Louise Mehrman Goodman, RN
OR nursing inte rvent ion for the alcoholic
Can a patient’s alcoholism make a difference in the outcome of his surgery? Can the operating room nurse contribute to the alcoholic patient’s chance for successful recovery? Can the operating room nurse serve as a “gatekeeper” in detection of alcoholism? Can the operating room nurse successfully intervene to halt progression of a patient’s alcoholism? The answer to these questions is yes. The nurse who is knowledgeable, interested, and has the proper attitude can be a significant factor in the recovery of alcoholic patients. According to Andrew Abrahams, MD, director of the BedfordStuyvesant Alcoholism Treatment Center, Brooklyn, studies done for the New York City Health Services Ad-
ministration have shown that 50% of beds occupied in 19 municipal hospitals were occupied by persons being treated for secondary complications of alcoholism. Only 1%of the beds were occupied by persons whose primary diagnosis was alcoholism. The findings in 19 private hospitals were similar: ~ WofOthe beds were occupied by persons suffering from medical or surgical problems derived from alcoholism while only 2% had been admitted for alcoholism.’ In these studies, alcoholism was defined as a “chronic disease manifested by repeated implicative drinking so as to cause injury to the drinker’s health or to his social functioning.’12 When the patient’s alcoholism is undiagnosed and left untreated, the
AORN Journal, November 1976, Vol24, No 5
867
patient is placed in jeopardy and his chances for recovery are greatly reduced. Although we may be more comfortable treating the patient’s “official” diagnosis, we must not let negative attitudes, lack of knowledge, or discomfort with confrontation prevent us from addressing the underlying problem, alcoholism. If we ignore it, we ensure difficulties in the treatment process, further complications, readmission for an exacerbated condition, and perhaps even the alcoholic’s premature death. As nurses, we can be gatekeepers. Since we sometimes spend more time with patients than physicians do, we can observe patients in a variety of situations and pick up clues and symptoms that may have been missed on examination. Keen observation will reveal signs of alcoholism that might otherwise be overlooked or ascribed to another illness. What are the secondary diseases of alcoholism and what are the implications for the operating room nurse? Alcohol is the most toxic drug known to man. Not one organ or system escapes its depressant or irritating effects. Fatty liver, alcoholic hepatitis, cirrhosis of the liver, gastritis, cerebellar degeneration, cerebral atrophy, and esophageal varices are conditions most commonly associated with chronic alcoholism and alcohol abuse. Other less-often-recognized secondary diseases of alcoholism are: acute and chronic pancreatitis, hypoglycemia, secondary diabetes, cardiac myopathy, hypertension, anemia, peripheral neuropathy, paralysis, peptic or duodenal ulcers, chronic diarrhea, vitamin deficiencies, convulsive disorders, muscular myopathy, and cancer of the larynx, esophagus, or stomach. Since 50% of highway and 4% of home accidents are alcohol related, a great
868
proportion of emergency surgical and orthopedic patients must be assumed to have alcohol problems. Any of the above diagnoses should alert the operating room nurse to the possibility that alcoholism may be involved. A detailed history and physical are in order, because if the alcoholism goes undetected, there may be complications in the operating room or recovery room. The patient may go into delirium tremens (DTs) after surgery. Alcohol‘s effects. Alcohol is a sedative in the same pharmacological group as barbiturates, Pentothal, Amytal, ether, and chloral hydrate. It also has an agitating or irritating effect, which is cumulative both in intensity and in time and outlasts the sedative effect. This agitating effect is responsible for the increase in anxiety, irritability, and psychomotor activity after a drinking episode. In persons who have been drinking heavily over a period of time, the irritating effects of alcohol sometimes break through the sedative effect and cause restlessness, violence, and even hallucinations in spite of high blood alcohol levels. Irritability causes alcoholic convulsions and hallucinations and tremors associated with alcohol withdrawal, of which DTs are the severest form.
Louise Mehrman Goodman, R N , is coordinator of family services, South Oaks Hospital, Amityville, N Y . She designed and coordinates a continuing education course sponsored by the hospital, “The nurse faces alcoholism.” Goodman is a member of the steering committee of the newly organized National Nurses Society on Alcoholism (NNSA), a component of the National Council on Alcoholism. She received a BSN from the College of Mount St Vincent, Riverdale, N Y .
AORN Journal, November 1976, Vol24, No 5
he OR nurse can be a gatekeeper in detecting alcoholism.
