Estes Case Study

James and Edward

Background scenario

James and Edward are both men in their late forties. Life partners, they have been coming to the clinic for nearly two years. Edward has a chemical dependency and is enrolled in ongoing treatment. They keep to themselves and have no contacts in the gay community. Both of their families have rejected them. They arrive at the clinic and are openly arguing. Edward looks unkempt. His shirt is torn and his pants are stained and dirty. He is walking with assistance from James. James has a black eye and appears frightened and upset. You immediately intervene and take them to a private conference room so as not to disturb the other clients.

Interview

James:

"I am so frustrated and angry with him! Last month, he got in a fight with this straight guy that’s constantly harassing us. Edward got beat up pretty badly. Then he started missing work. His boss got mad and fired him."

Edward:

"Oh quit acting like my mother. So! I spent the money. I didn’t want to go aneewaaay!” (client is wildly shaking his hands at James)."

Examination

Vital signs:

Respiration: 16

Blood pressure: 140/80

Pulse: 75

Temperature: 99.5° F

Observation:

Pupils are equal and reactive to light.

Skin is warm and flushed.

Client has bruise on right hip consistent with a recent fall.

Client has odor of alcohol on clothes and breath.

Client is unshaven and unkempt.

Palpation:

Abdomen is soft and non tender in all quadrants.

Ribs and sternum are free of tenderness.

Liver is not tender to palpation.

Percussion:

Chest percussion is normal.

Liver percussion appears to have enlarged area of dullness.

Auscultation:

Bowel sounds are normal in all quadrants.

No bruits heard over aorta.

Breath sounds are clear with no rales or rhonchi.

A moderate wheeze is noted on inspiration.

Blood work:

(BAC): 27

Additional information as time passes

Edward was sent to the hospital for testing, observation, and withdrawal from alcohol poisoning. You went to see him the day after he came intoxicated to the clinic. During your visit, he agreed to check in to a drug and alcohol rehabilitation center for help. In the interim, you will work with the center to provide an outpatient program that is appropriate for Edward upon his release. James has been in to see Edward and has offered to support him in every way he can. You have provided James education about the disease and have discussed ways to decrease stress and develop support systems to help him deal with alcohol, drugs, and lifestyle issues that are affecting his health and well-being.

Nursing diagnoses:

121 Deficient knowledge (alcohol and drug abuse)

051 Impaired verbal communication

121 Disturbed personal identity

148 Fear

053 Social isolation

063 Dysfunctional family process: Alcoholism (substance abuse)

066 Spiritual distress

125 Powerlessness

124 Hopelessness

069 Ineffective coping

Background:

A homosexual person is a minority often in a situation uncommon to other minority groups. Often he is alone, with a lack of role models or a family member or friend who has gone through the same experience. Gay adolescents are often rejected by their families and have no access to supportive peers and communities. These difficulties can lead to depression, anxiety, anger, or hopelessness. The individual may begin to self-medicate with alcohol or other abuses.

Substance abuse is a serious problem for both gays and lesbians. Gays and lesbians are at three times the risk of the heterosexual population for developing alcoholism. Alcoholism has been linked to nonacceptance of gay identity. Substance abuse has been empirically linked to committing acts of violence.

Contributing Factors

It is thought that almost anyone who takes a mood-altering substance in large quantity for a long enough time will experience physical and/or psychological dependence. Some contributing factors include a biochemical or genetic factor, early separation from one or both parents, inadequate parenting, physical or sexual abuse, growing up in a family with multigenerational substance abusers, as well as other psychosocial, environmental, and cultural factors.

Behavior characteristics that might indicate the presence of substance abuse include abrupt changes or quality in work or school habits; temper flare-ups; changes in attitude, appearance, or grooming; association with known substance abusers; borrowing money or stealing from friends, family, or employer, and unusual secretive behaviors, such as frequent trips to the restroom or wearing dark eyewear to conceal the pupils.

