Taking care of alcoholics or patients who has alcohol abuse problems is one of the most difficult task that an orthopaedic nurse must perform. It is difficult in a sense that a nurse might get hurt in the process because of the patient’s resistance due to delirium tremens and alcohol withdrawals. That is why, it is important for a nurse to be able to identify if the patient is alcoholic or not. A nurse must be able to see the symptoms before it even triggers. When proven that the patient is alcoholic, the nurse must also know how to deal with this patient properly and must be able to ensure that the nursing care he or she is giving to the patient would be helpful in the development of the patient. For a task as crucial as this, a nurse must be knowledgeable about the theories regarding alcoholism. A nurse should also have knowledge on the behavior of alcoholic persons: e.g. the way they move; speak; relate with other people, etc. Having equipped with these facts, a nurse can ensure the well-being and development, both physically and mentally, of his or her patient as well as his or hers. This paper intends to link the theories in alcoholism to the aspect of nursing practised by the author as an orthopaedic nurse using related literatures. The process would help underpin the communication strategies that should be best used to inform a patient.
The aspect of nursing that the author practises is the psychiatric nursing or one-on-one nurse patient relationship. The author chooses this practise because it does not restrain itself into the physical well-being of the alcoholic patient. Instead, it focuses in the mental and emotional health and stability of the patient where, by being alcoholic, is one of the most vulnerable. This practise fits well with Mellow’s theoretical framework as was depicted by Suzanne Lego (1999). Mellow’s theory centers on the development of a nurse-patient relationship which will hopefully be “corrective” for the patient. It is called nursing therapy and draws on the psychoanalytic theory in the sense that an intensive, symbiotic relationship is developed between the nurse and patient. It promotes and emphasizes on providing a remedial emotional experience rather than on investigation of the pathological process or of the interpersonal developmental process. (Lego, 2002, p. 1) Although this practise is effective when applied to alcoholic patients, it is still limited in a sense that it could still promote negative backlashes. One example is the “chronic helpfulness,” cited by Lego (1999) from Rouslin (1963). Chronic helpfulness is the phenomenon of dependency leading to excessive helpfulness, which is stabilized over time in an unsatisfying interpersonal behavior pattern. Another intervention that nurses who use psychiatric nursing experience from patients is the “Patient’s Gift.” It was cited by Lego (2002) from Clack (1963), and it was described as the problem of the patient who needs to give to the nurse in order to meet certain needs of his own.
In order to further develop psychiatric nursing approach, to be able to identify and to tell a patient that he or she is alcoholic, a good nurse must first have a broad knowledge on alcoholism. The author has provided some literatures that would help support the paper.
Through observations, one can conclude a persons behavior changes after taking several amounts of alcoholic beverages. But the problem does not start here. The problem occurs when a person is already in the brink of clean living, having him being pulled by the hands of alcoholism. Don Martindale (1977) wrote that there are several types and phases of alcoholism. In the introduction of these phases, Martindale stresses that there are two categories of alcoholism. The Alcoholism Subcommittee of the World Health Organization enumerated these two categories as “alcohol addicts” and “habitual symptomatic excessive drinkers,” referred to as non-addictive alcoholics. Martindale cites an opinion from E. M. Jellinek, one of the leading authorities in alcoholism, which states that the disease conception refers only to the alcohol addicts. Both the alcohol addicts and the non-addictive alcoholics are characterized by excessive drinking that reflects underlying social or psychological problems. But alcohol addicts, after several years of excessive drinking, lose control, while non-addictive alcoholics do not. In his opinion, Jellinek also observes that that many excessive drinkers consume as much as or more than addicts over a period of thirty or forty years without loss of control. This suggests to Jellinek that a superimposed process (perhaps psychological, perhaps physiological) makes the difference between prolonged excessive drinking and addiction.
The four phases of alcoholism by Martindale (1977) do represent the typical course of events that leads from social drinking to alcohol addiction. These four phases are: the pre-alcoholic symptomatic phase, the prodromal phase, the crucial phase, and the chronic phase. The pre-alcoholic symptomatic phase starts with the occasional drinking. As was stressed by Martindale (1997), “most drinking begins in social situations. But the prospective alcoholic finds more than ordinary relief from the tensions of living in drinking, and therefore may deliberately frequent those social situations where liquor flows freely. At first these situations are occasional, but, within a period of from six months to two years, he falls into a pattern of daily drinking. From occasional drinking to unwind, the drinker progresses to constant drinking accompanied by an increase in alcohol tolerance (and the need to drink more to achieve the desired effect).”
