Feb 22, 2011

Alcohol: Acute Withdrawal

Alcohol, a CNS depressant drug, is used socially in our society for many reasons: to enhance the flavor of food, to encourage relaxation and conviviality, for celebrations, and as a sacred ritual in some religious ceremonies. Therapeutically, it is the major ingredient in many OTC/prescription medications. It can be harmless, enjoyable, and sometimes beneficial when used responsibly and in moderation. Like other mind-altering drugs, however, it has the potential for abuse, and, in fact, is the most widely abused drug in the United States (research suggests 5%–10% of the adult population) and is potentially fatal.

Care setting

May be inpatient on a behavioral unit or outpatient in community programs. Although patients are not generally admitted to the acute care setting with this diagnosis, withdrawal from alcohol may occur secondarily during hospitalization for other illnesses/conditions. A short hospital stay may be required during the acute phase because of severity of general condition, or a delayed discharge from acute care can be the result of alcohol withdrawal beginning within 6–48 hr of admission.

Related concerns

Cirrhosis of the liver

Upper gastrointestinal/esophageal bleeding

Heart failure

Psychosocial aspects of care

Substance dependence/abuse rehabilitation

Patient Assessment Database

Data depend on the duration/extent of use of alcohol, concurrent use of other drugs, degree of organ involvement, and presence of other pathology.

activity/rest

May report: Difficulty sleeping, not feeling well rested

circulation

May exhibit: Generalized tissue edema (due to protein deficiencies)

Peripheral pulses weak, irregular, or rapid

Hypertension common in early withdrawal stage but may become labile/progress to hypotension

Tachycardia common during acute withdrawal; numerous dysrhythmias may be identified

Ego integrity

May report: Feelings of guilt/shame; defensiveness about drinking

Denial, rationalization

Multiple stressors/losses (relationships, employment, finances)

Use of alcohol to deal with life stressors, boredom

Elimination

May report: Diarrhea

May exhibit: Bowel sounds varied (may reflect gastric complications, e.g., hemorrhage)

Food/fluid

May report: Nausea/vomiting; food intolerance

May exhibit: Gastric distension; ascites, liver enlargement (seen in cirrhosis)

Muscle wasting, dry/dull hair, swollen salivary glands, inflamed buccal cavity, capillary fragility (malnutrition)

Bowel sounds varied (reflecting malnutrition, electrolyte imbalances, general bowel dysfunction)

Neurosensory

May report: “Internal shakes”

Headache, dizziness, blurred vision; “blackouts”

May exhibit: Psychopathology, e.g., paranoid schizophrenia, major depression (may indicate dual diagnosis)

Level of consciousness/orientation varies, e.g., confusion, stupor, hyperactivity, distorted thought processes, slurred/incoherent speech

Memory loss/confabulation

Affect/mood/behavior: May be fearful, anxious, easily startled, inappropriate, silly, euphoric, irritable, physically/verbally abusive, depressed, and/or paranoid

Hallucinations: Visual, tactile, olfactory, and auditory, e.g., patient may be picking items out of air or responding verbally to unseen person/voices

Eye examination: Nystagmus (associated with cranial nerve palsy); pupil constriction (may indicate CNS depression); arcus senilis-ringlike opacity of the cornea (although normal in aging populations, suggests alcohol-related changes in younger patients)

Fine motor tremors of face, tongue, and hands; seizures (commonly grand mal)

Gait unsteady (ataxia), may be due to thiamine deficiency or cerebellar degeneration (Wernicke’s encephalopathy)

Pain/discomfort

May report: Constant upper abdominal pain and tenderness radiating to the back (pancreatic inflammation)

respiration

May report: History of smoking, recurrent/chronic respiratory problems

May exhibit: Tachypnea (hyperactive state of alcohol withdrawal)

Cheyne-Stokes respirations or respiratory depression

Breath sounds diminished, adventitious sounds (suggests pulmonary complications, e.g., respiratory depression, pneumonia)

safety

May report: History of recurrent trauma such as falls, fractures, lacerations, burns, blackouts, or motor vehicle crashes

