ALCOHOL-RELATED DISORDERS

DSM-IV
ALCOHOL-INDUCED DISORDERS
303.00 Alcohol intoxication
291.81 Alcohol withdrawal
291.89 Alcohol-induced mood disorder
291.89 Alcohol-induced anxiety disorder
292.81 Intoxication delirium
Alcohol is a CNS deressant dru! that is used socially in our society "or many
reasons #e.!.$ to enhance the %a&or o" "ood$ to encoura!e relaxation and con&i&iality$
"or "eelin!s o" cele'ration$ and as a sacred ritual in some reli!ious ceremonies(.
)heraeutically$ it is the ma*or in!redient in many +)C/rescrition medications. It
can 'e harmless$ en*oya'le$ and sometimes 'ene,cial when used resonsi'ly and in
moderation. -i.e other mind-alterin! dru!s$ howe&er$ it has the otential "or a'use
and$ in "act$ is the most widely a'used dru! in the /nited States #research su!!ests
01 to 101 o" the adult oulation( and is otentially "atal. 2re3uently$ the client in a
residential care settin! has 'een usin! alcohol in con*unction with other dru!s. It is
'elie&ed that alcohol is o"ten used 'y clients who ha&e other mental illnesses to
assua!e the ain they "eel. )he term 4dual dia!nosis5 is used to mean an association
'etween the use6a'use o" dru!s #includin! alcohol( and other sychiatric dia!noses.
It may 'e di7cult to determine cause and e8ect in any !i&en situation to determine
an accurate dia!nosis. 9owe&er$ it is imortant to reco!ni:e when 'oth conditions
are resent so that the o"ten-o&erwhelmin! ro'lems o" treatment are instituted "or
'oth conditions.
)his lan o" care addresses acute intoxication6withdrawal and is to 'e used in
con*unction with C;< Su'stance =eendence6A'use >eha'ilitation.
ETIOLOGICAL THEORIES
Psychodynamics
)he indi&idual remains ,xed in a lower le&el o" de&eloment$ with retarded e!o
and wea. suere!o. )he erson retains a hi!hly deendent nature$ with
characteristics o" oor imulse control$ low "rustration tolerance$ and low sel"-esteem.
Bioloical
?n:ymes$ !enes$ 'rain chemistry$ and hormones create and contri'ute to an
indi&idual@s resonse to alcohol. )he two tyes o" alcohol-related disorders are #1(
"amilial$ which is lar!ely inherited$ and #2( ac3uired. A childhood history o" attention-
de,cit disorder or conduct disorder also increases a child@s ris. o" 'ecomin! alcoholic.
Certain hysiolo!ical chan!es also may cause addiction to alcohol$ or alcoholism.
!amily Dynamics
+ne in 12A10 ersons has serious ro'lems "rom drin.in!. In a dys"unctional
"amily system$ alcohol may 'e &iewed as the rimary method o" relie&in! stress.
Children o" alcoholics are B times more li.ely to de&elo alcoholism than children o"
nonalcoholics. )he child has ne!ati&e role models and learns to resond to stress"ul
situations in li.e manner. )he use o" alcohol is cultural$ and many "actors in%uence
one@s decision to drin.$ how much$ and how o"ten. =enial o" the illness can 'e a
ma*or 'arrier to identi,cation and treatment o" alcoholism and alcohol a'use.
CLIENT ASSESSMENT DATA BASE
=ata deend on the duration6extent o" alcohol use$ concurrent use o" other
dru!s$ de!ree o" or!an in&ol&ement$ and resence o" other sychiatric conditions.
Ac"i#i"y$R%s"
=i7culty sleein!$ not "eelin! well rested
Ci&c'la"ion
;eriheral ulses wea.$ irre!ular$ or raid
9yertension common in early withdrawal sta!e 'ut may 'ecome la'ile6ro!ress to
hyotension
)achycardia common durin! acute withdrawal
Eo In"%&i"y
2eelin!s o" !uilt6shameC de"ensi&eness a'out drin.in!
=enial$ rationali:ation
>eorts o" multile stressorsC ro'lems with relationshis
Dultile stressors6losses #relationshis$ emloyment$ ,nancial(
/se o" su'stances to deal with li"e stressors$ 'oredom$ etc.
