SUFFOLK COUNTY COMMUNITY COLLEGE Michael J. Grant Campus at Brentwood

NUR 136 Case Study

 Dave Stress, a 40-year-old car salesman who has a problem with alcohol;

 Diane Stress, a 37-year-old homemaker who works part-time as a laboratory technician;

 Melissa Stress, a 16-year-old Junior in High School who has suffered with UIcerative Colitis since she was 13 years old;

 Michael Stress, an 11-year-old in the fifth grade who has had occasional episodes of asthma associated with dust and animal dander;

 And Diane’s mother, Helen Gerian, age 65, who has recently been widowed and so she has moved in to live with the Stress family.

STUDENTS RESPONSIBILITIES FOR LEARNING USING A CASE STUDY APPROACH:

1. Review all materials you receive pertaining to each member of the Stress family.

2. Research and answer the questions included in the case study anecdotes.

3. Be prepared to discuss each situation during lecture or the college lab, as appropriate.

EAM /10 SUFFOLK COUNTY COMMUNITY COLLEGE Michael J. Grant Campus at Brentwood

NR36 FAMILY CASE STUDY CASE STUDY OF AN ADDICTIVE FAMILY SYSTEM

It is 11:00 at night and Diane Stress is sitting alone at her kitchen table with her head bowed down over her arms. She sighs deeply. It is the day after Melissa’s surgery and she has been at the hospital most of the day. Michael is finally asleep after making a big fuss about going to bed since he’s hardly seen his mom for the past two days.

Diane straightens up and glares at the kitchen clock. “Where is Dave? What will his excuse be this time? He has really let me down! How could he NOT go and see Melissa like he promised? She was so brave today, but she was weepy when I said I didn’t think Dad could make it today. I figured I’d better say he had a late meeting so she won’t feel so bad.”

Diane looks at the clock again. Her ears strain to hear if the car is being pulled into the driveway. Nothing! She sighs again and a tear rolls out of the corner of each eye. “I wish Muriel were home. I really miss her. She is so responsible! I know she’d make supper and clean up the kitchen. It’s too bad the others aren’t like her. Melissa’s always so remote and dreamy, hanging out in her room with that Walkman on all the time. And Michael! He’s been acting up in school again, always clowning around to get attention.

Any my mother! Good grief! I can’t believe her! I thought she’d be some help to me and all she does is complain, criticize, and nag, nag, nag. “Why don’t you get ride of Dave? He’s more trouble than he’s worth. Always hanging out in bars till all hours. She doesn’t understand how it is for him. Things haven’t been too good at work. He has the worst luck, doing all the ground work and someone else steals his sale. It’s not fair! He hasn’t had a sale in two months.”

It’s now 12:00. No Dave. “I have to go to bed. I’ve got to go to the lab tomorrow morning or they’ll be in chaos without me. I know Anne said she’d manage but they really depend on me.” She sighs again. “I can’t go on like this much longer. I feel like I’m cracking up! I don’t know what to do anymore.” She toils wearily up to bed.

The telephone is ringing and ringing. Diane groans as she is waking up. She peers at the clock. Three AM! “Hello?” “Diane, this is Dave. I’m at the police station. They want to hold me on a DWI. Get the check book and come down and bail me out.”

Diane says “I have to ask Anne if she can come and stay with Michael.” What’s the matter with Melissa doing it?” asks David. Diane replies, “What do you mean, what’s the matter – she just had surgery yesterday and where the hell were you? Some father you are!” She slams the phone down. “This is the last straw. Things have got to get better.”

Diane goes next door to Anne’s house. She knows Anne used to be married to an alcoholic so she’ll understand the situation. “Anne? You’ve got to help me! Dave is at the police station for a DWI and I have to bail him out! I need you to stay with Michael. Mom’s staying at the hospital with Melissa tonight.”

