Substance Use Disorder- ALCOHOLISM

Useful for Nursing Students as per INC Syllabus

1. Substance Use Disorders
Mr. Visanth .V.S
Asso.Professor
IGSCON, Amethi

2. Substancerelateddisordersare
composedoftwogroups:
◦Thesubstanceusedisorders(dependence
andabuse)
◦Substance induced disorders
(intoxication,withdrawal,delirium,
dementia,amnesia,psychosis,mood
disorders,anxietydisorder,sexual
dysfunction,andsleepdisorders

3. Terminologies
Intoxication:Thetransienteffectsduetorecent
substanceingestion,whichdisappearwhenthe
substanceiseliminated.
Addiction:compulsiontouseadrug,usuallyforits
psychic,ratherthantherapeutic,effects.
Tolerance: The state in which the same amount of a
drug produces a decreased effect, so that increasingly
larger doses must be administered to obtain the
effects observed with the original use.
PhysicalDependence:Thedevelopmentof
withdrawalsymptomsonceadrugisstopped.

4. Contd…….
Withdrawal:Aphysiologicalstatethatfollows
cessationorreductionintheamountofadrug
used.
SubstanceDependence:is“amaladaptive
patternofsubstanceusewithadverseclinical
consequences.”
SubstanceAbuse:Aclassofsubstance-related
disordersthatincludesbothsubstanceabuseand
substancedependence.
Toxicity:Poisonousnature;poisonousquality.

5. What is a drug?
A drug is a substance that
has an action on biological
tissues when administered
Some drugs influence mood
cognition and behavior
◦Psychoactive/Psychotropic
drugs are like alcohol,
cocaine, diazepam etc.

6. Psychoactive Drugs
Substancesactiveon
CNStissueswhen
administered
therebycausing
changesinmood,
cognition,behavior

7. Psychoactive Substance
Psychoactive (psychotropic) substance is any
substance which after absorption has
influence on mental processes both
cognitive and affective.

8. Drug Action on the Nervous System
Mostdrugsthatareabusedhaveacommon
effectonaparticularNTpathway.Thebasic
addictionpathwayinthebrainisadopamine
pathwayfollowedbyserotonin.
Activationofthispathwayaccountsforthe
positivereinforcement,feelingandmakesus
wanttorepeattheactionthattriggeredthe
feeling.
ActiononNTsystems
Agonist
Antagonist

9. Drug Action on the Nervous System on
Repeated Use
Tolerance
◦Decreased response to repeated exposure
Dependence
◦System adapts to presence of drug. Drug necessary
for homeostasis
Withdrawal
◦Response to drug leaving the system
Addiction
◦Compulsive engagement in reinforcing behavior

10. Therearefourimportantpatternsof
substanceusedisorders,whichmay
overlapwitheachother.
Acuteintoxication,
Withdrawalstate,
Dependencesyndrome
Harmfuluse.

11. Substance abuse Definition
Amaladaptivepatternofsubstanceleadingto
clinicallysignificantimpairmentordistressas
manifestedbyoneormoreofthefollowing:
Failuretofulfillmajorroleobligationsathome,
school,orwork.
Recurrentsubstanceuseinsituationsinwhichitis
physicallyhazardous.
Recurrentsubstancerelatedlegalproblems.
Recurrentsubstanceusedespitepersistentorrecurrent
socialorinterpersonalproblemscausedor
exacerbatedbytheeffectsofthesubstance.