Elimina"ion
=iarrhea
Eowel sounds &aried #may re%ect !astric comlications Fe.!.$ !astric hemorrha!eG(
!ood$!l'id
Nausea6&omitin!$ "ood tolerance
Duscle wastin!$ dry/dull hair$ swollen sali&ary !lands$ in%amed 'uccal ca&ity$
caillary "ra!ility #malnutrition(
Henerali:ed tissue edema may 'e noted #rotein de,ciencies(
Hastric distensionC ascites$ li&er enlar!ement #seen in cirrhosis(
N%'&os%nso&y
4Internal sha.es5
9eadache$ di::iness$ 'lurred &ision$ 4'lac.outs5
;sychoatholo!y such as aranoid schi:ohrenia$ ma*or deression #may indicate
dual dia!nosis(
L%#%l o( Conscio'sn%ss$O&i%n"a"ion) Con"usion$ stuor$ hyeracti&ity$ distorted
thou!ht rocesses$ slurred/incoherent seech
Demory loss/con"a'ulation
A*%c"$Mood$B%ha#io&) Day 'e "ear"ul$ anxious$ easily startled$ inaroriate$ silly$
euhoric$ irrita'le$ hysically6&er'ally a'usi&e$ deressed$ and6or aranoid
Hall'cina"ions) Iisual$ tactile$ ol"actory$ and auditory #e.!.$ ic.in! items out o" air
or resondin! &er'ally to unseen erson6&oices(
Nysta!mus #associated with cranial ner&e alsy(
;uil constriction #may indicate CNS deression(
Arcus senilis$ a rin!li.e oacity o" the cornea #normal in a!in! oulations$ su!!ests
alcohol-related chan!es in youn!er clients(
2ine motor tremors o" "ace$ ton!ue$ and handsC sei:ure acti&ity #commonly !rand
mal(
Hait unsteady6ataxia #may 'e due to thiamine de,ciency or cere'ellar de!eneration
FJernic.e@s encehaloathyG(
Pain$Discom(o&"
Day reort constant uer a'dominal ain and tenderness radiatin! to the 'ac.
#ancreatic in%ammation(
R%s+i&a"ion
9istory o" to'acco use$ recurrent/chronic resiratory ro'lems
)achynea #hyeracti&e state o" alcohol withdrawal(
Cheyne-Sto.es resirations or resiratory deression
B&%a"h So'nds) =iminished/ad&entitious sounds #su!!ests ulmonary comlications
Fe.!.$ resiratory deression$ neumoniaG(
Sa(%"y
9istory o" recurrent accidents$ such as "alls$ "ractures$ lacerations$ 'urns$ 'lac.outs$
or automo'ile accidents
S,in) 2lushed "ace/alms o" hands$ scars$ ecchymotic areas$ ci!arette 'urns on
,n!ers$ sider ne&i #imaired ortal circulation(C ,ssures at corners o" mouth
#&itamin de,ciency(
2ractures$ healed or new #si!ns o" recent6recurrent trauma(
)emerature ele&ation #dehydration and symathetic stimulation(C
%ushin!6diahoresis #su!!ests resence o" in"ection(
Suicidal ideation6attemts #some research su!!ests alcoholic suicide attemts are
301 hi!her than national a&era!e "or !eneral oulation(
Social In"%&ac"ions
2re3uent sic. days o8 wor.6school$ ,!htin! with others$ arrests #disorderly conduct$
motor &ehicle &iolations F=/IsG(
=enial that alcohol inta.e has any si!ni,cant e8ect on the resent condition/situation
=ys"unctional "amily system o" ori!inC ro'lems in current relationshis
Dood chan!es a8ectin! interactions with others
T%achin$L%a&nin
9istory o" alcohol and/or other dru! use/a'use #includin! to'acco(
I!norance and/or denial o" addiction to alcohol or ina'ility to cut down or sto
drin.in! desite reeated e8orts
-ar!e amount o" alcohol consumed in last 2BAB8 hours$ re&ious eriods o"
a'stinence/withdrawal
;re&ious hositali:ations "or alcoholism/alcohol-related diseases #e.!.$ cirrhosis$
esoha!eal &arices(
2amily history o" alcoholism/su'stance use
DIAGNOSTIC STUDIES
Blood Alcohol$D&' L%#%ls) Alcohol le&el may/may not 'e se&erely ele&ated
deendin! on amount consumed and len!th o" time 'etween consumtion and
testin!. In addition to alcohol$ numerous controlled/illicit su'stances may 'e
identi,ed in a olydru! screen #e.!.$ amhetamine$ cocaine$ morhine$ ;ercodan$
Kuaalude(.