Anne takes Diane’s hands in her own and says “Diane, listen to me. I want you to go back home and leave Dave in jail. This is just the kind of situation we talked about at Al Anon last week. Remember? You have got to make him face the consequences of his own behavior!” Diane replies, “I can’t do that! How can you suggest such a thing! Have you no feelings? I have to go get him!” Again Anne says, “Diane, I know how hard this is, but it’s the only way. Trust me. Go home and let him solve his own problem.” Case Study Of An Addictive Family System Page 2

Diane is shocked. She can’t believe Anne would let her down like this. “What am I going to do? You have to help me. If I don’t get Dave, he may never come home. Then what will I do? I’ve got three kids to support and a house to run. My mother is depending on me. I have to do this! I have no other choice!”

ANALYSIS

1. List each person described in this case study and choose the family role that person has taken as commonly seen in a dysfunctional family.

a.

b.

c.

d.

e.

f.

2. Give examples for each of Diane’s coping strategies:

a. caretaking behaviors:

b. controlling behaviors:

c. use of denial:

d. dependency behaviors:

e. ability to express feelings: Case Study Of An Addictive Family System Page 3

3. List the effects that alcohol consumption has on:

Dave?

Diane?

Muriel?

Melissa?

Michael?

Helen (Diane’s Mom)?

4. Decide whether you agree or disagree with Anne’s advice and discuss why:

5. What so you think Diane should do?

“Uh…five, five, three, two, nine, no…eight, four, two.” Rinnnggg…Rinnnggg…”C’mon, c’mon, answer the damn phone!!” “Hello?” “Diane. This is Dave. I’m at the police station. They wasn’t to hold me on a D.W.I. Get the checkbook and come bail me out.”

Diane says, “I have to ask Anne if she can come stay with Michael.” What’s the matter with Melissa doing it?” Asks Dave. Diane replies, “What do you mean, what’s the matter – she had surgery yesterday and where the hell were you? Some father you are.” Slamm!!

“Hello…Hello…” Dead, no answer. Dave slams the phone down. “Bitch. No good bitch,” he grumbles. Case Study Of An Addictive Family System Page 4

”All of this is her fault, her and her kids. I work all day to provide for them and they don’t appreciate it. Ungrateful, all of them.” Dave stumbles back to the cell and flops on the bunk, staring up at the lights. He passes out a few minutes later.

It’s six hours later. Dave wakes up and starts bellowing, “Where the hell is my wife? She should have been here hours ago.” “Calm down Mr. Stress. Your wife called and said you can stay here until you sober up.” shouts the guard. “Sober up? I am sober. I want to use the phone. I have to call that witch,” Dave retorts.

The guard shrugs his shoulders and says, “Make it snappy!” “Hi honey. It’s me, Dave. I’m sorry. I didn’t Mean to drink so much,” Dave says in a child like voice. “You know how things are going at work. I just Stopped by to have a few, loosen up, you know what I mean.” There is silence. “Well?...Are you gonna come get me? I want to go home,” he says pathetically.

After a short pause Diane says, “No, Dave. This is a time when you have to face up to your problem. You neglect your children and think only of yourself. What do you expect from me? To bail you out and everything will be fine? No. You stay there. I’ve had enough!” Click.

Dave couldn’t believe it. How could she betray him like this after all he has been through during he life time. Working at age fourteen to support his mother and his two sisters after his father died in al alcohol related accident. He never was able to finish High School. Then he married Diane. He was nineteen and she was sixteen and pregnant. He now had another family to support.

After ten years of selling used cars he received a small promotion to senior salesman. With it came more responsibility and a little more money. But it wasn’t enough money to save. They always lived from hand to mouth, to pay the rent and buy groceries. Along came Melissa and Michael which meant more mouths to feed. So Diane had started working part time to supplement their income. And now Helen had moved in! “She” always hated me. “Got her darling daughter in trouble!” Yah! She thought he was a no good and never hid her opinion.

Dave went over and over these thoughts. “I wish I had a drink,” he said. “It is getting cold in here and I’m starting to feel shaky. I need it to calm my nerves.” Dave started to feel sick to his stomach and was becoming anxious. He tried to relax but couldn’t. He wanted out. Out of this jail. Out of this confinement. He felt trapped. Calm myself, calm down, Dave thought. But I have to get out of here. I need that drink. What am I going to do? Why can’t I get out? I want out! I want out! Dave’s thoughts went round and round. Out…out. I can’t find my way out! Dave envisioned the walls moving closer and closer. My god. Why doesn’t it stop. What’s that on the floor? Snakes! Hundreds of snakes! Dave’s mind saw snakes from the shadows of the bars. His heart started to pound. Fear was gripping him. Sweat again began to shine over his face and fall off his forehead. “go away!” he screamed.