12. ICD Classification
F10Mentalandbehaviouraldisordersduetouseofalcohol
F11Mentalandbehaviouraldisordersduetouseofopioids
F12Mentalandbehaviouraldisordersduetouseofcannabinoids
F13Mentalandbehaviouraldisordersduetouseofsedativesor
hypnotics
F14Mentalandbehaviouraldisordersduetouseofcocaine
F15Mentalandbehaviouraldisordersduetouseofotherstimulants,
includingcaffeine
F16Mentalandbehaviouraldisordersduetouseofhallucinogens
F17Mentalandbehaviouraldisordersduetouseoftobacco
F18Mentalandbehaviouraldisordersduetousetovolatilesolvents
F19Mentalandbehaviouraldisordersduetomultipledruguseanduse
ofotherpsychoactivesubstances

13. COMMONLY USED PSYCHOACTIVE SUBSTANCES
CNS depressants
◦Alcohol
◦Sedatives, hypnotics or anxiolytics
◦Inhalants (Volatile Solvents)
CNS stimulants
◦Amphetamines
◦Cocaine
◦Caffeine
◦Nicotine (tobacco)
Cannabis
Opioids
Hallucinogens
Phencyclidine
Others (e.g. anabolic Steroids, anticholinergic).

14. Etiology
Genetics
Geneticstudiesshowsthevulnerabilityespeciallyevident
withalcoholism,andlesssowithothersubstances.
Childrenofalcoholicsarethreetimesmorelikelythan
otherchildrentobecomealcoholics.
BiochemicalFactors
Neurotransmitterslikedopamineandnorepinephrinehave
aroleincocaine,ethanolandopioiddependence.Alcohol
mayproducemorphine-likesubstancesinthebrainthatare
responsibleforalcoholaddiction.

15. Individual-related Risk Factors
Early age of onset
Presence of early childhood behavioral
problems
Poor academic performance
Risk-taking behaviors
Favorable beliefs about substance use
Increased impulsivity
Self medication hypothesis: alcohol for
anxiety

16. Family-related Risk Factors
Favorable beliefs about substance use in
parents
Parental tolerance of substance use
Lack of closeness and attachment between
adolescent and parent
Lack of discipline/supervision by parent
Parental substance use
Childhood physical or sexual abuse

17. Peer-related Risk Factors
Peer substance use
Favorable peer attitudes to use
Greater orientation of adolescents to peers as
opposed to parents
Community-related Risk Factors
◦Low Socio economic status
◦High population density
◦High crime rate
◦Easy availability of drugs

18. Alcohol Use Disorders

19. Alcohol
Alcohol/ethanol/ethylalcoholisa
chemicalintoxicatingingredientfoundin
beer,wine,andliquor.
Alcoholisproducedbythefermentationof
yeast,sugars,andstarches.
ItexertsadepressanteffectontheCNS,
resultinginbehavioral&moodchanges
thatarerapidlyabsorbedfromthestomach
andsmallintestineintothebloodstream.

20. Alcohol: Our Most Primitive Intoxicant
Egypt
◦Barleybeerisprobablytheoldestdrinkinthe
worldwithitsorigininEgyptpriorto4200
BC
China
◦7000BC-theproductionofaprehistoric
mixedfermentedbeverageofrice,honeyand
fruit
◦2000BC-uniquecerealbeverages(Shangand
WesternZhouDynasties)

21. InIndia,analcoholicbeveragecalledsura,
distilledfromrice,wasinusebetween3000and
2000B.C.
TheBabyloniansworshipedawinegoddessas
earlyas2700B.C.
Greekliteratureisfullofwarningsagainst
excessivedrinking.
SeveralNativeAmericansdevelopedalcoholic
beveragesinpre-Columbiantimes.
Avarietyoffermentedbeverageswereusedinthe
AndesregionofSouthAmericawerecreatedfrom
corn,grapesorapples,called“chicha.”

22. Alcoholism -Definition
Itistheuseofalcoholicbeveragestothe
pointofcausingdamagetothe
individual,societyorboth.

23. Properties Of Alcohol
Alcoholisaclearliquidwithastrong
burningtaste.
Rapidabsorptionismoreintothe
bloodstream.

24. Stages of Alcohol Use
Therearebasically3stagesinwhichall
alcoholicsmaygothrough,theyare;
EarlyStage(Stage1)
◦Torelax,relievestress
◦Beginstobecomeintoxicatedregularly.
◦Makesexcusesandtriestorationalize
drinkingbehaviorfrequently.