CBC) =ecreased #9'/9ct( may re%ect such ro'lems as iron-de,ciency anemia or
acute/chronic HI 'leedin!. Jhite 'lood cell count may 'e increased with in"ection
or decreased$ i" immunosuressed.
Gl'cos%) 9yer!lycemia/hyo!lycemia may 'e resent$ related to ancreatitis$
malnutrition$ or deletion o" li&er !lyco!en stores.
El%c"&oly"%s) 9yo.alemia and hyoma!nesemia are common.
Li#%& !'nc"ion T%s"s) C;L$ -=9$ AS)$ A-)$ and amylase may 'e ele&ated$ re%ectin!
li&er or ancreatic dama!e.
N'"&i"ional T%s"s) Al'umin is low and total rotein decreased. Iitamin de,ciencies
are usually resent$ re%ectin! malnutrition/mala'sortion.
O"h%& Sc&%%nin S"'di%s -%../ H%+a"i"is/ HIV/ TB0) =eendent on !eneral
condition$ indi&idual ris. "actors$ and care settin!.
U&inalysis) In"ection may 'e identi,edC .etones may 'e resent related to
'rea.down o" "atty acids in malnutrition #seudodia'etic condition(.
Ch%s" 1-Ray) Day re&eal ri!ht lower lo'e neumonia #malnutrition$ deressed
immune system$ asiration( or chronic lun! disorders associated with to'acco
use.
ECG) =ysrhythmias$ cardiomyoathies$ and/or ischemia may 'e resent owin! to
direct e8ect o" alcohol on the cardiac muscle and/or conduction system$ as well
as e8ects o" electrolyte im'alance.
Addic"ion S%#%&i"y Ind%2 -ASI0) An assessment tool that roduces a 4ro'lem
se&erity ro,le5 o" the client$ includin! chemical$ medical$ sycholo!ical$ le!al$
"amily/social$ and emloyment/suort asects$ indicatin! areas o" treatment
needs.
NURSING PRIORITIES
1. Daintain hysiolo!ical sta'ility durin! withdrawal hase.
2. ;romote client sa"ety.
3. ;ro&ide aroriate re"erral and "ollow-u.
B. ?ncoura!e/suort S+ in&ol&ement in Inter&ention #con"rontation( rocess.
DISCHARGE GOALS
1. 9omeostasis achie&ed.
2. Comlications re&ented/resol&ed.
3. So'riety 'ein! maintained on a day-to-day 'asis.
B. +n!oin! articiation in a reha'ilitation ro!ram/attendance at !rou theray
#e.!.$ Alcoholics Anonymous(.
0. ;lan in lace to meet needs a"ter dischar!e.
)his lan o" care is to 'e used in con*unction with C;< Su'stance
=eendence/A'use >eha'ilitation.
NURSING DIAGNOSIS BREATHING PATTERN/ &is, (o& in%*%c"i#%
Ris, !ac"o&s May Incl'd%) =irect e8ect o" alcohol toxicity on resiratory
center and6or sedati&e dru!s !i&en to decrease
alcohol withdrawal symtoms
)racheo'ronchial o'struction
;resence o" chronic resiratory ro'lems$
in%ammatory rocess
=ecreased ener!y6"ati!ue
Possi3ly E#id%nc%d 3y) FNot alica'leC resence o" si!ns and symtoms
esta'lishes an actual dia!nosis.G
D%si&%d O'"com%s E#al'a"ion C&i"%&ia4 Daintain e8ecti&e resiratory attern with
Cli%n" 5ill) resiratory rate within normal ran!e$ lun!s clear$
"ree o" cyanosis and other si!ns6symtoms o"
hyoxia.