T
A third and little-understood property of alcohol is its addictiveness, which appears to be both physical and psychological. Physical addiction can be produced in any animal by giving it alcohol in increasing amounts over a period of time. As the body receives alcohol, it builds tolerance for it and demands increasing amounts. Eventually, the animal will be able to tolerate blood alcohol levels that initially would have been lethal, but now are tolerable because of the mechanism of cell adaptation. Although not everyone with a high tolerance for alcohol will become an alcoholic, increase in tolerance is one of the early symptoms of alcoholism. Unfortunately, in our society a high alcohol tolerance is usually a source of pride. Many believe the ability to consume large quantities of alcohol is a sign of manliness or sophistication. Because alcohol is an addictive drug and because there are no controls on its use as there are for other sedatives, alcohol should never be prescribed as a sedative. Once a person or animal has become physically addicted to alcohol (or any sedative), withdrawal symptoms will appear when the drug is no longer consumed. Mild withdrawal symptoms of alcohol addiction are elevated pulse, blood pressure, and temperature; diaphoresis; increased psychomotor activity; irritability; and anxiety. In addi-
tion, moderate withdrawal symptoms include headache, nausea, vomiting, and tremors. For severe withdrawal, additional symptoms are extreme agitation and restlessness, hallucinations, and sometimes convulsions. Over and above the physical tolerance and withdrawal syndrome associated with addiction, humans also seem to experience psychological addiction to the drug alcohol manifested by its use in an uncontrollable, compulsive manner. It is this compulsive, excessive use of alcohol that characterizes alcoholism, a disease afflicting one out of ten drinkers. An estimated 10 million Americans have the disease, but because of its progressive nature, only a few manifest symptoms usually associated with the stereotype chronic alcoholic. The rest are in the early or middle stages of the illness and are in the mainstream of society. It is estimated that only 3% of the victims of alcoholism are on skid row. Knowledgeable persons who come in contact with alcoholics in the early and middle stages can help if they recognize symptoms, confront the alcoholic, and offer treatment. How can the OR nurse help? First, let’s consider the emergency surgical patient-the alcoholic who needs treatment for a ruptured ulcer, a fracture, a subdural hematoma, or laceration. As a rule, the sober alcoholic requires larger amounts of anesthetic
AORN Journal, November 1976, Vol24, No 5
869
A
lcoholic convulsions may occur as anesthesia wears off.
than a nonalcoholic because of crosstolerance to sedative drugs. However, alcohol has a potentiating or synergistic effect on other sedatives. If the patient is intoxicated or has been drinking prior to surgery, a normal dose of barbiturate or anesthetic may result in a Mickey Finn effect and even be lethal. If the patient has not been drinking, a normal dose of anesthesia may be inadequate and result in the patient’s awakening during surgery. The danger of aspiration is especially high in a patient who has been drinking prior to surgery because of the high likelihood of vomiting induced by the alcohol. Because alcohol lowers prothrombin time and destroys platelets, these patients tend to bleed more. They also tend to develop infections more readily because alcohol depresses production of white blood cells and globulin. If the patient has been sent to the operating room from the emergency room in an intoxicated state, other conditions may be present but masked by intoxication. Subdural hematomas, hypoglycemic coma, skull fracture, diabetic coma, and uremia are most common. There is also a possibility that alcohol may have been taken in combination with other drugs. If the patient does not regain consciousness in a reasonable amount of time in the recovery room, these conditions need to be investigated as possible causes of unconsciousness.
870
It is important to prevent alcoholic patients from vomiting, especially if they are in the later stages of the disease, because of the danger of rupturing esophageal varices or causing a cerebrovascular accident. As mentioned earlier, alcohol causes hypertension and elevated blood pressure accompanies alcohol withdrawal. Intravenous fluids need to be carefully monitored because alcoholic patients are usually overhydrated. Although alcohol has a diuretic effect when the blood alcohol level is high, there is a rebound antidiuretic effect when the blood alcohol level falls. Patients have died because of inappropriate administration of intravenous fluids. Dryness of buccal mucosa is most often due to the drying effect of alcohol on the mouth and not to dehydration. Unless the patient has been vomiting or has had diarrhea, dehydration usually is not a problem. Alcoholic convulsions may take place as anesthesia wears off and the patient begins to experience withdrawal. Most often, however, convulsions appear three to five days after the onset of withdrawal and may occur up to ten days later. If convulsions occur in the recovery room, they can usually be prevented from recurring by intramuscular administration of diazepam or magnesium sulfate. Skillful, knowledgeable nursing care in the recovery room can save an alcoholic’s life by buying time to later
AORN Journal, November 1976, Vol24, N o 5
