Alcohol Withdrawal

This is a presentation of one of my patients that I had to do for class...hope it helps!

1. ALCOHOL
Acute Withdrawal

2. Alcohol is a CNS depressant. It can be harmless,
enjoyable and sometimes beneficial when used in
moderation.
It has a potential for abuse and is potentially fatal.

3. What is Alcoholism?
Alcoholism: Alcoholism is the compulsive urge to
drink alcohol despite knowing the negative impact
on one's health.
Alcoholism: Habitual intoxication; prolonged and
excessive intake of alcoholic drinks leading to a
breakdown in health and an addiction to alcohol
such that abrupt deprivation leads to severe
withdrawal symptoms.
http://www.wrongdiagnosis.com

4. 15.1 million alcohol-abusing or alcohol-dependent
individuals in our country alone!
National Institute on Alcohol Abuse and Alcoholism
www.niaaa.nih.gov
Prevalence

7. The patient is a 63 year old male with a past medical
history of alcohol abuse and multiple cessation
attempts that required acute hospital care. He has a
suprapubic catheter in place for 10 years because of a
botched exploratory prostate surgery. His labs were
notable for transaminitis (ALT 120, AST 324) and
hypokalemia (potassium 3.2).

8. He arrived the previous evening by ambulance
stating that he was trying to quit drinking on his own
but he had the shakes so bad he called 911.

9. Assessment findings revealed uncontrollable tremors
in all four extremities. He also had nystagmus of the
eyes. He reports anxiety, has a rapid heart beat
(98-109 bpm), and increased blood pressure
(135/92), all typical symptoms of early ETOH
withdrawal.

10. Lab Values
WBC-5.4
HGB-13.8
HCT-42.4%
PLT-185
K+-3.2
CA++-8.1
RBC-4.45
ALT-120
AST-324
ETOH-394
Norm-5,000-10,000
Norm-13.1-17.2
Norm-42-52%
Norm- 150-400
Norm- 3.5-5.0
Norm-9.0-10.5
Norm-4.7-6.1
Norm-9-40
Norm-10-35

11. The presence of elevated transaminases, commonly the
transaminases alanine transaminase (ALT) and aspartate
transaminase (AST), may reflect liver or pancreatic damage.
Alcoholism occasionally results in hypokalemia. About one
half of alcoholics hospitalized for withdrawal symptoms
experience hypokalemia. This occurs in alcoholics for a
variety of reasons, usually poor nutrition, vomiting, and
diarrhea. Hypokalemia can result in dysrhythmias.
Hgb & Hct are on the very low end of normal, possibly r/t an
iron-deficiency anemia.

12. Several factors account for the association between
occurrence of hypocalcemia and severe alcoholism.
In alcoholics, poor diet or liver disease results in
diminished albumin levels, thereby limiting the
amount of calcium that can remain dissolved in the
blood.

13. Alcohol Toxicity:
Blood Alcohol Level, Classification, and
Assessment Findings
80-200mg/dL (mild to moderate intoxication). Mood and behavior
changes, impaired judgment, and poor motor coordination.
Hypotension may occur in patients with levels >100 mg/dL.
250-400mg/dL (marked intoxication). Staggering ataxia and emotional
lability. Symptoms may progress to confusion and stupor or coma.
Greater than 500 mg/dL (severe intoxication). Death is due to
respiratory depression.
Ignatavicius,D . D ., Workm an, M. L., “Medical-S urgical Nursing, ”Patient-Centered Collaborative Care,
6
th
ed.,S aunders Elsevier, Missouri, 201 0, pp.83

14. This patients blood ETOH level upon arrival to the
hospital was 394, though he states his last drink was
in the morning and he arrived in the evening.

15. The doctor explained to the patient that if he was not
serious about giving up ETOH then he would be sent
home to drink. That is how serious this situation can
be. The doctor further explained to me the cardiac
risk factors of quitting ETOH. The patient can suffer
from severe, possibly fatal dysrhythmias.

16. Assessment Data

17. Patient reports difficulty sleeping r/t his anxiety
level, which he reported as a 10/10
Activity/Rest

18. Circulation
Peripheral pulses are rapid
Hypertension is present (commonly seen in early
ETOH withdrawal, may progress to hypotension)
Tachycardia is present (common during acute
withdrawal)
No dysrhythmias present at this time

19. Ego Integrity
Patient spoke to me about feelings of guilt r/t his drinking,
states he wishes he would be satisfied with only drinking
beer like his neighbor
Patient reports multiple life stressors such as his water pipes
freezing, his electricity is borrowed from his neighbor by
way of extension cord
He also states he is anxious all the time and when I
asked how he deals with this he said he drinks to deal
with it

20. Elimination
Patient states his last BM was the night before and it
was normal
Patient had suprapubic catheter with a good output
but the urine was cloudy with particulates
Bowel sounds were hyperactive

21. Food/Fluid
Patient drank 1600 ml of water during my 12 hour
shift
He ate 50% of breakfast, 0% of lunch, and 15% of
dinner
No reports of N/V/D

22. Neurosensory
Patient reports “internal shakes” and exhibits “external
shakes”
Mood ~ anxious and depressed
Patient exhibits nystagmus
Patients reports an unsteady gait, I did not observe him out
of bed

23. Pain
Patient reports pain 0/10

24. Respiration
No hx of smoking
Clear breath sounds

25. Safety
Hx of falls r/t unsteady gait and intoxication

26. Social Interaction
Only family is his mom in MI
Has a neighbor who is a good friend but also an
alcoholic. They take turns making meals and he uses
this neighbors electricity via extension cord
No other social interactions besides this neighbor