Alcohol poisoning is the result of extremely high blood alcohol levels. Alcohol poisoning symptoms include impairment judgment, slowed reflexes, slow or labored breathing, impaired motor function, sleepiness or drowsiness, vomiting while sleeping without waking up, coma, or in case of overdose; death.

Recovery/Community Health Nurse

Gay special-interest 12-step programs (and, perhaps, gay group therapy) can help the recovering alcoholic. Successful long-term recovery requires the client to come to terms with personal sexuality and to learn to cope with day-to-day life, one step at a time. Maintenance of recovery is an ongoing task. The potential for relapse in alcohol and drug addiction appears to persist indefinitely. The addicted person and the physician must be aware of this enduring risk. The acute craving may disappear after several weeks or months, but the relapse trigger may occur spontaneously at any time.

Community health nurses function by assessing and identifying individuals with substance abuse difficulties in the community, and linking up individuals, family, and employers with available sources of support and education. The nurse offers follow-up assessment and ongoing intervention as needed, and can be a strong source of support for an individual coping with the unique and difficult aspects of a gay or lesbian identity along with a substance abuse disorder.

Quiz

1. Edward was diagnosed with substance abuse and dependence. What is the appropriate nursing diagnosis for this case?

a. Parental role conflict

b. Disturbed energy field

c. Social isolation

d. Feeding self-care deficit

2. The idea that almost anyone who takes a mood-altering substance in large quantity for a long enough time will experience physical and/or psychological dependence is well established. However, there are predisposing factors to chemical dependency. Which of the following is the least/less likely factor predisposing to chemical dependence?

a. Early separation from one or both parents early in life

b. Genetic factors

c. Growing up in a family with multigenerational abuse

d. Being given alcohol before age 5

3. Gays and lesbians have a higher risk for developing alcoholism. They are likely to develop alcoholism at what rate compared to heterosexuals?

a. Two times

b. Three times

c. Four times

d. Five times

4. Alcohol poisoning is the result of extremely high blood alcohol levels. A client that is experiencing alcohol poisoning may experience:

a. Increased energy

b. Vomiting followed by hunger

c. Increased reflexes and breathing

d. Sleepiness

5. Clients sometimes exhibit behavior characteristics that might indicate the presence of substance abuse. A behavior characteristic associated with substance abuse would be:

a. Listening to heavy metal, rap, or hip-hop music

b. General fatigue

c. Wearing of dark eyewear at inappropriate times

d. Taking extended trips

6. Alcoholism has been linked to nonacceptance of gay identity. How has substance abuse been linked?

a. Substance abuse is not linked to violence.

b. Substance abuse is linked to violence only in young men.

c. Substance abuse has been empirically linked to committing acts of violence

d. A history of violent behavior causes substance abuse

7. A homosexual person is a minority often in a situation uncommon to other minority groups. Which statement supports this?

a. Laws protect him or her from discrimination

b. His or her minority status is always visible

c. The person is often without role models, friends, or family in similar circumstances

d. He or she can choose not to be a minority

8. The acute craving related to alcohol or drug addiction may disappear for a while, but the relapse trigger may occur at any time. How long might a craving disappear?

a. Several weeks or months

b. A decade

c. Several months or years

d. A couple of days

9. Gay adolescents are often rejected by their families and have no access to supportive peers and communities. The depression, anxiety, anger, or hopelessness that results may lead a gay adolescent to experiment with:

a. Dropping out of high school

b. Moving to a half-way house

c. Self-medicating with alcohol or drugs

d. Becoming a heterosexual

10. The community health nurse is a strong source of support for an individual coping with the unique and difficult aspects of a gay or lesbian identity along with a substance abuse disorder. What function does the community health nurse provide that assists in this endeavor?

a. Assessing and identifying individuals with substance abuse difficulties in the community and providing available sources of support and education

b. Assessing and identifying individuals with substance abuse difficulties in the community and signing them up for a 12-step program.

c. Assessing and identifying individuals with substance abuse difficulties in the community and turning in their suppliers.

d. Assessing and identifying individuals with substance abuse difficulties in the community and maintaining an open dialogue with their employers.