Running Head: DEALING WITH THE DIFFICULT CASES

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Dealing with the Difficult Cases: Alcohol Withdrawal and Nurse Coping
Melissa Jenkins
Trent University
















DEALING WITH THE DIFFICULT CASES

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Dealing with the Difficult Cases: Alcohol Withdrawal and Nurse Coping
To date there has only been one case that has truly caused me to question whether I am
cut out to be a nurse. In the third week of my pre-consolidation I was working nights and was
assigned to a 32 year-old female admitted with the diagnosis of alcoholic liver disease, ascites,
and a gastrointestinal bleed. The patient also had a history of alcohol abuse and hospitalizations
resulting in withdrawal. The case, not remarkable in itself, was my first encounter with a patient
in this situation and many external and internal factors contributed to this case and my perception
of it.
Having never witnessed a person going through alcohol withdrawal there was much I was
not prepared for when dealing with this patient. From researching alcohol withdrawal during and
after the fact, I now have a clearer understanding of the stages and the severity of withdrawal this
patient was ultimately experiencing. Alcohol withdrawal can be categorized into four stages that
last varying amounts of time and are of varying severities (Corfee 2011; Keys, 2011). The first
phase occurs within 6 to 36 hours after last drink and is considered minor withdrawal (Keys,
2011). Patients in this phase experience anxiety, agitation, headache, palpitations, anorexia,
tachycardia, diaphoresis, and tremors (Keys, 2011). The second phase, occurring within 8-48
hours, is characterized by visual and/or tactile hallucinations (Corfee, 2011). Seizure activity
occurs anywhere between 12 to 48 hours, and is considered the third phase (Corfee, 2011). The
final stage is the one that is most recognized and is most often seen in the acute care setting
(Corfee, 2011). Delirium tremens (DTs) are the final stage and occur within 2 days (Corfee,
2011). DTs are characterized by delirium, agitation, hallucinations, hypertension, fever, and
diaphoresis (Corfee, 2011; Keys, 2011). It can also lead to cardiac and/or respiratory collapse
(Corfee, 2011).
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Given this information, I have come to the conclusion that over the two nights I helped
care for this patient she was experiencing DTs by the second night. With everything going on
with this patient medically, the addition of DTs made this patient quite critically ill. Given her
condition, I along with the other nurses on the floor were surprised she had not been admitted to
the intensive care unit (ICU), where she could be closely monitored. Staff to patient ratios in the
ICU and the medical floors are vastly and understandably different. ICU nurses often nurse at a
ratio of 1:2 or 1:1 depending on the severity of cases. On the medical floors during the day
staffing is generally 1:4 or 1:5. At night however this ratio increases to 1:8 on average. Having a
patient that was seriously ill and in need of almost constant monitoring and care impacted the
care that could be provided to the other patients in our assignment. This was fairly frustrating to
me as I felt torn between providing the care that I wanted to be able to do and the care that I was
able to provide. A further element of frustration was added when we became aware that the ICU
did not have any patients at the time we were caring for this patient.
Management of alcohol withdrawal can be complicated, especially when other medical
conditions are involved. Benzodiazepines are the drug of choice for alcohol withdrawal (cofree).
Chosen mainly for their similarities in pharmacodynamics effects in the brain with alcohol,
effectively weaning the patient as well as preventing seizures and tremors (cofree). The use of
benzodiazepines does come with its side effects such as nausea, vomiting, constipation,
insomnia, forgetfulness, and lack of balance or coordination. These side effects are of more
concern given the amount of drug often needed to control symptoms (Keys, 2011).
Knowing the adverse of effects benzodiazepines and the amount that was given to this
patient was troubling to me especially when they appeared not to have any desired effect. I was
also concerned of the addiction potential of benzodiazepines.
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Treating withdrawal symptoms is one part in the care of this patient. Another part is
getting the patient the help they need when they leave hospital to prevent a similar or same
situation in the future (Elliot, Geyer, Lionetti, & Doty, 2012). This patient appeared willing
enough to change her life, especially when faced with the fact that future drinking would cause
death. With this in mind we tried very hard to help her and her mother arrange for mental health
and a place in a rehabilitation center. I felt at the time that without proper support upon discharge
that it was very likely that the patient would continue to drink heavily. I feel that the patient and