25. MiddleStage(Stage2)
◦Drinkerdeniesortriestohideproblem.
◦GraduallyBodydevelopstolerance.
◦Frequentlyabsentfromschoolorwork.
◦Drinkingbecomesiscentraleventina
person’slifeanddrinksdaily.
◦Drinkslotwhenalone
◦Drinksfirstthinginthemorning

26. FinalStage(Stage3)
◦Personbecomesaggressive&isolatedinthis
stage.
◦PersonbecomeMalnourishedbecausedrinker
consumesalcoholanddoesnotworryabout
food.
◦Bodyisaddictedtoalcohol.
◦Trytoquitleadstowithdrawal
◦DeliriumTremens:hot/coldflashes,tremors,
nightmares,hallucinations,fearofpeopleand
animals

27. Blood Alcohol Concentration and Its
Symptoms
25 -100 mg% excitement.
100 -200 mg % leads to serious intoxication,
slurred speech, in coordination, nystagmus
300-350 mg% -Hypothermia, dysarthria, cold
sweats
350 -400 mg% -Coma, respiratory depression.
400 mg% -Death may occur.

28. Types of drinkers
Moderate drinkers
Problem drinkers
◦The excessive consumption is starts with
Experimental
Recreational
Relaxational
compulsive

29. Epidemiology
Predominantlyseeninmalesthaninfemales
andtheratesforfemaleusersofalcoholare
verylowandlessthan5%ofallthefemale.
InIndiashowstheuseofalcoholingeneral
populationis25.6–74.2%andinstudentsitis
21.8to58.4%andamongmedicalprofessionals
itis8.5to66.7%
Thelifetimeprevalenceofalcoholdisorders
withschizophreniaandaffectivedisordersis
33.7%and21.8%respectively.

30. Etiology
Biological Factors
Geneticvulnerability-familyhistory
Co-morbidpsychiatricdisorderorpersonality
disorder
Co-morbidmedicaldisorders
Withdrawaleffectsandcraving(explains
continuationofdruguse)
Biochemicalfactors-roleofdopamineand
norepinephrine

31. Psychological Factors
Curiosity
Generalrebelliousness
Earlyinitiationofalcohol
Poorimpulsecontrol
Lowself-esteem
Concernsregardingpersonalautonomy
Poorstressmanagementskills
Childhoodtraumaorloss
Relieffromfatigueand/orboredom
Escapefromreality
Lackofinterestinconventionalgoals
Psychologicaldistress

32. Social Factors
Peerpressure
Modeling(imitatingbehaviourofothers)
Easeofavailabilityofalcohol
Strictnessofdruglawenforcement
Intra-familialconflicts
Poorsocial/familialsupport
Rapidurbanization

33. EEFECTS OF ALCOHOL ON THE BODY
Shorttermeffects
◦Upsetinstomach
◦Headaches
◦Breathingdifficulties
◦Distortedvisionand
hearing
◦Impairedjudgment
◦Slurredspeech
◦Drowsiness
◦Vomiting
◦Diarrhoea
◦Decreasedperception
andcoordination
◦Unconsciousness
◦AnaemiaComa
◦Blackouts(memory
lapses,wherethe
drinker cannot
remembereventsthat
occurredwhileunder
theinfluence)

34. Long-term effects
Intentionalinjuriessuchas
sexualassault,domestic
violence.
Unintentionalinjuriessuchas
carcrash,falls,burns,
drowning
Increasedfamilyproblems,
brokenrelationships
Alcoholpoisoning
Highbloodpressure,stroke,
and otherheart-related
diseases
Liverdisease
Nervedamage
Sexualproblems
Permanentdamagetothebrain
VitaminB
1deficiency,which
canleadtoadisorder
characterizedbyamnesia,
apathyanddisorientation(see
nextpageforitstreatment).
Gastritisandulcers.
Malnutrition
Cancerofthemouthandthroat

35. Psychiatric Disorders due to Alcohol Dependence
Acute Intoxication
Withdrawal Syndrome
Alcohol Induced Amnestic Disorders
Alcohol Induced Psychiatric Disorders