May exhibit: Skin: Flushed face/palms of hands; scars, ecchymotic areas; cigarette burns on fingers, spider nevus (impaired portal circulation), fissures at corners of mouth (vitamin deficiency)

Fractures healed or new (signs of recent/recurrent trauma)

Temperature elevation (dehydration and sympathetic stimulation); flushing/diaphoresis (suggests presence of infection)

Suicidal ideation/suicide attempts (some research suggests alcoholic suicide attempts are 30% higher than national average for general population)

social interaction

May report: Frequent sick days off from work/school; fighting with others, arrests (disorderly conduct, motor vehicle violations/driving under the influence [DUI])

Denial that alcohol intake has any significant effect on present condition

Dysfunctional family system of origin (generational involvement); problems in current relationships

Mood changes affecting interactions with others

Teaching/learning

May report: Family history of alcoholism

History of alcohol and/or other drug use/abuse

Ignorance and/or denial of addiction to alcohol, or inability to cut down or stop drinking despite repeated efforts; previous periods of abstinence/withdrawal

Large amount of alcohol consumed in last 24–48 hr

Previous hospitalizations for alcoholism/alcohol-related diseases, e.g., cirrhosis, esophageal varices

Discharge plan DRG projected mean length of inpatient stay: 4.9 days

considerations: May require assistance to maintain abstinence and begin to participate in rehabilitation program

Refer to section at end of plan for postdischarge considerations.

diagnostic studies

Blood alcohol/drug levels: Alcohol level may/may not be severely elevated, depending on amount consumed, time between consumption and testing, and the degree of tolerance, which varies widely. In the absence of elevated alcohol tolerance, blood levels in excess of 100 mg/dL are associated with ataxia; at 200 mg/dL the patient is drowsy and confused; respiratory depression occurs with blood levels of 400 mg/dL and death is possible. In addition to alcohol, numerous controlled substances may be identified in a poly-drug screen, e.g., amphetamine, cocaine, morphine, Percodan, Quaalude.

CBC: Decreased Hb/Hct may reflect such problems as iron-deficiency anemia or acute/chronic GI bleeding. WBC count may be increased with infection or decreased if immunosuppressed.

Glucose/Ketones: Hyperglycemia/hypoglycemia may be present, related to pancreatitis, malnutrition, or depletion of liver glycogen stores. Ketoacidosis may be present with/without metabolic acidosis.

Electrolytes: Hypokalemia and hypomagnesemia are common.

Liver function tests: LDH, AST, ALT, and amylase may be elevated, reflecting liver or pancreatic damage.

Nutritional tests: Albumin is low and total protein may be decreased. Vitamin deficiencies are usually present, reflecting malnutrition/malabsorption.

Other screening studies (e.g., hepatitis, HIV, TB): Depend on general condition, individual risk factors, and care setting.

Urinalysis: Infection may be identified; ketones may be present, related to breakdown of fatty acids in malnutrition (pseudodiabetic condition).

Chest x-ray: May reveal right lower lobe pneumonia (malnutrition, depressed immune system, aspiration) or chronic lung disorders associated with tobacco use.

ECG: Dysrhythmias, cardiomyopathies, and/or ischemia may be present because of direct effect of alcohol on the cardiac muscle and/or conduction system, as well as effects of electrolyte imbalance.

Addiction Severity Index (ASI): An assessment tool that produces a “problem severity profile” of the patient, including chemical, medical, psychological, legal, family/social, and employment/support aspects, indicating areas of treatment needs.