confront him with his alcoholism and possibly motivate him to accept treatment. If your patient is having elective surgery, you have a chance to detect untreated alcoholism during preoperative evaluation before it causes operative or postoperative complications. It is a sad reflection on our skills in observation and history-taking when patients who have undergone elective surgery go into withdrawal postoperatively. Obviously, it is better to detoxify a patient before he has surgery. Since so many of the alcoholic’s symptoms are behavioral, can the nurse detect the problem without observing him in a social setting? Yes. You have access to information that others don’t have such as laboratory test results, a trained sense of observation, and information the patient will give you if you know how to ask the right questions. If you want to help alcoholics, you should first examine your own attitudes toward alcohol, drinking, and alcoholics. If you can approach the patient without judging, condemning, or being self-righteous and can keep in check natural inclinations to rescue and mother the patient, you may be able to help. You will need knowledge, compassion, and firmness. What should you look for? Observe the patient. Does he have shaky hands? Is he diaphoretic? Restless? Irritable? Anxious? Are there cigarette burns on his fingers? Sores on his
skin? Is his face puffy and red? Are there petechiae on his face? Look at the patient’s chart. Is the diagnosis alcohol related? Is it a recurring problem? Does the patient require more than usual sedation? Is pulse, blood pressure, or temperature elevated? If there has been no drinking since admission, withdrawal may be taking place and symptoms may be hidden or indicate the onset of more severe symptoms. What do laboratory test results show? Anemia? Low folic acid? Low clotting time? Low magnesium level? Lactic acid elevation? Potassium depletion? Serum glutamic oxaloacetic transaminase (SGOT), serum glutamic pyruvic transaminase (SGPT), bromsulfalein (BSP) or bilirubin elevations? Electrocardiograph abnormalities? Electroencephalograph abnormalities? All these point to possible alcoholism. Talk to the patient. Explain to him or her (there are just as many women alcoholics as men) that a person’s drinking habits are important to operating room personnel because the amount a person drinks affects the amount and kind of anesthesia he will require. Explain that a heavy drinker will require a larger amount of sedation than a moderate drinker. Ask him the following questions: Does he drink every day? About how much does he drink? What does he drink? How long has he been drinking? Is his tolerance going up or down? (Decreasing toler-
AORN Journal, November 1976, Vol24, No 5
871
Clinical speclalist in alcohol program Editor’s note: Nurses are assuming an increasingly active role not only in providing community alcoholism treatment services but in educating hospital staff to recognize signs of alcoholism and make proper referrals for treatment. Sandra Jaffe, FIN, MA, describes her work as a member of a multidisciplinary team that provides consultative services to a general hospital. A graduate of Mount Sinai School of Nursing, she received her BS from Hunter College, New York City, and her MA in adult psychiatric nursing from New York University. Since June 1975, I have been employed as a nurse clinical specialist in the alcoholism program at St Vincent‘s Hospital and Medical Center, New York City. I am a member of a six-member multidisciplinary consultation team to the general hospital which includes one physician, one nurse, one social worker, and three alcoholism counselors. The impetus for development of an alcoholism consultation team came from research findings that 53% of the male ward patients in the general hospital during a specific month were alcoholics. The authors cite the reason for this statistically higher rate than other hospital surveys is based upon the physician’s ability to obtain a more adequate assessment of the patient’s drinking patterns. My goals are directed primarily toward creating curiosity among the nursing staff about alcoholism. This generally implies self-awareness of staff attitudes toward alcohol, alcoholism, and the alcoholic. Another goal is to inform staff and patients
ance indicates a later stage of alcoholism.) Has he ever tried to go without drinking? What happened? Is he drinking now? (Family members may be bringing in alcoholic beverages during visiting hours, or the patient may have a hidden supply. Be suspicious if the patient needs little seda-
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that alcoholism is a treatable disease and not a question of willpower or self-control. Educational workshops are held on each nursing unit to discuss the overall alcoholism treatment program, case findings, and issues related to managing alcoholic patients. Reinforcement is provided through films shown on the unit, nursing rounds, and individual consultation. The unit staff is invaluable in encouraging patients to seek treatment for alcoholism. Without this encouragement the patient may continue to deny his illness. Several patients have later come in for treatment on their own and expressed appreciation for information given by a staff nurse about alcoholism at the time of their hospitalization for a primary disease other than alcoholism. In managing patients with alcoholism, it is important to assist the staff to relabel behavior based on knowledge of the disease rather than feelings the alcoholic may evoke due to defenses he uses to cope with reality Staff members need continuous opportunity to ventilate their feelings of hopelessness in working with alcoholic patients. Feedback about recovering alcoholics in the program is important in encouraging the staff. The staffs receptivity to talk openly about alcoholism gives the patient the message he has a legitimate disease that needs treatment. It is hoped this message will help transform an isolated hopeless alcoholic into a sober, recovering alcoholic who views the future with optimism. Not08 1. William C Panepinto, Susanne A Kohut, “Alcoholism:treatment through understanding,” Hospkals 45 (Nov 16, 1971) 57.
tion at night.) Ask the same questions about sedative drugs, tranquilizers (especially chlordiazepoxide and diazepam) and sleeping pills. If you suspect a drinking problem, you can pursue this with the patient, asking him if he has experienced any family arguments or problems at work
AORN Journal, November 1976, Vol24, No 6
B
e suspicious if the patient needs little sedation.