36. Acute Intoxication
Acute intoxication develops during or shortly
after alcohol ingestion.
It is characterized by,
Aggressive Behavior
Inappropriate Sexual Behavior
Mood Liability
Poor Judgment
Slurred Speech
Unsteady Gait
Nystagmus

37. Withdrawal Symptoms
Inpersonswhohavebeendrinkingheavily
overaprolongedperiodoftime,anyrapid
decreaseintheamountofalcoholinthebodyis
likelytoproducewithdrawalsymptoms.
Theseare:
1.Simplewithdrawalsyndrome
2.Deliriumtremens

38. 1.Simple withdrawal symptoms
◦The most common withdrawal syndrome is a
hangover on the next morning
◦Mild Tremor
◦Anxiety
◦Increased heart rate and blood pressure
◦Sweating
◦Nausea, vomiting
◦Insomnia
◦Weakness
◦Impaired attention
◦Irritability

39. 2. DeliriumTremens
Asuddenformofwithdrawalthatinvolvessuddenand
severementalorneurologicalchanges
Features
◦Mentalstatuschanges/psychomotoragitation/restlessness/
excitement/decreasedattentionspan/irritability/cloudingof
consciousness/alteredsensorium
◦Fluctuatingconsciousness
◦Vividhallucinations
◦Agitation/shouting/fear
◦Severeuncontrollabletremors/panicattack
◦Mildhyperpyrexia/sweating/dilatedpupils/tachycardia/
convulsions
◦Dehydration/leukocytosis/adrenergicstorm
◦Onset48-72hoursafterthelastdrink(upto7days)
◦Mortality:10-15%(untreated)

40. Alcohol Induced Amnestic Disorder
WERNICKESENCEPHALOPATHY
◦Thisisanacutereactionwhichoccursdue
severedeficiencyofthiamine,inchronic
alcoholusers,becausealcoholreducesthe
absorptionabilityofthiamineinthestomach.
◦Theclinicalsignsare;
Ocularsigns:Nystagmus,ophthalmoplegiawith
bilateralexternalrectusparalysis.
Highermentalfunctiondisturbance:Recent
memorydisturbances,Disorientation,confusion,
poorattentionspananddistractibility.

41. KORSAKOFF’SPSYCHOSIS
Mostofthetimeitoccursfollowedby
Wernicke’sencephalopathy.
Clinicallyitcharacterizedbygross
memorydisturbancewithconfabulation.
Insightisoftenimpaired.

42. Alcoholic Seizures/Rum Fits
Generalizedtonic-clonicseizures
occurinabout10%ofalcohol
dependencepatients
Developsusuallyafter12-48hours
ofheavyboutofdrinking.

43. Alcohol induced Psychiatric Disorders
Alcohol-induceddementia:
Alcoholicparanoidpsychosis
Delusions-jealous,persecute
Alcohol-inducedanxietydisorder
Alcoholinducedmooddisorders-Depression
andSuicidality,
Alcoholichallucinosis
◦Auditoryhallucinationswithoutcloudingof
sensorium

44. Medical Complications
GastroIntestinalComplications
Gastritis,pepticulcer,reflux
esophagitis,carcinomaofstomachand
esophagus
Fattyliver,cirrhosisofliver,hepatitis,
livercellcarcinoma
Acuteandchronicpancreatitis
Malabsorptionsyndrome

45. Cardiovascular system
Alcoholic cardiomyopathy
High risk for myocardial infarction
Central nervous system
Peripheral neuropathy
Epilepsy
Head injury
Cerebellar degeneration

46. Miscellaneous
Protein malnutrition
Vitamin deficiency disorder
Peripheral muscle weakness
Acne
Sexual dysfunction in males, failure of ovulation in
females
Social
Marital disharmony
Occupational problems
Financial problems
Criminality
Accidents

47. Fetal alcoholic syndrome
Fetalalcoholsyndrome
◦Facialabnormality
◦Lowbirthweight
◦Lowintelligence
Increasedstillbirths.
Alcoholdependenceisresponsiblefor
3percentofallcasesofmental
retardation