Nursing priorities

1. Maintain physiological stability during acute withdrawal phase.

2. Promote patient safety.

3. Provide appropriate referral and follow-up.

4. Encourage/support SO involvement in “Intervention” (confrontation) process.

5. Provide information about condition/prognosis and treatment needs.

Discharge goals

1. Homeostasis achieved.

2. Complications prevented/resolved.

3. Sobriety being maintained on a day-to-day basis.

4. Ongoing participation in rehabilitation program/attending group therapy, e.g., Alcoholics Anonymous.

5. Condition, prognosis, and therapeutic regimen understood.

6. Plan in place to meet needs after discharge.

This plan of care is to be used in conjunction with CP: Substance Dependence/Abuse Rehabilitation.


NURSING DIAGNOSIS: Breathing Pattern, risk for ineffective

Risk factors may include

Direct effect of alcohol toxicity on respiratory center and/or sedative drugs given to decrease alcohol withdrawal symptoms

Tracheobronchial obstruction

Presence of chronic respiratory problems, inflammatory process

Decreased energy/fatigue

Possibly evidenced by

[Not applicable; presence of signs and symptoms establishes an actual diagnosis]

DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL:

Respiratory Status: Ventilation (NOC)

Maintain effective breathing pattern with respiratory rate within normal range, lungs clear; be free of cyanosis and other signs/symptoms of hypoxia.


ACTIONS/INTERVENTIONS

Respiratory Monitoring (NIC)

Independent

Monitor respiratory rate/depth and pattern as indicated. Note periods of apnea, Cheyne-Stokes respirations.

Auscultate breath sounds. Note presence of adventitious sounds, e.g., rhonchi, wheezes.

Airway Management (NIC)

Elevate head of bed.

Encourage cough/deep-breathing exercises and frequent position changes.

Have suction equipment, airway adjuncts available.

RATIONALE

Frequent assessment is important because toxicity levels may change rapidly. Hyperventilation is common during acute withdrawal phase. Kussmaul’s respirations are sometimes present because of acidotic state associated with vomiting and malnutrition. However, marked respiratory depression can occur because of CNS depressant effects of alcohol if acute intoxication is present. This may be compounded by drugs used to control alcohol withdrawal symptoms (AWS).

Patient is at risk for atelectasis related to hypoventilation and pneumonia. Right lower lobe pneumonia is common in alcohol-debilitated patients and is often due to chronic aspiration. Chronic lung diseases are also common, e.g., emphysema, bronchitis.

Decreases potential for aspiration; lowers diaphragm, enhancing lung inflation.

Facilitates lung expansion and mobilization of secretions to reduce risk of atelectasis/pneumonia.

Sedative effects of alcohol/drugs potentiates risk of aspiration, relaxation of oropharyngeal muscles, and respiratory depression, requiring intervention to prevent respiratory arrest.



ACTIONS/INTERVENTIONS

Airway Management (NIC)

Collaborative

Administer supplemental oxygen if necessary.

Review serial chest x-rays, ABGs/pulse oximetry as available/indicated.

RATIONALE

Hypoxia may occur with CNS/respiratory depression.

Monitors presence of secondary complications such as atelectasis/pneumonia; evaluates effectiveness of respiratory effort, identifies therapy needs.

NURSING DIAGNOSIS: Cardiac Output, risk for decreased

Risk factors may include

Direct effect of alcohol on the heart muscle

Altered systemic vascular resistance

Electrical alterations in rate, rhythm, conduction

Possibly evidenced by

[Not applicable; presence of signs and symptoms establishes an actual diagnosis]

DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL:

Circulation Status (NOC)

Display vital signs within patient’s normal range; absence of/reduced frequency of dysrhythmias.

Demonstrate an increase in activity tolerance.


ACTIONS/INTERVENTIONS

Hemodynamic Regulation (NIC)

Independent

Monitor vital signs frequently during acute withdrawal.

Monitor cardiac rate/rhythm. Document irregularities/
dysrhythmias.

RATIONALE

Hypertension frequently occurs in acute withdrawal phase. Extreme hyperexcitability, accompanied by catecholamine release and increased peripheral vascular resistance, raises BP and heart rate; however, BP may become labile/progress to hypotension. Note: Patient may have underlying cardiovascular disease, which is compounded by alcohol withdrawal.