27. Teaching/Learning
Patient will demonstrate an understanding of:
the need to recognize post-acute withdrawal
symptoms
The basics of disease concept of alcoholism and the
addictive process
The need to continue treatment in a rehabilitative
program

28. Nursing Priorities
1. Maintain physiological stability during acute WD
phase
2. Promote patient safety
3. Provide info regarding condition/prognosis and tx
outcomes
4. Provide appropriate referral and follow-up

29. Discharge Goals
1. Homeostasis achieved
2. Complications prevented/resolved
3. Referral to AA or similar program/support group
4. Condition and therapeutic regimen understood
5. Understanding of the need for follow-up by
physician

30. Nursing Diagnosis

31. Risk for injury related to abrupt withdrawal of ETOH
Nursing priorities
Maintain patient's
physical safety
Be alert for changes in
status that may
indicate development
of complications
Desired outcome
Throughout the length of
the stay, patient will
remain free from
injury AEB
maintaining stable VS,
and showing no
evidence of WD, such
as seizures or infection

32. Interventions
When the patient is
conscious, perform a
mental status evaluation
Place the patient in private
room, close to nurse's
station. Check on patient
every 15 minutes.
Rationale
The mental status exam will
determine orientation
The patients condition may
change rapidly. Increased
monitoring will help
decrease the risk of injury.

33. Imbalanced nutrition: less than body requirements r/t
lack of food intake AEB consumption of less than 25% of
meals
Nursing Priorities
Ensure adequate intake of
nutrients
Be alert for changes in
nutritional status (body
weight and fluid intake)
Desired outcomes
Throughout the length of
stay patient will maintain
body weight and fluid
hydration at acceptable
levels AEB eating a
balanced diet, and
maintaining electrolyte
balance within normal
limits

34. Interventions
Assess weight upon
admission and daily while
hospitalized
Assess appetite and GI
tolerance. Inquire as to
food preferences.
Rationale
Baseline assessment is
essential to determine
what is normal for the
patient, and facilitates
determination of
fluctuations
Part of baseline assessment,
considering culture and
background offers a
holistic approach

35. Severe Anxiety r/t cessation of ETOH
intake/physiological withdrawal AEB increased tension,
apprehension
Desired outcomes
The patient will demonstrate a
decrease in anxiety AEB a
reduction in presenting
physiological, emotional, and/
or cognitive manifestations of
anxiety verbalization of relief
of anxiety within 24 hours.
Nursing priorities
Assess level of anxiety
Assist client to identify
feelings and begin to deal
with problems
Promote wellness;
teaching/discharge
considerations

36. Interventions
Involve patient in the process of
identifying cause of anxiety.
Explain that WD increases
anxiety. Reassess on an ongoing
basis
Develop a trusting relationship
through frequent contact, being
honest and non-judgmental;
project an accepting attitude about
alcoholism
Rationale
Person in acute phase of WD may
be unable to identify what is
happening. Understanding of
what is happening may help to
decrease anxiety levels
Provides patient with a sense of
humanness, helping to
decrease paranoia and distrust.
Patient will be able to detect
biased or condescending
attitude of caregivers

37. GABA/Dopamine
ETOH intake represses GABA, which inhibits
dopamine, keeping levels low, when ETOH is
eliminated dopamine rebounds to normal level
causing excitation and alterations in thought,
perception and orientation

38. Medication
lorazepam/Ativan
Short acting benzodiazapine is the drug of choice
when there is known liver disease
Benzodiazapines potentiate effects of GABA, which
produces a calming effect
Before I administered the Ativan I had to perform a
CIWA (Clinical Institute Withdrawal Assessment)
interview

39. CIWA
What it Measures: The CIWA can measure 10
symptoms. Scores of less than 8 to
10 indicate minimal to mild withdrawal. Scores of 8
to 15 indicate moderate withdrawal
(marked autonomic arousal); and scores of 15 or
more indicate severe withdrawal. The
assessment requires 2 minutes to perform (Sullivan,
et al, 1989).

40. CIWA
If CIWA score is > 0 but < 8 and vital signs are stable, no
medication is required.
Repeat vital signs q 4 hours and the CIWA q 8 hours.
If CIWA is > 8 but < 15, give Lorazepam (Ativan) 2 mg PO/
IM and repeat vital signs q 2 hours and the CIWA q 4 hours.
If CIWA is >15 or DBP > 110 mmHg, give Lorazepam
(Ativan) 2 mg PO/IM q hour until patient has a CIWA of <
15

41. Support/resources at discharge
Alcoholics Anonymous -
www.alcoholics-anonymous.org
National Institute on Alcohol Abuse and Alcoholism
-
www.niaaa.nih.gov
Al-Anon/Alateen -
www.al-anon.org

43. Which question is most likely to predict the onset of
withdrawal symptoms if client is dependent on
alcohol?
A. What is your experience with alcohol?
B. How much alcohol do you usually have?
C. When did you last have something to drink?
D. How often do you usually drink?
Questions

44. Answer
C- this question is important since withdrawal
symptoms can begin as early as 4-6 hours after
substance use

45. Question
What priority nursing diagnosis should be addressed
within 72 hours of admission?
A. Ineffective coping
B. Ineffective denial
C. Risk for injury
D. Altered nutrition

46. Answer
D- nutrition is very important, because a client with
alcohol dependency drinks instead of eating
nourishing food, causing malabsorption of essential
vitamins. Deficiency and malabsorption if vitamin B
can lead to Wernicke's disease, a severe problem
with decreased cognitive functioning.