As the guards approached Dave, they found him cowered in the corner of his cell. His face was flushed, he was shaking, and he was short of breath. Dave gasped, “Help me, please help me. I can’t breathe. I think I’m having a heart attack!”

Dave was transferred via an ambulance to the hospital emergency room Page 5

ANALYSIS

1. What behaviors indicate Dave is intoxicated upon arrival at the police station?

List additional signs seen in alcohol intoxication:

2. What defense mechanisms does Dave use in processing his problems?

Give an example of each: a)

b)

3. Assess Dave for signs of alcohol withdrawal syndrome (AWS) and list the behaviors and symptoms identified:

4. Review the anecdotes for Diane and Dave looking for manipulative behaviors.

a) Describe Diane’s use of manipulative behavior:

b) Discuss Dave’s use of manipulative behavior using three to four examples:

5. Choose a priority nursing diagnosis for and set an outcome criterion for each of the following:

Diane:

Dave:

The Family: Page 6

When Dave arrived in the hospital emergency room, he was immediately placed on a cardiac monitor. His vital signs were:

B/P 150/90 P 120 R 26 and shallow T 100F.

The initial nursing history and assessment indicated that Dave was experiencing uncomplicated alcohol withdrawal syndrome. The physician wrote the following orders: 1. Admit to the detox unit for AWS (Alcohol withdrawal syndrome). 2. Librium 100 mg. I.M. stat. 3. Thiamine 100 mg. I.M. stat. 4. SMA 20 and CBC 5. Urinalysis 6. BAL (Blood Alcohol Level)

DAVE’S LAB RESULTS

HCT 39% *SGOT 545 I.U. Calcium 4.l mg/dl HGB 12gm SGPT 835 I.U. Sodium 122 mEq RBC 3.5/cmm LDH 340 I.U. Chloride 109 mEq WBC 3/7cmm *GGTP 705 U/L Potassium 3.4 mEq Platelets 140,000 Triglycerides 290 mg/dl Magnesium 1.3 mEq *MCV 105u33 ALK PHOS 195 I.U. BAL 04 gm./210 liters Urine specific gravity 1.035

*ELEVATED GGTP, MCV AND SGOT ARE STRONGLY INDICATIVE OF ALCOHOLISM

The following protocol was ordered for Dave on the Detox unit:

1. Vital signs qh x 8 to 12 hours until stable, then q4h x 48 hours, then q.i.d. 2. ½ N/S and 5% D/W at 125 ml. per hour. Add multivitamins to alternate liters. 3. Librium 50 mg. po q 2-4 PRN for anxiety or agitation x 3 days, then reduce Librium to 25 mg. po q2h PRN x 1 day, then to 25 mg. q3h PRN x 1 day, then to 25 mg. q4h PRN x l day and then Librium 15 mg. po q4h PRN. 4. Check level of consciousness qh x 24 hours PRN. 5. Thiamine 100 mg. po q.i.d. 6. Folic acid 1 mg. po q.i.d. 7. Magnesium sulfate 1g IM q6h x 2 days 8. Catapres 0.1 mg. po b.i.d. for B/P over 120 systolic or 90 diastolic. 9. High CHO diet with 2000 ml fluid per day. 10. Intake and output. 11. Bed rest. Page 7 ANALYSIS

1. Why are Dave’s vital signs elevated?

2. Explain the rationale for the initial Librium order:

3. Explain the need for Thiamine stat?

4. Analyze the laboratory results for:

a) the CBC, Platelets and MCV:

b) the enzymes:

c) the electrolytes:

d) the BAL:

e) specific gravity:

5. Why are Dave’s vital signs monitored so frequently?

6. Is Dave’s IV therapy order appropriate? Why?

7. What are the nursing implications of the Librium orders?

8. What is the purpose of the order for the magnesium sulfate?

9. Catapres, Tenormin or Inderal may be ordered for patients like Dave. What symptoms are relieved by these drugs?