Long-term alcohol abuse may result in cardiomyopathy/
HF. Tachycardia is common because of sympathetic response to increased circulating catecholamines. Irregularities/dysrhythmias may develop with electrolyte shifts/imbalance. All of these may have an adverse effect on cardiac function/output.



ACTIONS/INTERVENTIONS

Hemodynamic Regulation (NIC)

Independent

Monitor body temperature.

Monitor I&O. Note 24-hr fluid balance.

Be prepared for/assist in cardiopulmonary resuscitation.

Collaborative

Monitor laboratory studies, e.g., serum electrolyte levels.

Administer fluids and electrolytes, as indicated.

Administer medications as indicated, e.g.:

Clonidine (Catapres), atenolol (Tenormin);

Potassium.

RATIONALE

Elevation may occur because of sympathetic stimulation, dehydration, and/or infections, causing vasodilation and compromising venous return/cardiac output.

Preexisting dehydration, vomiting, fever, and diaphoresis may result in decreased circulating volume that can compromise cardiovascular function. Note: Hydration is difficult to assess in the alcoholic patient because the usual indicators are not reliable, and overhydration is a risk in the presence of compromised cardiac function.

Causes of death during acute withdrawal stages include cardiac dysrhythmias, respiratory depression/arrest, oversedation, excessive psychomotor activity, severe dehydration or overhydration, and massive infections. Mortality for unrecognized/untreated delirium tremens (DTs) may be as high as 25%.

Electrolyte imbalance, e.g., potassium/magnesium, potentiate risk of cardiac dysrhythmias and CNS excitability.

Severe alcohol withdrawal causes the patient to be susceptible to fluid losses (associated with fever, diaphoresis, and vomiting) and electrolyte imbalances, especially potassium, magnesium, and glucose.

Although the use of benzodiazepines is often sufficient to control hypertension during initial withdrawal from alcohol, some patients may require more specific therapy. Note: Atenolol and other b-adrenergic blockers may speed up the withdrawal process and eliminate tremors, as well as lower the heart rate, blood pressure, and body temperature.

Corrects deficits that can result in life-threatening dysrhythmias.


NURSING DIAGNOSIS: Injury, risk for [specify]

Risk factors may include

Cessation of alcohol intake with varied autonomic nervous system responses to the system’s suddenly altered state

Involuntary clonic/tonic muscle activity (seizures)

Equilibrium/balancing difficulties, reduced muscle and hand/eye coordination

Possibly evidenced by

[Not applicable; presence of signs and symptoms establishes an actual diagnosis]

DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL:

Risk Control (NOC)

Demonstrate absence of untoward effects of withdrawal.

Experience no physical injury.


ACTIONS/INTERVENTIONS

Substance Use Treatment:
Alcohol Withdrawal (NIC)

Independent

Identify stage of AWS (alchohol withdrawal syndrome); i.e., stage I is associated with signs/symptoms of hyperactivity (e.g., tremors, sleeplessness, nausea/
vomiting, diaphoresis, tachycardia, hypertension). Stage II is manifested by increased hyperactivity plus hallucinations and/or seizure activity. Stage III symptoms include DTs and extreme autonomic hyperactivity with profound confusion, anxiety, insomnia, fever.

Monitor/document seizure activity. Maintain patent airway. Provide environmental safety, e.g., padded side rails, bed in low position.

Check deep-tendon reflexes. Assess gait, if possible.

Assist with ambulation and self-care activities as needed.

RATIONALE

Prompt recognition and intervention may halt progression of symptoms and enhance recovery/improve prognosis. In addition, recurrence/progression of symptoms indicates need for changes in drug therapy/more intense treatment to prevent death.

Grand mal seizures are most common and may be related to decreased magnesium levels, hypoglycemia, elevated blood alcohol, or history of head trauma/preexisting seizure disorder. Note: In absence of history of/other pathology causing seizures, they usually stop spontaneously, requiring only symptomatic treatment. Note: Antiepileptic drugs are not indicated for alcohol withdrawal seizures.

