term, but that [] can be arrested through totalabstinence from alcohol in any form" (AA, 2 2). What is important is toobtain information about the patient's physical condition by asking "aboutphysical symptoms of substance abuse," including but not limited to GIproblems, as well as behavior (Fox, 1998). If this paper is not what you are looking for, you can search again: Search for: or Click here to request an essay written just for you.

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