Chapter 6 Substance Use Assessment Alcohol Use and Abuse - Alcohol consumption has dose-related effects: the more you drink, the higher the risk - Morbidity and morality data reflect adverse consequences of excessive alcohol use o A high number of medications are classified as alcohol interactive o Alcohol dependence increases the risk for ED visits, ICU admissions and sepsis o Binge drinking associated with increasing health risks Seven categories of illicit drug use o Marijuana/hashish o Cocaine (including crack) o Heroin o Hallucinogens o Inhalants o Prescription-type drugs used nonmedically Developmental Competence: Adolescents - Effects of alcohol on decreasing brain development and maturity - Associated risk between alcohol use and other high-risk behavior o Sexual high-risk o Academic problems in school Developmental Competence: Pregnancy - Dangers to mother as well as fetus - Development of Fetal Alcohol Spectrum o Physical deformities, as well as learning, and behavioral problems Developmental Competence: Aging adult - Characteristics that increase risks associated with alcohol use: - Decrease in body’s metabolic functions (liver, water, and renal) leading to increased bioavailability - Muscle mass decline leads to increased concentration in the body - Effects of polypharmacy may interact with alcohol. - Increases risk for cognitive decline - Drinking alcohol increases risk for falls, depression, and gastrointestinal problems. Subjective Data - Data collected by examiner asking questions - Questionnaires as self-reports o Audit Questionnaire o Standard Clinical Diagnostic Criteria Ask “in the past 12 months____” and about use of illicit substances o TWEAK questions o SMAST-G Questionnaire Audit Questionnaire - Quantitative format uses numbers to identify a response. Helps detect less severe alcohol problems as well as alcohol abuse and dependence disorders o Three domains: alcohol consumption, drinking behavior or dependence, and adverse consequences (Maximum score: 40) o Useful in primary care with adolescents and older adults o Relatively free of gender and cultural bias o AUDIT-C: shorter form for acute and critical care units (maximum score: 12) TWEAK Questions - Screening women for alcohol problems (helps identify at-risk drinking in women, especially pregnant women) o Tolerance: how many drinks can you hold? Or how many drinks does it take to make you feel high? o Worry: have close friends or relatives complained about your drinking? o Eye-opener: do you sometimes take a drink in morning when you first get up? o Amnesia: has a friend or family member told you about things you said but could not remember? o Kut down: do you sometimes feel the need to cut down? SMAST-G Questionnaire - Screening aging adults o Use for older adults who report ANY type of drinking o 10 Questions with yes/no responses that address these factors Two or more “yes” questions indicate alcohol problems Objective Data: Clinical Lab Data - Less sensitive and specific than self-report questionnaires o Serum protein, gamma glutamyl transferase (GGT): commonly used biochemical marker of alcohol drinking Occasional alcohol drinking will not raise this measure, but chronic heavy drinking will. Be aware that nonalcoholic liver disease also can increase GGT levels in the absence of alcohol. o Carbohydrate-deficient transferring (CDT) Gender issue—higher levels seen in healthy females thus combining it with GGT may improve accuracy o Serum aspartate aminotransferase (AST) Enzyme found in high concentrations in heart and liver o Mean corpuscular volume (MCV) index of red blood cell size MCV is not sensitive enough to use as only biomarker. Can detect earlier drinking after long period of abstinence o Direct biomarker phosphatidylethanol (Peth) Sensitive indicator used to evaluate abstinence o Breath alcohol analysis Chapter 7 Domestic and Family Violence Assessment Intimate partner Violence - 4 main categories o Physical Violence (force resulting in injury or death) o Sexual Violence (Attempted or completed acts without permission) o Stalking (repeated unwanted attention through various methods o Psychological aggression (emotional abuse of an aggressive nature) Child Abuse and Neglect - Defined at state and federal levels- The Child Abuse Prevention and Treatment Act o Includes sex and human trafficking o Enhanced protection for infants with Fetal Alcohol Spectrum Disorder Barriers to Treatment of Intimate Partner violence - Societal stressors o Poverty level leading to increased difficulties in daily struggle and conflict in relationships o Past experience with discrimination based on lack of understanding of cultural diversity - Legal Status o Immigration statue may prevent individual from seeking care based on fear of deportation o Violence Against Women Act (AWA) provides legal support - Lack of access to culturally appropriate care o Traditional roles foster dependency o Need for bilingual cultural interpreters in clinical practice settings Documentation: IPV, Child Abuse, or Older Adult Abuse - Provide detail - Non-biased progress notes, injury maps, and photographic evidence - Transcribe verbatim - Information received from individual - Physical exam - Thorough documentation using forensic technology terms - Provide digital photographic documentation in the medical record - Obtain consent - May have to separate - The patient from the parent, spouse, and/or caregiver—follow protocol Routine Screening for Intimate Partner Violence (IPV) - US Preventative Task Force Guidelines (USPTF) - All women of childbearing age (14-46) should be screened - Insufficient evidence to support screening of older adult or vulnerable adults How to Assess for IPV - Gathering of Subjective Data - Use of open-ended questions to start the conversation - Interview the individual separately from the perpetrator - Listen for cues which may indicate a pattern or Reponses that don’t match the “physical” injury that is present - Be aware of state laws and requirement to report - Screening tools - Know PV tool used in your clinical setting - May be as simple as a single question – “Do you feel safe at home?” - USPTF prefers standardized tools HITS – 4 item questionnaire STaT – 3 item questionnaire How to assess for