Reflexes may be depressed, absent, or hyperactive. Peripheral neuropathies are common, especially in malnourished patient. Ataxia (gait disturbance) is associated with Wernicke’s syndrome (thiamine deficiency) and cerebellar degeneration.

Prevents falls with resultant injury.



ACTIONS/INTERVENTIONS

Substance Use Treatment:
Alcohol Withdrawal (NIC)

Independent

Provide for environmental safety when indicated. (Refer to ND: Sensory-Perceptual alterations, following.)

Collaborative

Administer medications as indicated e.g.:

Benzodiazepines (BZDs), e.g., chlordiazepoxide (Librium), diazepam (Valium), clonazepam (Klonopin), oxazepam (Serax), clorazepate (Tranxene);

Haloperidol (Haldol);

Thiamine;

Magnesium sulfate.

RATIONALE

May be required when equilibrium, hand/eye coordination problems exist.

BZDs are commonly used to control neuronal hyperactivity because of their minimal respiratory and cardiac depression and anticonvulsant properties. Studies have also shown that these drugs can prevent progression to more severe states of withdrawal. IV/PO administration is preferred route because IM absorption is unpredictable. Muscle-relaxant qualities are particularly helpful to patient in controlling “the shakes,” trembling, and ataxic quality of movements. Patient may initially require large doses to achieve desired effect, and then drugs may be tapered and discontinued, usually within 96 hr. Note: These agents are used cautiously in patients with known hepatic disease because they are metabolized by the liver, although Serax has a shorter half-life.

May be used in conjunction with BZDs for patients experiencing hallucinations.

Thiamine deficiency (common in alcohol abuse) may lead to neuritis, Wernecke’s syndrome, and/or Korsakoff’s psychosis.

Reduces tremors and seizure activity by decreasing neuromuscular excitability.


NURSING DIAGNOSIS: Sensory-Perceptual alterations (specify)

May be related to

Chemical alteration: Exogenous (e.g., alcohol consumption/sudden cessation) and endogenous (e.g., electrolyte imbalance, elevated ammonia and BUN)

Sleep deprivation

Psychological stress (anxiety/fear)

Possibly evidenced by

Disorientation to time, place, person, or situation

Changes in usual response to stimuli; exaggerated emotional responses, change in behavior

Bizarre thinking

Listlessness, irritability, apprehension, activity associated with visual/auditory hallucinations

Fear/anxiety

DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL:

Cognitive Ability (NOC)

Regain/maintain usual level of consciousness.

Distorted Thought Control (NOC)

Report absence of/reduced hallucinations.

Identify external factors that affect sensory-perceptual abilities.


ACTIONS/INTERVENTIONS

Substance Use Treatment:
Alcohol Withdrawal (NIC)

Independent

Assess level of consciousness; ability to speak, response to stimuli/commands.

Observe behavioral responses, e.g., hyperactivity, disorientation, confusion, sleeplessness, irritability.

Note onset of hallucinations. Document as auditory, visual, and/or tactile.

RATIONALE

Speech may be garbled, confused, or slurred. Response to commands may reveal inability to concentrate, impaired judgment, or muscle coordination deficits.

Hyperactivity related to CNS disturbances may escalate rapidly. Sleeplessness is common due to loss of sedative effect gained from alcohol usually consumed before bedtime. Sleep deprivation may aggravate disorientation/
confusion. Progression of symptoms may indicate impending hallucinations (stage II) or DTs (stage III).

Auditory hallucinations are reported to be more frightening/threatening to patient. Visual hallucinations occur more at night and often include insects, animals, or faces of friends/enemies. Patients are frequently observed “picking the air.” Yelling may occur if patient is calling for help from perceived threat (usually seen in stage III AWS).