The prodromal phase is characterized by sudden blackouts or amnesia, technically termed alcoholic palimpsests. The amnesia is not accompanied by loss of consciousness and is not necessarily due to an excessive amount of immediate alcoholic intake. It develops the drinker a drinking pattern and behavior that suggests that alcohol is his necessity and a life without it is unbearable. Characteristic of the pattern are surreptitious drinking, preoccupation with alcohol, and avid drinking (gulping of first drinks). He may have a few drinks at home before going out for the evening, or, if he knows his companions well, he may bring along his own supply to fortify him until he returns home. Guilty feelings will soon follow which lead to the avoidance of conversation in reference to alcohol. Another warning symptom in the prodromal phase is the increase in the frequency of alcoholic palimpsests. The duration of the prodromal period varies from six months to four or five years and ends with alcohol addiction, at which point the drinker experiences loss of control over his alcoholic intake. (Martindale, 1977, p. 216)
One of the dangerous phases of alcoholism occurs in the crucial phase. The crucial or acute phase of alcoholism begins with the drinker’s loss of control over alcoholic intake. He now requires only a single drink to set him off. Any consumption of alcohol sets into motion a chain reaction of compulsive alcohol intake; the drinker cannot stop until he becomes too ill to drink any longer. After a few days or weeks, he may go on another drinking spree. Although the drinker is unable to stop once he starts drinking, he is usually still able to decide when he will go on another drinking spree. If he wishes, he can remain sober for weeks at a time between episodes. As the drinker loses control, he or she finds excuses and rationalisation to his or her behavior towards alcohol consumption. This starts the intricate system of self-deception. An alcoholic starts to notice the social pressure is already bothering his or her passion for drinking, he often displays grandiose behavior such as buying extravagant things for himself or his family. His family becomes part of the system of self-deception, and often one hears the exclamation, “He’s so wonderful when he’s sober!” But he often begins to isolate himself from his social environment, and marked aggressive behavior. patterns may set in. Alternate periods of generosity and brutality may appear. Periods of remorse lead only to more drinking rather than about how his drinking affects his way of life. The addict begins to lose interest in outside activities. A reinterpretation of his interpersonal relations is accompanied by marked self-pity. He starts thinking about “getting away from it all” (geographically not suicidally). Changes in family habits, brought on by the drinker’s erratic behavior, cause the addict to develop unreasonable resentments. To avoid having his wife confiscate his supply of alcohol the drinker hides his bottles all over the house, in the garage, the basement, the attic, and even the doghouse. Increased drinking leads to neglect of proper nutrition, first hospitalization, a decrease in sexual activity and accusations, possibly compensatory, of extramarital affairs against the wife. The crucial phase ends with the addict’s need for regular morning drinking. Up to this point, heavy drinking has been usually limited to the evening, but now the addict must have a drink upon rising, another at mid-morning, and yet another following noon lunch; heavier drinking starts before dinner. (Martindale, 1977, p. 216)
The most dangerous phase amongst the phases of alcoholism is the chronic phase. It is in this phase that alcohol increasingly dominates the drinker’s life. Martindale (1997) states it up like this:
“Morning drinking sets up a demand that breaks down his resistance until he becomes intoxicated during the daytime even on weekdays. Prolonged intoxication or benders follow and result in incapacitation, speech and thought impairment, and marked ethical deterioration. In 10 percent or less of alcoholics, true alcoholic psychoses may occur. By this time most of the alcoholic’s friends have left him and he drinks with other persons involved in heavy drinking. When he doesn’t have the money for his usual drinks he will substitute rubbing alcohol, canned heat, bay rum, shaving lotion, or vanilla; in general, he is quite prepared to consume any products with alcohol in them, even shoe polish. The addict suffers a loss of alcohol tolerance and develops indefinable fears and tremors when he is without alcohol. Without alcohol, he is also unable to perform simple mechanical acts. In an effort to control the fears and tremors his drinking takes on an obsessive character. Vague religious desires sometimes develop and the entire rationalization system collapses. The addict, at this point, sometimes admits defeat and is amenable to treatment.” (Martindale, 1977, p. 216)