because of drinking. If he is not alcoholic, he will not be defensive. If he is in the early stages of the disease, he will probably admit drinking is causing problems. A middle-stage alcoholic, however, will say he can stop drinking any time he wants, assert he can “handle” it, and blame his employer, spouse, and family, accusing them of not being understanding or of having too-rigid values. He will tell you how he “doesn’t” drink, for instance, “never in the morning,” or “only beer,” or “only a couple.” He will insist he can take it or leave it, that he doesn’t have a problem. The late-stage alcoholic may be either honest or more firmly entrenched in denial, but his physical condition will betray him. If you have been successful in establishing rapport with the patient and he is receptive, you can then educate him about his disease. Alcoholics are easiest to motivate when they are suffering the painful consequences of a crisis that has occurred as a result of drinking. Hospitalization can be seen as such a crisis and skillfully used as a source of motivation. Alcoholics drink to anesthetize emotional pain. They usually decide to stop drinking when the pain they experience as a result of drinking outweighs pain they are trying to relieve. Many alcoholics stop drinking when they are in trouble but resume when they get “off the hook.” Unless they
receive treatment, however, most of them eventually return to drinking, reexperience the loss of control, and create more problems. Alcoholics need confrontation and directive counseling while they are hurting. If you wait until the patient is feeling better, you will have lost him. Know your community resources. Have telephone numbers of Alcoholic Anonymous (AA) members or alcoholism counselors a t hand so when the patient indicates a desire for help, you can suggest someone with special training to visit him. What if they don’t want help? Whether or not the alcoholic responds to your confrontation, tell his attending physician what you suspect or have discovered so detoxification can take place before surgery if possible. If you can, try to find time to meet with family members. They are not only a valuable source of information but they also are victims and in need of help. Most families, because of shame, ignorance, guilt, fear, and a misguided sense of loyalty and love, hide, protect, and cover up for the alcoholic. Without realizing it, they aid and abet the very behavior they seek to eliminate. You can render a great service by spending a few minutes with them, referring them to Al-Anon and Alateen, organizations to assist families of alcoholics. If you are not sure but suspect a patient is alcoholic, a n interview with family members may disclose informa-
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tion you need to confirm your suspicions. In helping the family, you may indirectly help the patient. If the alcoholic stops drinking, changed family attitudes and behavior will do much to reinforce his decision to stay sober. If he doesn’t stop, the family’s change in attitude and behavior may precipitate a crisis or become a strong motivating force in his recovery later on. Recognition that alcoholism is a family disease and the entire family must be involved in treatment is essential to enlightened treatment of the alcoholic. Since the children of alcoholics have been identified as being in the highest risk category for becoming alcoholics, it is vital to help these youngsters before they make major life decisions and approach the legal drinking age. The patient may reject offers of help, and his family may continue to deny and cover up. But we must believe that our efforts are worthwhile. Weeks or even years later, the words we had thought useless may be remembered and become the force that motivates the person to seek help. For each alcoholic who recovers, many others benefit. Our actions are more farreaching than we can imagine. Everyone who comes in contact with an alcoholic has an opportunity to improve the quality of his life. 0 Notes 1. Conversation with Andrew Abrahams, September 1976. 2. Mark Keller, “Definition of alcoholism and estimation of its prevalence,” in Society, Culture and Drinking Patterns, D J Pittrnan, Charles Snyder, eds. (New York: John Wiley & Sons, 1962) 316.
References Blume, Sheila B. “Iatrogenic alcoholism.” Quarterly Journal of Studies on Alcohol 34 (December 1973) 1348-1352. Criteria Committee, National Council on Alcoholism. “Criteria for the diagnosis of alcoholism.” American Journal of Psychiatry 129 (August 1972) 127-135.
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Gitlow, Stanley E. “A pharmacologicalapproach to alcoholism.” AA Grapevine (October 1968). First Special Report to the US Congress on Alcohol and Health from the Secretary of Health, Education, and Welfare, December 1971 (DHEW Publication No [ADM] 74-68 Formerly [HSM] 73-9031). Washington, DC. Second Special Report to the US Congress on Alcohol and Health from the Secretary of Health, Education, and Welfare, June 1974 (DHEW Publication No [ADM] 75-212). Washington, DC. Seixas, Frank A. “Alcohol: A hidden factor in physical illness.” RN (July 1974) 31-34. Seixas, Frank A. “Uncovering and counseling the alcoholic.” RN (July 1974) 36-37. Weinberg, John R. “Interview techniques for diagnosing alcoholism.” American Family Physician 9 (March 1974) 107-115.
Cancer risk of thyroid supplements Prolonged use of thyroid supplements seems to be related to increase of breast cancer, according to a report in Journal of the American Medical Association (JAMA). In the study, by Chandrakant C Kapdi, MD, and John N Wolfe, MD, of Hutzel Hospital, Detroit, it was found that incidence of breast cancer among patients receiving the thyroid supplement was 12.13%, while in a control group not taking the supplement the incidence was 6.2%. Likelihood of breast cancer increased with the number of years on the thyroid supplement, up to 19.48% for those taking the substance more than 15 years. The incidence was higher among women who had never given birth. William R Barclay, MD, JAMA editor, pointed out that most of the women taking thyroid supplements did not develop breast cancer . Thyroid supplements are so essential for individuals with inactive or sluggish thyroid glands that physicians should continue to prescribe thyroid supplements when indicated but with proper patient counseling regarding the risk, Dr Barclay said. Low thyroid output can lead to debilitating, serious health problems, unless corrected by supplements, he said.