ACTIONS/INTERVENTIONS

Substance Use Treatment:
Alcohol Withdrawal (NIC)

Independent

Provide quiet environment. Speak in calm, quiet voice. Regulate lighting as indicated. Turn off radio/TV during sleep.

Provide care by same personnel whenever possible.

Encourage SO to stay with patient whenever possible.

Reorient frequently to person, place, time, and surrounding environment as indicated.

Avoid bedside discussion about patient or topics unrelated to the patient that do not include the patient.

Provide environmental safety, e.g., place bed in low position, leave doors in full open or closed position, observe frequently, place call light/bell within reach, remove articles that can harm patient.

Collaborative

Provide seclusion, restraints as necessary.

Monitor laboratory studies, e.g., electrolytes, magnesium levels, liver function studies, ammonia, BUN, glucose, ABGs.

Administer medications as indicated, e.g.:

Antianxiety agents as indicated. (Refer to ND: Anxiety [severe/panic]/Fear), following);

RATIONALE

Reduces external stimuli during hyperactive stage. Patient may become more delirious when surroundings cannot be seen, but some respond better to quiet, darkened room.

Promotes recognition of caregivers and a sense of consistency, which may reduce fear.

May have a calming effect, and may provide a reorienting influence.

May reduce confusion, prevent/limit misinterpretation of external stimuli.

Patient may hear and misinterpret conversation, which can aggravate hallucinations.

Patient may have distorted sense of reality or be fearful or suicidal, requiring protection from self.

Patients with excessive psychomotor activity, severe hallucinations, violent behavior, and/or suicidal gestures may respond better to seclusion. Restraints are usually ineffective and add to patient’s agitation, but occasionally may be required to prevent self-harm.

Changes in organ function may precipitate or potentiate sensory-perceptual deficits. Electrolyte imbalance is common. Liver function is often impaired in the chronic alcoholic, and ammonia intoxication can occur if the liver is unable to convert ammonia to urea. Ketoacidosis is sometimes present without glycosuria; however, hyperglycemia or hypoglycemia may occur, suggesting pancreatitis or impaired gluconeogenesis in the liver. Hypoxemia and hypercarbia are common manifestations in chronic alcoholics who are also heavy smokers.

Reduces hyperactivity, promoting relaxation/sleep. Drugs that have little effect on dreaming may be desired to allow dream recovery (REM rebound) to occur, which has previously been suppressed by alcohol use.



ACTIONS/INTERVENTIONS

Substance Use Treatment:
Alcohol Withdrawal (NIC)

Collaborative

Thiamine, vitamins C and B complex, multivitamins, Stresstabs.

RATIONALE

Vitamins may be depleted because of insufficient intake and malabsorption. Vitamin deficiency (especially thiamine) is associated with ataxia, loss of eye movement and pupillary response, palpitations, postural hypotension, and exertional dyspnea.

NURSING DIAGNOSIS: Anxiety [severe/panic]/Fear

May be related to

Cessation of alcohol intake/physiological withdrawal

Situational crisis (hospitalization)

Threat to self-concept, perceived threat of death

Possibly evidenced by

Feelings of inadequacy, shame, self-disgust, and remorse

Increased helplessness/hopelessness with loss of control of own life

Increased tension, apprehension

Fear of unspecified consequences; identifies object of fear

DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL:

Anxiety or Fear Control (NOC)

Verbalize reduction of fear and anxiety to an acceptable and manageable level.

Express sense of regaining some control of situation/life.

Demonstrate problem-solving skills and use resources effectively.


ACTIONS/INTERVENTIONS

Anxiety Reduction (NIC)

Independent

Identify cause of anxiety, involving patient in the process. Explain that alcohol withdrawal increases anxiety and uneasiness. Reassess level of anxiety on an ongoing basis.

Develop a trusting relationship through frequent contact being honest and nonjudgmental. Project an accepting attitude about alcoholism.

RATIONALE

Person in acute phase of withdrawal may be unable to identify and/or accept what is happening. Anxiety may be physiologically or environmentally caused. Continued alcohol toxicity will be manifested by increased anxiety and agitation as effects of medication wear off.