48. Alcohol intoxication Alcohol withdrawal syndrome
Itoccursasaresulttheamountofalcoholinbloodstream
increases.Thehigherthebloodalcoholconcentrationis,themore
impaired.
Symptomsincude;
Inappropriate behavior,
unstable moods,
Impaired judgment,
Impaired attention.
Slurred speech,
Impaired attention or memory.
Poor coordination.
Aggression.
Labilityof mood.
Unsteady gait.
Difficulty standing.
Nystagmus.
"Blackouts," where person don't remember any events
during intoxicated period.
Decreased level of consciousness (e.g. stupor, coma).
Very high blood alcohol levels can lead to coma or even
death.
Acute alcohol intoxication when severe may be
accompanied by hypotension, hypothermia and Depression
of the gag reflex.
Itcanoccurwhenalcoholusehasbeenheavyandprolonged
andisthenstoppedorgreatlyreduced.Itcanoccurwithin
severalhourstofourorfivedayslater.
Symptomsinclude;
Sweating,rapidheartbeat,handtremors.
Problemssleeping(insomnia).
Highbloodpressure
Nauseaandvomiting.
Hallucinations.
Restlessnessandagitation.
Anxiety,andoccasionallyseizures.
Symptomscanbesevereenoughtoimpairabilitytofunction
atworkorinsocialsituations.
(Above symptoms are more noticeable when person wake up
with less alcohol in blood.)
The most severe type of withdrawal syndrome is known as
delirium tremens (DT). Its signs and symptoms include:
-Extreme confusion.
-Extreme agitation.
-High Fever.
-Seizures (Grand mal convulsions)
-Tactile hallucinations, such as having a sense of
itching or burning that isn’t actually occurring.
-Auditory hallucinations or hearing sounds that
don’t exist.
-Visual hallucinations, or seeing images that don’t
exist

49. Diagnosis
Thorough history
MSE
Physical Examination
Blood examination
LFT
Nutritional test
Chest radiography etc

50. TREATMENT

51. ALCOHOL USE DISORDER
(Alcohol Abuse And Dependence)
ALCOHOL DETERRENT THERAPY
Deterrentagentsarethosewhicharegivento
desensitizetheindividualtotheeffectsofalcohol
andmaintainabstinence.Themostcommonly
useddrugisDisulfiramorAntabuse.
Antabuse(disulfiram)blocksanenzymethatis
involvedinmetabolizingalcoholintake.
Disulfiramproducesveryunpleasantsideeffects
whencombinedwithalcoholinthebody.

52. Mechanismofaction
◦Disulfiramisanoraldrugusedfortreating
alcoholism.
◦Alcoholisconvertedinthebodyintoacetaldehyde
byanenzymecalledalcoholdehydrogenase.
Another enzyme calledacetaldehyde
dehydrogenasethenconvertsacetaldehydeinto
aceticacid.
◦Disulfirampreventsacetaldehydedehydrogenase
fromconvertingacetaldehydeintoaceticacid,
leadingtoabuildupofacetaldehydelevelsinthe
bloodandinpresenceofalcoholitproduces
acetaldehyde-alcoholreactioninthebodywhichis
anunpleasantfeelingtoaperson.

53. Ethanol AcetateAcetaldehyde
•Flushing
•Headache
•Palpitations
•Dizziness
•Nausea
ADH ALDH
Disulfiram-Action

54. Disulfiram-Ethanol Reactions
Disulfiram-ethanolreactionsoftendevelopwithin15minutesafter
exposuretoethanol;
symptomsusuallypeakwithin30minutesto1hour,andthengradually
subsideoverthenextfewhours.
Symptomsmaybesevereandlife-threatening.
Thedisulfiram-alcoholreactionischaracterisedby:
◦Intensevasodilationofthefaceandneckcausingflushing,
◦Increasedbodytemperature,
◦Sweating,nausea,vomiting.
◦Pruritis,urticaria.
◦Anxiety,dizziness,headache.
◦Blurredvision.
◦Dyspnoea,palpitationsandhyperventilation.
◦Inseverecasestachycardia,hypotension,respiratorydepression,chestpain,
arrhythmias,comaandconvulsionsmayoccur.
◦Rarecomplicationsincludehypertension,bronchospasmandmethaemoglobinaemia.