AORN Journal, November 1976, Vol24, No 5
OR nursing inte rvent ion for the alcoholic
Can a patient’s alcoholism make a difference in the outcome of his surgery? Can the operating room nurse contribute to the alcoholic patient’s chance for successful recovery? Can the operating room nurse serve as a “gatekeeper” in detection of alcoholism? Can the operating room nurse successfully intervene to halt progression of a patient’s alcoholism? The answer to these questions is yes. The nurse who is knowledgeable, interested, and has the proper attitude can be a significant factor in the recovery of alcoholic patients. According to Andrew Abrahams, MD, director of the BedfordStuyvesant Alcoholism Treatment Center, Brooklyn, studies done for the New York City Health Services Ad-
ministration have shown that 50% of beds occupied in 19 municipal hospitals were occupied by persons being treated for secondary complications of alcoholism. Only 1%of the beds were occupied by persons whose primary diagnosis was alcoholism. The findings in 19 private hospitals were similar: ~ WofOthe beds were occupied by persons suffering from medical or surgical problems derived from alcoholism while only 2% had been admitted for alcoholism.’ In these studies, alcoholism was defined as a “chronic disease manifested by repeated implicative drinking so as to cause injury to the drinker’s health or to his social functioning.’12 When the patient’s alcoholism is undiagnosed and left untreated, the
AORN Journal, November 1976, Vol24, No 5
867
patient is placed in jeopardy and his chances for recovery are greatly reduced. Although we may be more comfortable treating the patient’s “official” diagnosis, we must not let negative attitudes, lack of knowledge, or discomfort with confrontation prevent us from addressing the underlying problem, alcoholism. If we ignore it, we ensure difficulties in the treatment process, further complications, readmission for an exacerbated condition, and perhaps even the alcoholic’s premature death. As nurses, we can be gatekeepers. Since we sometimes spend more time with patients than physicians do, we can observe patients in a variety of situations and pick up clues and symptoms that may have been missed on examination. Keen observation will reveal signs of alcoholism that might otherwise be overlooked or ascribed to another illness. What are the secondary diseases of alcoholism and what are the implications for the operating room nurse? Alcohol is the most toxic drug known to man. Not one organ or system escapes its depressant or irritating effects. Fatty liver, alcoholic hepatitis, cirrhosis of the liver, gastritis, cerebellar degeneration, cerebral atrophy, and esophageal varices are conditions most commonly associated with chronic alcoholism and alcohol abuse. Other less-often-recognized secondary diseases of alcoholism are: acute and chronic pancreatitis, hypoglycemia, secondary diabetes, cardiac myopathy, hypertension, anemia, peripheral neuropathy, paralysis, peptic or duodenal ulcers, chronic diarrhea, vitamin deficiencies, convulsive disorders, muscular myopathy, and cancer of the larynx, esophagus, or stomach. Since 50% of highway and 4% of home accidents are alcohol related, a great
868
proportion of emergency surgical and orthopedic patients must be assumed to have alcohol problems. Any of the above diagnoses should alert the operating room nurse to the possibility that alcoholism may be involved. A detailed history and physical are in order, because if the alcoholism goes undetected, there may be complications in the operating room or recovery room. The patient may go into delirium tremens (DTs) after surgery. Alcohol‘s effects. Alcohol is a sedative in the same pharmacological group as barbiturates, Pentothal, Amytal, ether, and chloral hydrate. It also has an agitating or irritating effect, which is cumulative both in intensity and in time and outlasts the sedative effect. This agitating effect is responsible for the increase in anxiety, irritability, and psychomotor activity after a drinking episode. In persons who have been drinking heavily over a period of time, the irritating effects of alcohol sometimes break through the sedative effect and cause restlessness, violence, and even hallucinations in spite of high blood alcohol levels. Irritability causes alcoholic convulsions and hallucinations and tremors associated with alcohol withdrawal, of which DTs are the severest form.
Louise Mehrman Goodman, R N , is coordinator of family services, South Oaks Hospital, Amityville, N Y . She designed and coordinates a continuing education course sponsored by the hospital, “The nurse faces alcoholism.” Goodman is a member of the steering committee of the newly organized National Nurses Society on Alcoholism (NNSA), a component of the National Council on Alcoholism. She received a BSN from the College of Mount St Vincent, Riverdale, N Y .
AORN Journal, November 1976, Vol24, No 5
he OR nurse can be a gatekeeper in detecting alcoholism.