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.



ACTIONS/INTERVENTIONS

Anxiety Reduction (NIC)

Independent

Inform patient about what you plan to do and why. Include patient in planning process and provide choices when possible.

Reorient frequently. (Refer to ND: Sensory-Perceptual alterations.)

Collaborative

Administer medications as indicated, e.g.:

Benzodiazepines, e.g., chlordiazepoxide (Librium), diazepam (Valium);

Barbiturates, e.g., phenobarbital, or possibly secobarbital (Seconal), pentobarbital (Nembutal).

Arrange “Intervention” (confrontation) in controlled setting.

Provide consultation for referral to detoxification/
crisis center for ongoing treatment program as soon as medically stable (e.g., oriented to reality).

RATIONALE

Enhances sense of trust, and explanation may increase cooperation/reduce anxiety. Provides sense of control over self in circumstance where loss of control is a significant factor. Note: Feelings of self-worth are intensified when one is treated as a worthwhile person.

Patient may experience periods of confusion, resulting in increased anxiety.

Antianxiety agents are given during acute withdrawal to help patient relax, be less hyperactive, and feel more in control.

These drugs suppress alcohol withdrawal but need to be used with caution because they are respiratory depressants and REM sleep cycle inhibitors.

Process wherein SO/family members, supported by staff, provide information about how patient’s drinking and behavior have affected each one of them, helps patient acknowledge that drinking is a problem and has resulted in current situational crisis.

Patient is more likely to contract for treatment while still hurting and experiencing fear and anxiety from last drinking episode. Motivation decreases as well-being increases and person again feels able to control the problem. Direct contact with available treatment resources provides realistic picture of help. Decreases time for patient to “think about it”/change mind or restructure and strengthen denial systems.

POTENTIAL CONSIDERATIONS following acute care (dependent on patient’s age, physical condition/
presence of complications, personal resources, and life responsibilities)

Refer to: Substance Abuse/Rehabilitation plan of care, and plans of care for any specific underlying medical condition(s).


Sample CP: Alcohol Withdrawal Program. ELOS: 5 Days Behavioral Unit

ND and Cate- Time Time Time

gories of Care Dimension Goals/Actions Dimension Goals/Actions Dimension Goals/Actions

Risk for injury (varied autonomic and sensory responses)

Referrals

Diagnostic studies

Additional assessments

Medications

Allergies:

____________

Patient education

Day 1

Day 1

Day 1

Day 1

Day 1–4

Ongoing

Stage I

Stage II

Stage III

Day 1

Day 1–4

Day 2

Day 1

Verbalize understanding of unit policies, procedures, and safety concerns relative to individual needs

Cooperate with therapeutic regimen

RN-NP or MD

If indicated:

Internist

Cardiologist

Neurologist

BA level

Drug screen (urine and blood)

If indicated:

CXR

Pulse oximetry

ECG

VS, temp, respiratory status/breath sounds q4h

I&O q8h

Motor activity, body language, verbalizations, need for/type of restraint

Withdrawal symptoms:

Tremors, N/V, hypertension, tachycardia, diaphoresis, sleeplessness

Increased hyperactivity, hallucinations, seizure activity

Extreme autonomic hyperactivity, profound confusion, anxiety, fever

Librium 200 mg PO

Thiamine 100 mg IM

Librium 160 mg PO

Orient to room/unit, schedule, procedures

Day 3

Day 4

Day 2

Day 2–3

Day 3

Day 4

Day 3–4

Vital signs stable

I&O balanced

Display marked decrease in objective symptoms

SMA 20

Serum Mg, amylase

RPR

UA

VS q8h if stable

Librium 120 mg PO

Librium 80 mg PO

Need for ongoing therapy

Goals/availability of AA program

Day 5

Day 4

Day 4–5

Day 5

Day 5

Be free of injury resulting from ETOH withdrawal

Display no objective symptoms of withdrawal

Repeat of selected studies as indicated

VS gd

Librium 40 mg PO

Schedule of follow-up visits if indicated


Sample CP: Alcohol Withdrawal Program. ELOS: 5 Days Behavioral Unit (Continued)