The author observed that in some point in time, alcoholic patients could be violent depending on the nurse’s tone of voice. It seems like through the tone of one’s voice, an alcoholic patient can measure the nurse’s degree of respect. This story is a good example. There was this new nurse at a certain hospital who went into her alcoholic patient’s room. She was being followed by two of her assistants. The patient was lying sideways on the bed. He looked almost ready to put his head between the side rails. He was elderly and disheveled with an ecchymotic (bruised) area around his one eye with swelling that caused his eyelid to close. The nurses discussed the doctor’s refusal to write an order for Haldol (a tranquilizer). The patient was so agitated that they retied his arm restraints and moved his water pitcher out of reach. “He’s a Houdini,” said the new nurse. He kept complaining about having to go to the bathroom (urinate) even though each nurse told him to go to the bathroom through his tube. He was confused and afraid of wetting the bed. He did not realize that he had a Foley (urinary catheter) in place. While the nurses did not touch the patient roughly, the tones of their voices revealed attitudes of disrespect. This patient consistently caused the nurses to worry about how he might harm himself. He pulled his Foley out, nearly strangled himself with IV tubing, and frequently pulled his IV out of his arm. He spat on one of the nurse. While the nurses were amused at some of his antics, they were also worried and annoyed. Their ambivalence was evident as they tolerantly and impatiently spoke of him during report.
There are certain psychological theories about alcoholism. One of these is Freud’s escape theory where in his early in his observations, he states that strong oral influences of childhood (the oral stage being the first stage of psychosexual development) is a major cause of excessive drinking, and he viewed the alteration of mood by alcohol as its most valuable contribution to the drinker. The individual, thereby, achieved gratification from thinking that was uncontrolled by logic because of the redirection of thought processed by the alcohol. This theory considers the use of alcohol as an escape from reality.
(Chafetz and Demone Jr., 1962, p. 40) Another theory about alcoholism came from Adler, as was cited again by Chafetz and Demone Jr. (1962). In this theory, Adler believes that an individual acquires alcoholism because of inferiority. According to him, inferiority is the root of all alcoholism problems.
In the author’s own experience, a nurse must never spoil a patient because this would only lead to “chronic helpfulness.” Certain rules and regulations must still be applied and it is the nurse’s duty to ensure this. It usually leads to the development of behavior patterns that would backfire eventually to both concerned parties. But in doing this, the author feels that a nurse must also be patient with their patients. Patience is a virtue that should never be forgotten. It should be applied, especially to alcoholic patients because, as was mentioned earlier in the phases of alcoholism, as the symptoms develop, the alcoholic receives a vast number of emotional blows in the process, which leads to deterioration of the ego. Although, according to Adler, alcoholics mostly have inferiority complex, every individual has an ego no matter how minute it is and it is important to value this to avoid unpleasant conflicts between two persons – patient and nurse. According to Freud, alcoholism is a form of escapism. Therefore, alcoholic patients need more understanding because they just have been reintroduced to reality. The nurse must be able to introduce this reality to the patient in a pleasing way. The nurse must show his or her respect to the patient. This can only be achieved by understanding the phases of alcoholism because it could estimate the amount of pain that has been taken by the patient. Having an idea on that, it is much easier for the nurse to find the compassion that would result in his or her satisfactory and humanely service on the patient.
References:
Lego, Suzanne. (1999). The One-to-One Nurse-Patient Relationship.
Perspectives in Psychiatric Care. Volume: 35. Issue: 4. Nursecom, Inc. COPYRIGHT 2002 Gale Group
ROUSLIN, S. (1963). Chronic helpfulness: maintenance or intervention.
Perspect.Psychiatr.Care. Cited by Lego in The One-to-One Nurse-Patient Relationship.Perspectives in Psychiatric Care. Volume: 35. Issue: 4. Nursecom, Inc. COPYRIGHT 2002 Gale Group
CLACK, J (1963). The Patient’s Gift. In Some Clinical Approaches to Psychiatric
Nursing, ed. by S.F. Burd and M.A. Marshall. New York, Macmillan Co.
Chafetz M. and Demone Jr. H. (1962). Alcoholism and Society. Oxford
University Press, New York.
Martindale, Don. (1977). The Social Dimensions of Mental Illness, Alcoholism
and Drug Dependence. Greenwood Press. Westport, CT.
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