ACTIONS$INTERVENTIONS RATIONALE
Ind%+%nd%n"
Donitor resiratory rate/deth and attern as 2re3uent assessment is imortant 'ecause
toxicity
indicated. Note eriods o" anea$ Cheyne-Sto.es le&els may chan!e raidly. 9yer&entilation is
resirations. common durin! acute withdrawal hase.
Lussmaul resirations are sometimes resent
'ecause o" acidotic state associated with
&omitin!
and malnutrition. 9owe&er$ mar.ed resiratory
deression can occur 'ecause o" CNS deressant
e8ects o" alcohol. )his may 'e comounded 'y
dru!s used to control alcohol withdrawal
symtoms.
?le&ate head o" 'ed. =ecreases ossi'ility o" asirationC lowers
diahra!m$ enhancin! lun! in%ation.
?ncoura!e cou!h/dee 'reathin! exercises and 2acilitates lun! exansion and mo'ili:ation o"
"re3uent osition chan!es. secretions to reduce ris. o"
atelectasis/neumonia.
Auscultate 'reath sounds. Note resence o" Client is at ris. "or atelectasis related to
ad&entitious sounds #e.!.$ rhonchi$ whee:es(. hyo&entilation and neumonia. >i!ht lower lo'e
neumonia is common in alcohol-de'ilitated
clients and is o"ten due to asiration. Chronic
lun!
diseases are also common #e.!.$ emhysema$
chronic 'ronchitis(.
9a&e suction e3uiment$ airway ad*uncts a&aila'le. Sedati&e e8ects o" alcohol/dru!s
otentiate ris. o"
asiration$ relaxation o" oroharyn!eal muscles$
and resiratory deression$ re3uirin! inter&ention
to re&ent resiratory arrest.
Colla3o&a"i#%
Administer sulemental oxy!en i" necessary. 9yoxia may occur with CNS/resiratory
deression.
>e&iew chest x-rays$ ulse oximetry as Donitors resence o" secondary comlications
a&aila'le/indicated. such as atelectasis/neumoniaC e&aluates
e8ecti&eness o" resiratory e8ort$ identi,es
theray needs.
NURSING DIAGNOSIS CARDIAC OUTPUT/ &is, (o& d%c&%as%d
Ris, !ac"o&s May Incl'd%) =irect e8ect o" alcohol on the heart muscle
Altered systemic &ascular resistance
?lectrical alterations in rate$ rhythm$ conduction
Possi3ly E#id%nc%d 3y) FNot alica'leC resence o" si!ns and symtoms
esta'lishes an actual dia!nosis.G
D%si&%d O'"com%s$E#al'a"ion C&i"%&ia4 =islay &ital si!ns within client@s normal ran!eC
Cli%n" 5ill) a'sence o"6reduced "re3uency o" dysrhythmias.
=emonstrate an increase in acti&ity tolerance.
Ier'ali:e understandin! o" the e8ect o" alcohol
on the heart.
ACTION$INTERVENTIONS RATIONALE
Ind%+%nd%n"
Donitor &ital si!ns "re3uently durin! acute 9yertension "re3uently occurs in acute
withdrawal. withdrawal hase. ?xtreme hyerexcita'ility
accomanied 'y catecholamine release and
increased eriheral &ascular resistance raises E;
#and heart rate(. 9owe&er$ E; may 'ecome
la'ile/ro!ress to hyotension. No"%) Client may
ha&e underlyin! cardio&ascular disease that is
comounded 'y su'stance withdrawal.
Donitor cardiac rate/rhythm. =ocument -on!-term alcohol a'use may result in
irre!ularities/dysrhythmias. cardiomyoathy/con!esti&e heart "ailure.
)achycardia is common owin! to symathetic
resonse to increased circulatin! catecholamines.
Irre!ularities/dysrhythmias may de&elo with
electrolyte shi"ts/im'alance. All o" these may
ha&e
an ad&erse e8ect on cardiac "unction/outut.
Donitor 'ody temerature. ?le&ation may occur 'ecause o" symathetic
stimulation$ dehydration$ and/or in"ections$
causin! &asodilation and comromisin! &enous
return/cardiac outut.