family were also concerned about this. So it was important to put in motion what was needed to
get her support. To do this we helped to arrange mental health referral and alerted her care team
of her desire to go to rehab. I was quite frustrated and saddened to find out that she had been
discharged without these supports.
In the end this case was fairly emotional for me. I was placed in a situation where I was
caring for a patient that was not much older than me, had made decisions that contributed to her
state, was critically ill, and I felt I did not have the knowledge or experience to support her as a
nurse. This ultimately forced me to look at my own coping mechanisms and those of the nurses
around me. Among nursing students, emotional stress correlated with burnout before graduation
(Watson). Watson (year) also found that students who used emotional oriented coping
mechanisms to cope with stresses of nursing were more likely to experience burnout. Emotional-
oriented coping is considered to not be an effective coping technique as it does not deal directly
with the cause of the stress rather just the emotions (Lim, Bogossian, & Ahern, 2010). I would
say that I am an emotional oriented coper and this technique is not effective for me.
There are many stressors in nursing and many ways to cope with them. Reported in the
literature work-load, lack of social support, and critically unstable patients are considered some
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of the topic stressors faced by nurses (Lim et al., 2010; Hays et al., 2006). In this experience I
felt all of these stressors. Of significance is the lack of social support. Social support is
considered to be both a stressor and a coping mechanism (Lim et al., 2010). During the
experience I felt like I had little to no support from the other nurses working at the time and I felt
that collectively we were not getting support from the hospital to care for this patient. Reflecting
on the situation though, I realize now that I did have the support of the nurses working at the
time and my preceptor. As a method of coping I plan to explore the use of my peers more fully in
the future when feeling stressed. I see a lot of nurses using their peers to deal with the stress at
clinical and it is clear to me why it is considered in the literature as one of the most used and
effective methods of coping (Lim et al., 2010).
Another effective coping strategy reported in the literature is that of problem focused
problem solving. This strategy uses the idea that working towards eliminating the stressor is a
way of coping (Lim et al., 2010). I like the idea of this strategy, but am still unclear as to how
this strategy would have worked to eliminate the stress I felt when dealing with my patient. I
believe because I was having an emotional reaction to the experience, this strategy would not
have been of use to me, however, it is one to keep in mind for future stressful situations.
Nursing students feel additional stress that is placed on them from financial restraints and
academic demands (Lim et al., 2010). I did not consider these stresses at the time of the situation,
but on reflection I can see how being under additional stress outside the clinical setting
contributed to having a greater emotional response due to all the stress that was currently in my
life. Work-life and home-life often interplay, though many believe they can be separated. This is
important in nursing because as a profession nursing is considered one of the more stressful jobs
(Hays et al., 2006).
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From this experience I have learned that having emotional reactions to cases, patients,
and situations is going to be a part of the nursing experience. I have also learned that this does
not make me incapable of being a nurse, but rather may make me a better one. It is important to
be able to manage the stress that nursing can sometimes cause, needs to be effective to prevent
burnout. Part of the process is to find appropriate coping mechanisms that are effective for me,
which, going forward will be a goal of mine. Also to recognize that even though we try to do the
best for our patients we cannot control every aspect of their lives and not to feel as if we have
failed a patient because of the choices others make. All we can do is advocate for our patients.















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References
Corfee, F. A. (2011). Alcohol withdrawal in the critical care unit. Australian Critical Care, 24,
110-116.
Elliot, D., Geyer, C., Lionetti, T., & Doty, L. (2012). Managing alcohol withdrawal in
hospitalized patients. Nursing2012 Critical Care, 42, 22-30
Hays, M. A., All, A. C., Mannahan, C., Cauderes, E., & Wallace, D. (2006). Reported stressors
and ways of coping utilized by intensive care unit nurses. Dimensions of Critical Care Nursing,
25, 185-293
Keys, V. A. (2011). Alcohol withdrawal during hospitalization. AJN The American Journal of
Nursing, 111(1), 40-44.
Lim, J., Bogossian, F., & Ahern, K. (2010). Stress and coping in Australian nurses: A systematic
review. International Nursing Review, 57, 22-31