T
A third and little-understood property of alcohol is its addictiveness, which appears to be both physical and psychological. Physical addiction can be produced in any animal by giving it alcohol in increasing amounts over a period of time. As the body receives alcohol, it builds tolerance for it and demands increasing amounts. Eventually, the animal will be able to tolerate blood alcohol levels that initially would have been lethal, but now are tolerable because of the mechanism of cell adaptation. Although not everyone with a high tolerance for alcohol will become an alcoholic, increase in tolerance is one of the early symptoms of alcoholism. Unfortunately, in our society a high alcohol tolerance is usually a source of pride. Many believe the ability to consume large quantities of alcohol is a sign of manliness or sophistication. Because alcohol is an addictive drug and because there are no controls on its use as there are for other sedatives, alcohol should never be prescribed as a sedative. Once a person or animal has become physically addicted to alcohol (or any sedative), withdrawal symptoms will appear when the drug is no longer consumed. Mild withdrawal symptoms of alcohol addiction are elevated pulse, blood pressure, and temperature; diaphoresis; increased psychomotor activity; irritability; and anxiety. In addi-
tion, moderate withdrawal symptoms include headache, nausea, vomiting, and tremors. For severe withdrawal, additional symptoms are extreme agitation and restlessness, hallucinations, and sometimes convulsions. Over and above the physical tolerance and withdrawal syndrome associated with addiction, humans also seem to experience psychological addiction to the drug alcohol manifested by its use in an uncontrollable, compulsive manner. It is this compulsive, excessive use of alcohol that characterizes alcoholism, a disease afflicting one out of ten drinkers. An estimated 10 million Americans have the disease, but because of its progressive nature, only a few manifest symptoms usually associated with the stereotype chronic alcoholic. The rest are in the early or middle stages of the illness and are in the mainstream of society. It is estimated that only 3% of the victims of alcoholism are on skid row. Knowledgeable persons who come in contact with alcoholics in the early and middle stages can help if they recognize symptoms, confront the alcoholic, and offer treatment. How can the OR nurse help? First, let’s consider the emergency surgical patient-the alcoholic who needs treatment for a ruptured ulcer, a fracture, a subdural hematoma, or laceration. As a rule, the sober alcoholic requires larger amounts of anesthetic
AORN Journal, November 1976, Vol24, No 5
869
A
lcoholic convulsions may occur as anesthesia wears off.
than a nonalcoholic because of crosstolerance to sedative drugs. However, alcohol has a potentiating or synergistic effect on other sedatives. If the patient is intoxicated or has been drinking prior to surgery, a normal dose of barbiturate or anesthetic may result in a Mickey Finn effect and even be lethal. If the patient has not been drinking, a normal dose of anesthesia may be inadequate and result in the patient’s awakening during surgery. The danger of aspiration is especially high in a patient who has been drinking prior to surgery because of the high likelihood of vomiting induced by the alcohol. Because alcohol lowers prothrombin time and destroys platelets, these patients tend to bleed more. They also tend to develop infections more readily because alcohol depresses production of white blood cells and globulin. If the patient has been sent to the operating room from the emergency room in an intoxicated state, other conditions may be present but masked by intoxication. Subdural hematomas, hypoglycemic coma, skull fracture, diabetic coma, and uremia are most common. There is also a possibility that alcohol may have been taken in combination with other drugs. If the patient does not regain consciousness in a reasonable amount of time in the recovery room, these conditions need to be investigated as possible causes of unconsciousness.
870
It is important to prevent alcoholic patients from vomiting, especially if they are in the later stages of the disease, because of the danger of rupturing esophageal varices or causing a cerebrovascular accident. As mentioned earlier, alcohol causes hypertension and elevated blood pressure accompanies alcohol withdrawal. Intravenous fluids need to be carefully monitored because alcoholic patients are usually overhydrated. Although alcohol has a diuretic effect when the blood alcohol level is high, there is a rebound antidiuretic effect when the blood alcohol level falls. Patients have died because of inappropriate administration of intravenous fluids. Dryness of buccal mucosa is most often due to the drying effect of alcohol on the mouth and not to dehydration. Unless the patient has been vomiting or has had diarrhea, dehydration usually is not a problem. Alcoholic convulsions may take place as anesthesia wears off and the patient begins to experience withdrawal. Most often, however, convulsions appear three to five days after the onset of withdrawal and may occur up to ten days later. If convulsions occur in the recovery room, they can usually be prevented from recurring by intramuscular administration of diazepam or magnesium sulfate. Skillful, knowledgeable nursing care in the recovery room can save an alcoholic’s life by buying time to later
AORN Journal, November 1976, Vol24, N o 5