55. Dosage:Inthefirstphaseoftreatment,a
maximumof500mgdailyintheformof
tabletisgiveninasingledoseforonetotwo
weeks.
Usuallyitistakeninthemorning.
MaintenanceRegimenTheaverage
maintenancedoseis250mgdaily(range,125
to500mg),itshouldnotexceed500mg
daily.

56. Nurse responsibility in Disulfiram therapy
EducatethepatientaboutDisulfiramandobtaininformedconsent.
Waituntilthepatienthasabstainedfromalcoholatleast12hours
and/orbreathorbloodalcoholleveliszero.
AdvicepatienttowearIDcardwhichmentioning,about
Disulfiramtreatment,Doctorsname&Contactnumber.
Advicehimnottotakealcohol.
StartDisulfiramafter12hoursofalcohol.
Advicehimtoavoidthesubstancescontainalcohol.
InformaboutDER.
AvoidCNSdepressants.
Avoiddriving.
Advicethepatientnottouseanyalcoholcontentproductslike
aftershave,spray.etc,whilepatientisintherapy.

57. ACAMPROSATE (PREVENTING
RELAPSE):Itisusedtopreventrelapsein
recoveringalcohol-dependentpatients.Itis
contraindicatedincasesofrenalinsufficiencyor
severehepaticfailure.
NALTREXONE:Naltrexonetabletisindicated
foruseinalcoholdependencetoreducetherisk
ofrelapse,supportabstinenceandreduce
alcoholcraving.Thesedrugsonlydealwith
physicalsymptomsanddonottreatthe
psychologicalcausesofaddiction.

58. Medication Target Year Approved
Disulfiram Aldehyde
Dehydrogenase
1949
Research from animal models over the past 25 years has
provided promising targets for pharmacotherapy
Naltrexone Mu Opioid Receptor 1994
Acamprosate Glutamate and GABA-
Related
2004
Naltrexone Depot Mu Opioid Receptor 2006
FDA ApprovedMedications for Treating
Alcohol Dependence

59. TREATMENT ALCOHOL INDUCED DISOREDR
Detoxification Therapy
◦It’stheprocessbywhichanalcoholdependent
personrecoversfromtheintoxicationand
withdrawaleffectsinasupervisedmanner.
◦Benzodiazepines-chlordizepoxide80-200mg/day.
◦Diazepam40-80mg/daytocontrolanxiety,
agitationandtremors.
◦Thiamine100mgintramuscularfor3-5days
followedbyvitamin–Badministration100mgOD
foratleast6months.

60. THERAPIES TO TREAT ALCOHOL DISORDER
Motivational Interviewing
Individual Psychotherapy
Group Therapy
Counselling
Aversive Conditioning
Behaviour Modification Techniques
Family Therapy
Self Help Groups

61. Self Help Groups
Alcoholic anonymous (AA)
◦ThisisaselfhelporganizationfoundedintheUSAbytwo
alcoholicmen,DrBobsmithandBillWilsonon10
th
June
1935.
◦AAconsidersalcoholismasaphysical,mentalandspiritual
disease,aprogressiveone,whichcanbearrestedbutnot
cured.
◦Membersattendgroupmeetingsusuallytwiceaweekona
longtermbasis.
◦Eachmemberisassignedasupportperson.
◦Fromwhomhemayseekhelpwhenthetemptationstodrink
occur.
◦Incrisishecanobtainimmediatehelpbytelephone.