Older Adult Abuse and Neglect - Considered a vulnerable population - Recommend routine screening by multiple agencies but no specific tool specified - Assessment of abuse or neglect in cognitively challenged persons is complicated - Abuse suspicion index - Validated in primary care - For use with cognitively intact patients - Included 6 questions with 5 questions asked of the patient and the last answered by physician How to assess for Child abuse and neglect - Health care providers - Provide anticipatory guideline - Ideal individual to be able to monitor, observe, and assess for potential problems - Medical history is important part of examination and documentation as well Objective data collection: - Include baseline laboratory testing - CBC with platelet count, basic blood chemistries, serum LFTs, coagulation panel and UA Assessing for Risk for Homicide - 19 item yes/no instrument used extensively by nurses in the health care system Chapter 29 Complete physical assessment: infant, young child, and adolescent Sequence: Neonate and Infant - Apgar (1-5 minutes) - Provides evidence of newborn’s immediate adaptation to extrauterine life - Sequence may reordered based on: Infant’s sleep and wakefulness state Physical condition Infant is supine on warming table/exam table with overheating unit - Vital Signs and Measurement - Pulse, respirations, and temperature - Weight, length, and head circumference plotted against growth chart - General Appearance - Body symmetry - Skin color and characteristics - Symmetry and positioning of facial features - Alert, responsive effort - Strong, lusty cry - Assessment: Chest and Heart - Inspect (skin condition, chest configuration, nipples, and breast tissue) - Note movement of abdomen with respirations and any chest retractions - Palpate (apical impulse and note location, chest wall for thrills, and tactile fremitus if infant is crying - Auscultate (breath sounds, heart sounds in all locations, and bowel sounds in the abdomen and chest - Abdomen - Inspect (shape of abdomen and skin condition) Umbilicus, count cord vessels, condition of cord or stump, detection of hernia Skin turgor - Palpate Light palpation to note muscle tone, liver, spleen tip, and bladder Deep palpation to note kidneys and potential masses Femoral arteries and inguinal lymph nodes - Percuss all quadrants - Head and Face - Note molding after delivery, any swelling on cranium. Bulging of frontal with crying or at rest Palpate (fontanels, suture lines, any swellings) Inspect (positioning and symmetry of facial features at rest and while infant is crying) - - - To open neonate’s eyes (lower baby backward or ask parents to hold baby over his or her shoulder while you stand behind the parent) Eyes, Ears, and Nose - Eyes Inspect the lids (edematous in the neonate), palpebral slant, conjunctivae, any nystagmus, and any discharge Elicit pupillary reflex, blink reflex, and corneal light reflex using a penlight – assess movement and tracking of light Elicit red reflex using an ophthalmoscope - Ears Inspect size, shape, alignment of auricles, patency of canals. Any extra skin tags or pits Defer otoscopic exam until end of complete exam - Nose Determine patency of nares Note any nasal discharge, sneezing, and flaring with respirations Mouth, Throat, and Neck - Inspect Lips and gums, high-arched palate, buccal mucosa, tongues size, frenulum of tongue Absent or minimal salivation in neonate - Note Rooting reflex Sucking reflex, using gloves finger, palpate the palate Upper Extremities - Palmer grasp reflex birth-3 months) Lower extremities - Ortolani sign Examiner checks for “clunk” when maneuvering the infant’s thigh near the hip to determine if hip is dislocated - Plantar grasp reflex (8-10 mos) - Babinski reflex (fanning of toes until 24 months) Stimulus a firm painful stroke along lateral border of sole from heel to toe Response: movement or fanning of toes Chapter 13 Skin, hair, and nails Skin - Body’s largest organ Two layers - Epidermis - Dermis - (Subcutaneous layer) - Newborn infants - Lanugo: fine downy hair of newborn infant - Vernix caseosa: thick, cheesy substance - Sebum: holding water in the skin producing milia - Children - Epidermis thickens, darkens, and becomes lubricated - Hair growth accelerates - Adolescents - Secretions form apocrine sweat glands - Eyes - Know eye anatomy - Corneal light reflex - Cartoon eyes - Light should be reflected at same location in iris on both eyes - Snellen Eye Chart 20 feet away Left eye, right eye, both - Extraocular Movements 3 feet away, not too close - PERRLA Pupils Equal Round Reactive to Light and Accommodation *Stye (warm compress, don’t pop), Blepharitis, Conjunctivitis, Iritis (all inflammation or possible infections), Hyphema (blood in eye from trauma or big sneeze) ** Cataract, Glaucoma (can be symptomless) - Fundal Exam Ears and Hearing Test - Inspect external ear Test hearing acuity – whisper test - Weber and Rinne not very accurate Otitis Media Nose/Oral Cavity/Throat - Nose - Inspect external nose for symmetry, any deformity, or lesions - Palpation: test latency of each nostril - Nasal speculum to view nasal mucosa, septum, turbinates - Palpate the sinus area, observe for drainage - Mouth and throat - Inspect with penlight: tongue, teeth and gums, buccal mucosa, palate and tonsils, and pharyngeal wall - Palpate when indicated - Observe a swallow Lymph nodes Chapter 14 Head, face, and neck, and regional lymphatics Head - Skull (protects brain) - Includes bones of cranium and face - Supported by cervical vertebrae - Cranial bones - Frontal - Temporal - Parietal - Occipital - Sutures – Adjacent cranial bones mesh at sutures - Coronal - Sagittal - Lambdoid 14 facial bones also articulate at sutures Facial expressions formed by facial muscles, mediated by cranial nerve VII (the facial nerve) Two pairs of salivary glands accessible to examination on the face: Parotid glands in cheeks over mandible (not normally palpable) Submandibular glands beneath mandible at angle of jaw Third pair, sublingual glands, lies in floor of mouth Temporal artery – lies superior to temporalis muscle, and pulsation is palpable anterior to ear Neck muscles - Major Neck muscles Sternomastoid Enables Trapezius (both innervated by cranial nerve XI)