confront him with his alcoholism and possibly motivate him to accept treatment. If your patient is having elective surgery, you have a chance to detect untreated alcoholism during preoperative evaluation before it causes operative or postoperative complications. It is a sad reflection on our skills in observation and history-taking when patients who have undergone elective surgery go into withdrawal postoperatively. Obviously, it is better to detoxify a patient before he has surgery. Since so many of the alcoholic’s symptoms are behavioral, can the nurse detect the problem without observing him in a social setting? Yes. You have access to information that others don’t have such as laboratory test results, a trained sense of observation, and information the patient will give you if you know how to ask the right questions. If you want to help alcoholics, you should first examine your own attitudes toward alcohol, drinking, and alcoholics. If you can approach the patient without judging, condemning, or being self-righteous and can keep in check natural inclinations to rescue and mother the patient, you may be able to help. You will need knowledge, compassion, and firmness. What should you look for? Observe the patient. Does he have shaky hands? Is he diaphoretic? Restless? Irritable? Anxious? Are there cigarette burns on his fingers? Sores on his
skin? Is his face puffy and red? Are there petechiae on his face? Look at the patient’s chart. Is the diagnosis alcohol related? Is it a recurring problem? Does the patient require more than usual sedation? Is pulse, blood pressure, or temperature elevated? If there has been no drinking since admission, withdrawal may be taking place and symptoms may be hidden or indicate the onset of more severe symptoms. What do laboratory test results show? Anemia? Low folic acid? Low clotting time? Low magnesium level? Lactic acid elevation? Potassium depletion? Serum glutamic oxaloacetic transaminase (SGOT), serum glutamic pyruvic transaminase (SGPT), bromsulfalein (BSP) or bilirubin elevations? Electrocardiograph abnormalities? Electroencephalograph abnormalities? All these point to possible alcoholism. Talk to the patient. Explain to him or her (there are just as many women alcoholics as men) that a person’s drinking habits are important to operating room personnel because the amount a person drinks affects the amount and kind of anesthesia he will require. Explain that a heavy drinker will require a larger amount of sedation than a moderate drinker. Ask him the following questions: Does he drink every day? About how much does he drink? What does he drink? How long has he been drinking? Is his tolerance going up or down? (Decreasing toler-
AORN Journal, November 1976, Vol24, No 5
871
Clinical speclalist in alcohol program Editor’s note: Nurses are assuming an increasingly active role not only in providing community alcoholism treatment services but in educating hospital staff to recognize signs of alcoholism and make proper referrals for treatment. Sandra Jaffe, FIN, MA, describes her work as a member of a multidisciplinary team that provides consultative services to a general hospital. A graduate of Mount Sinai School of Nursing, she received her BS from Hunter College, New York City, and her MA in adult psychiatric nursing from New York University. Since June 1975, I have been employed as a nurse clinical specialist in the alcoholism program at St Vincent‘s Hospital and Medical Center, New York City. I am a member of a six-member multidisciplinary consultation team to the general hospital which includes one physician, one nurse, one social worker, and three alcoholism counselors. The impetus for development of an alcoholism consultation team came from research findings that 53% of the male ward patients in the general hospital during a specific month were alcoholics. The authors cite the reason for this statistically higher rate than other hospital surveys is based upon the physician’s ability to obtain a more adequate assessment of the patient’s drinking patterns. My goals are directed primarily toward creating curiosity among the nursing staff about alcoholism. This generally implies self-awareness of staff attitudes toward alcohol, alcoholism, and the alcoholic. Another goal is to inform staff and patients
ance indicates a later stage of alcoholism.) Has he ever tried to go without drinking? What happened? Is he drinking now? (Family members may be bringing in alcoholic beverages during visiting hours, or the patient may have a hidden supply. Be suspicious if the patient needs little seda-
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that alcoholism is a treatable disease and not a question of willpower or self-control. Educational workshops are held on each nursing unit to discuss the overall alcoholism treatment program, case findings, and issues related to managing alcoholic patients. Reinforcement is provided through films shown on the unit, nursing rounds, and individual consultation. The unit staff is invaluable in encouraging patients to seek treatment for alcoholism. Without this encouragement the patient may continue to deny his illness. Several patients have later come in for treatment on their own and expressed appreciation for information given by a staff nurse about alcoholism at the time of their hospitalization for a primary disease other than alcoholism. In managing patients with alcoholism, it is important to assist the staff to relabel behavior based on knowledge of the disease rather than feelings the alcoholic may evoke due to defenses he uses to cope with reality Staff members need continuous opportunity to ventilate their feelings of hopelessness in working with alcoholic patients. Feedback about recovering alcoholics in the program is important in encouraging the staff. The staffs receptivity to talk openly about alcoholism gives the patient the message he has a legitimate disease that needs treatment. It is hoped this message will help transform an isolated hopeless alcoholic into a sober, recovering alcoholic who views the future with optimism. Not08 1. William C Panepinto, Susanne A Kohut, “Alcoholism:treatment through understanding,” Hospkals 45 (Nov 16, 1971) 57.
tion at night.) Ask the same questions about sedative drugs, tranquilizers (especially chlordiazepoxide and diazepam) and sleeping pills. If you suspect a drinking problem, you can pursue this with the patient, asking him if he has experienced any family arguments or problems at work
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e suspicious if the patient needs little sedation.