62. AL-ANDN:-itisagroupstartedbywifeofDrBob
(Mrs.Anne),tosupportthespousesofalcoholics.
AL-ATEEN:-providessupporttotheirteenage
children.
HOSTELS:-theseareforthoserenderedhomeless
duetoalcohol-relatedproblems.Theyprovide
rehabilitationandcounselling.
ACOA(AdultChildrenofAlcoholics):-adultwho
grewupwithanalcoholicinthehome.
Childrenarepeople:-schoolagechildrenwithan
alcoholicfamilymembers.
Womenforsobriety:-meantforfemalealcoholics.

63. PREVENTION
Preventive programs: teach adolescents how
to resist social pressure to use drugs.
Detoxification: substance specific
Drug rehabilitation: develop new coping
skills
Self-help groups: alcoholics anonymous
Disulfiram
Naltrexone
methadone

64. Nursing Management
Assessment by CAGE questionnaire
◦whichconsistsoffourquestions:
Haveyoueverthoughtyoushouldcutdownonyour
drinking?
Havepeopleannoyedyoubycriticisingyourdrinking?
Haveyoueverfeltguiltyaboutyourdrinking?
Haveyoueverdrunkan"eye-opener",whichmeans:have
youeverdrunkalcoholfirstthinginthemorningtoget
overahangoverandsteadyyournerves?
◦Ifansweris"yes"tooneormoreofthequestionsabove,it
indicatethatthepersonhavingproblemwithdrinking.


65. Nursing Care Plan
NursingcareplanforAlcoholrelateddisorder
Nursingdiagnosis:RiskforineffectiveBreathingPatternrelatedtodirect
effectofalcoholtoxicityonrespiratorycentreandsedativedrugsgivento
decreasealcoholwithdrawalsymptoms
OutcomeIdentificationNursingIntervention
Client will be able to:
-Maintain
Effective
Breathing
PatternWith
Respiratory
RateWithin
NormalRange,
Monitor respiratory rate/depth and pattern. Note for
periods of apnea, Cheyne-Stokes respirations.
Auscultate for breath sounds. Note presence of
adventitious sounds (e.g., rhonchi, wheezes).
Elevate head end of the bed.
Encourage deep-breathing coughing exercises.
Change positions frequently.
Keep suction equipment, airways ready.
Administer supplemental oxygen if needed.
Review serial chest x-rays, arterial blood gases
(ABGs)/pulse oximetryas indicated.

66. Nursingdiagnosis:RiskforInjuryrelatedtoCessationofalcoholand
appearanceofwithdrawalsymptoms,Involuntaryclonic/tonicmuscleactivity
(seizures),reducedmuscleandhand/eyecoordination.
Outcome IdentificationNursing Intervention
Client will be able to:
-Demonstrate
absence of
untoward
effects of
withdrawal.
-Experienceno
physicalinjury.
Monitor for withdrawal symptoms.
Monitor/document seizure activity.
Maintain patent airway.
Provide safety to the patient (e.g., padded side
rails, bed in low position).
Assess for gait.
Palpate upper arm to conform actual
withdrawal versus medication-seeking
behavior.
Assist patient in ambulation and self-care
activities as needed.
Administer medications as indicated e.g.:
Benzodiazepines (BZDs)

67. Nursingdiagnosis:AnxietyorFearrelatedtophysiologicwithdrawal,
Situationalcrisis(hospitalization)andperceivedthreatofdeathasevidencedby
feelingsofinadequacy,shame,increasedhelplessness/hopelessnessandincreased
tension.
Outcome IdentificationNursing Intervention
Clientwillbeableto:
-Verbalize
reductionof
fear and
anxiety.
-Demonstrate
problem-
solvingskills
and use
resources
effectively.
Identifycauseofanxiety.
Explainthatalcoholwithdrawalusuallyincreases
anxietyanduneasiness.
Reassesslevelofanxietyonanongoingbasis.
Developatrustingrelationshipwithpatientthrough
frequentcontactbeinghonestandnonjudgmental.
Showanacceptingattitudeaboutalcoholism.
Reorientfrequently.
Administermedicationsasindicated,e.g.:BDZs(e.g.,
chlordiazepoxide[Librium],diazepam[Valium]).
ReferralpatientforDetoxificationandcrisiscentre.

68. Thank
You