ND and Cate- Time Time Time

gories of Care Dimension Goals/Actions Dimension Goals/Actions Dimension Goals/Actions

Additional nursing actions

Ineffective individual coping R/T personal vulnerability, situational crisis, inadequate coping methods

Referrals

Additional assessments

Medications

Patient education

Day 1

Day 1–2

Ongoing

Day 1–5

Day 2–5

Day 1

Day 2–5

Day 1

Day 1–2

Day 1

Day 1–2

Day 2

Bed rest 12 hr if in withdrawal

Position change, HOB elevated; C, DB exercises if on bed rest

Assist with ambulation, self-care as needed

Encourage fluids if free of N/V

Provide environmental safety measures, seizure precautions as indicated

Reorient as needed

Participate in development/
evaluation of treatment plan

Interact in group sessions

Psychiatrist

Group sessions

Understanding of current situation

Drinking pattern, previous withdrawal, other drug use, attitudes toward substance use

History of violence

Relationships with others: personal, work/school

Readiness for group activities

Physical effects of ETOH abuse

Types/use of relaxation techniques

Consequences of ETOH abuse

Day 3–5

Day 3

Day 4

Day 4

Day 2–3

Day 3–5

Day 5

Day 3–5

Day 4–5

Activity as tolerated

Verbalize under-standing of relationship of ETOH abuse to current situation

Identify/make contact with potential resources, support groups

Community classes: Assertiveness training

Stress management

Previous coping strategies/
consequences

Perception of drug use on life, employment, legal issues

Congruency of actions based on insight

Naltrexone 50 mg/

day if indicated

Human behavior and interactions with others/ transactional analysis (TA)

Community resources for self/family

Day 5

Day 5

Plan in place to meet needs postdischarge

Medication dose, frequency, side effects

Written instructions for therapeutic program


Sample CP: Alcohol Withdrawal Program. ELOS: 5 Days Behavioral Unit (Continued)

ND and Cate- Time Time Time

gories of Care Dimension Goals/Actions Dimension Goals/Actions Dimension Goals/Actions

Additional nursing actions

Altered nutrition: less than body requirements R/T poor intake, effects of ETOH on digestive system, and hyper-metabolic response to withdrawal

Referrals

Diagnostic studies

Additional assessments

Medications

Patient education

Additional nursing actions

Day 1–5

Day 2–5

Day 1 and prn

Day 1

Day 1

Day 1–2

Day 1–5

Day 1–5

Day 1–2

Day 1

Day 1–5

Support patient’s taking responsibility for own recovery

Provide consistent approach/ expectations for behavior

Set limits/confront inappropriate behaviors

Select foods appropriately to meet individual dietary needs

Dietitian

CBC, liver function studies

Serum albumin, transferrin

Weight, skin turgor, condition of mucous membranes, muscle tone

Bowel sounds, characteristics of stools

Appetite, dietary intake

Antacid ac and hs

Imodium 2 mg prn

Individual nutritional needs

Liquid/bland diet as tolerated

Encourage small, frequent, nutritious meals/snacks

Encourage good oral hygiene pc and hs

Day 2–5

Day 4

Day 2–5

Day 2–5

Day 4

Day 2–5

Identify goals for change

Discuss alternative solutions

Provide positive feedback for efforts

Support during confrontation by peer group

Encourage verbalization of feelings, personal reflection

Verbalize understandings of effects of ETOH abuse and reduced dietary intake on nutritional status

Fingerstick glucose prn

Multivitamin tab/qd

Principles of nutrition, foods for maintenance of wellness

Advance diet as tolerated

Day 5

Day 5

Display stable weight or initial weight gain as appropriate, and laboratory results WNL

Weight