because of drinking. If he is not alcoholic, he will not be defensive. If he is in the early stages of the disease, he will probably admit drinking is causing problems. A middle-stage alcoholic, however, will say he can stop drinking any time he wants, assert he can “handle” it, and blame his employer, spouse, and family, accusing them of not being understanding or of having too-rigid values. He will tell you how he “doesn’t” drink, for instance, “never in the morning,” or “only beer,” or “only a couple.” He will insist he can take it or leave it, that he doesn’t have a problem. The late-stage alcoholic may be either honest or more firmly entrenched in denial, but his physical condition will betray him. If you have been successful in establishing rapport with the patient and he is receptive, you can then educate him about his disease. Alcoholics are easiest to motivate when they are suffering the painful consequences of a crisis that has occurred as a result of drinking. Hospitalization can be seen as such a crisis and skillfully used as a source of motivation. Alcoholics drink to anesthetize emotional pain. They usually decide to stop drinking when the pain they experience as a result of drinking outweighs pain they are trying to relieve. Many alcoholics stop drinking when they are in trouble but resume when they get “off the hook.” Unless they
receive treatment, however, most of them eventually return to drinking, reexperience the loss of control, and create more problems. Alcoholics need confrontation and directive counseling while they are hurting. If you wait until the patient is feeling better, you will have lost him. Know your community resources. Have telephone numbers of Alcoholic Anonymous (AA) members or alcoholism counselors a t hand so when the patient indicates a desire for help, you can suggest someone with special training to visit him. What if they don’t want help? Whether or not the alcoholic responds to your confrontation, tell his attending physician what you suspect or have discovered so detoxification can take place before surgery if possible. If you can, try to find time to meet with family members. They are not only a valuable source of information but they also are victims and in need of help. Most families, because of shame, ignorance, guilt, fear, and a misguided sense of loyalty and love, hide, protect, and cover up for the alcoholic. Without realizing it, they aid and abet the very behavior they seek to eliminate. You can render a great service by spending a few minutes with them, referring them to Al-Anon and Alateen, organizations to assist families of alcoholics. If you are not sure but suspect a patient is alcoholic, a n interview with family members may disclose informa-
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tion you need to confirm your suspicions. In helping the family, you may indirectly help the patient. If the alcoholic stops drinking, changed family attitudes and behavior will do much to reinforce his decision to stay sober. If he doesn’t stop, the family’s change in attitude and behavior may precipitate a crisis or become a strong motivating force in his recovery later on. Recognition that alcoholism is a family disease and the entire family must be involved in treatment is essential to enlightened treatment of the alcoholic. Since the children of alcoholics have been identified as being in the highest risk category for becoming alcoholics, it is vital to help these youngsters before they make major life decisions and approach the legal drinking age. The patient may reject offers of help, and his family may continue to deny and cover up. But we must believe that our efforts are worthwhile. Weeks or even years later, the words we had thought useless may be remembered and become the force that motivates the person to seek help. For each alcoholic who recovers, many others benefit. Our actions are more farreaching than we can imagine. Everyone who comes in contact with an alcoholic has an opportunity to improve the quality of his life. 0 Notes 1. Conversation with Andrew Abrahams, September 1976. 2. Mark Keller, “Definition of alcoholism and estimation of its prevalence,” in Society, Culture and Drinking Patterns, D J Pittrnan, Charles Snyder, eds. (New York: John Wiley & Sons, 1962) 316.
References Blume, Sheila B. “Iatrogenic alcoholism.” Quarterly Journal of Studies on Alcohol 34 (December 1973) 1348-1352. Criteria Committee, National Council on Alcoholism. “Criteria for the diagnosis of alcoholism.” American Journal of Psychiatry 129 (August 1972) 127-135.
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Gitlow, Stanley E. “A pharmacologicalapproach to alcoholism.” AA Grapevine (October 1968). First Special Report to the US Congress on Alcohol and Health from the Secretary of Health, Education, and Welfare, December 1971 (DHEW Publication No [ADM] 74-68 Formerly [HSM] 73-9031). Washington, DC. Second Special Report to the US Congress on Alcohol and Health from the Secretary of Health, Education, and Welfare, June 1974 (DHEW Publication No [ADM] 75-212). Washington, DC. Seixas, Frank A. “Alcohol: A hidden factor in physical illness.” RN (July 1974) 31-34. Seixas, Frank A. “Uncovering and counseling the alcoholic.” RN (July 1974) 36-37. Weinberg, John R. “Interview techniques for diagnosing alcoholism.” American Family Physician 9 (March 1974) 107-115.
Cancer risk of thyroid supplements Prolonged use of thyroid supplements seems to be related to increase of breast cancer, according to a report in Journal of the American Medical Association (JAMA). In the study, by Chandrakant C Kapdi, MD, and John N Wolfe, MD, of Hutzel Hospital, Detroit, it was found that incidence of breast cancer among patients receiving the thyroid supplement was 12.13%, while in a control group not taking the supplement the incidence was 6.2%. Likelihood of breast cancer increased with the number of years on the thyroid supplement, up to 19.48% for those taking the substance more than 15 years. The incidence was higher among women who had never given birth. William R Barclay, MD, JAMA editor, pointed out that most of the women taking thyroid supplements did not develop breast cancer . Thyroid supplements are so essential for individuals with inactive or sluggish thyroid glands that physicians should continue to prescribe thyroid supplements when indicated but with proper patient counseling regarding the risk, Dr Barclay said. Low thyroid output can lead to debilitating, serious health problems, unless corrected by supplements, he said.
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