Donitor inta.e/outut. Note 2B-hour %uid 'alance.;reexistin! dehydration$ &omitin!$ "e&er$ and
diahoresis may result in decreased circulatin!
&olume$ which can comromise cardio&ascular
"unction. No"%) 9ydration is di7cult to assess in
the alcoholic 'ecause the usual indicators are not
relia'le$ and o&erhydration is a ris. in the
resence o" comromised cardiac "unction.
Ee reared "or/assist in cardioulmonary Causes o" death durin! acute withdrawal sta!es
resuscitation. include cardiac dysrhythmias$ resiratory
deression/arrest$ o&ersedation$ excessi&e
sychomotor acti&ity$ se&ere dehydration or
o&erhydration$ and massi&e in"ections. Dortality
"or unreco!ni:ed/untreated delirium tremens
#=)s( may 'e as hi!h as 101A201.
Colla3o&a"i#%
Donitor la'oratory studies #e.!.$ serum ?lectrolyte im'alance #e.!.$ otassium/
electrolyte le&els(. ma!nesium( otentiates ris. o" cardiac
dysrhythmias and CNS excita'ility.
Administer medications as indicated< e.!.$ clonidine Althou!h the use o" 'en:odia:eines is
o"ten
#Catares($ atenolol #)enormin(C su7cient to control hyertension durin! initial
withdrawal "rom alcohol$ some clients may
re3uire
more seci,c theray. No"%) Atenolol and other
'eta-adrener!ic 'loc.ers may seed u the
withdrawal rocess and eliminate tremors$ as well
as lower heart rate$ E;$ and 'ody temerature$
reducin! the need "or 'en:odia:eines.
;otassium. Corrects de,cits that can result in li"e-threatenin!
dysrhythmias.
NURSING DIAGNOSIS IN6UR7/ &is, (o& -s+%ci(y0
Ris, !ac"o&s May Incl'd%) Cessation o" alcohol inta.e with &aried autonomic
ner&ous system resonses to the suddenly
altered state
In&oluntary clonic6tonic muscle acti&ity
#con&ulsions(
?3uili'rium6'alancin! di7culties$ reduced muscle
and hand6eye coordination
Possi3ly E#id%nc%d 3y) FNot alica'leC resence o" si!ns and symtoms
esta'lishes an actual dia!nosis.G
D%si&%d O'"com%s$E#al'a"ion C&i"%&ia4 =emonstrate a'sence o" untoward e8ects o"
Cli%n" 5ill) withdrawal.
?xerience no hysical in*ury.
ACTIONS$INTERVENTIONS RATIONALE
Ind%+%nd%n"
Identi"y sta!e o" alcohol withdrawal$ symtoms< ;romt reco!nition and inter&ention may halt
Sta!e I is associated with si!ns/symtoms o" ro!ression o" symtoms and enhance
hyeracti&ity #e.!.$ tremors$ sleelessness$ nausea/ reco&ery/imro&e ro!nosis. In addition$
&omitin!$ diahoresis$ tachycardia$ hyertension(. recurrence/ro!ression o" symtoms
indicates
Sta!e II is mani"ested 'y increased hyeracti&ity need "or chan!es in dru! theray/more intense
lus hallucinations and/or sei:ure acti&ity. treatment.
Sta!e III symtoms include delirium tremens #=)s(
and extreme autonomic hyeracti&ity with
ro"ound con"usion$ anxiety$ insomnia$ "e&er.
Donitor/document sei:ure acti&ity. Daintain atent Hrand mal sei:ures are most common and
may 'e
airway. ;ro&ide en&ironmental sa"ety #e.!.$ added related to decreased ma!nesium le&els$
side rails$ 'ed in low osition(. hyo!lycemia$ ele&ated 'lood alcohol$ history o"
head trauma/reexistin! sei:ure disorder. No"%)
In a'sence o" re&ious history o" other atholo!y
causin! sei:ure acti&ity$ sei:ures usually sto
sontaneously$ re3uirin! only symtomatic
treatment.
Chec. dee-tendon re%exes. Assess !ait$ i" ossi'le. >e%exes may 'e deressed$ a'sent$ or
hyeracti&e.
;eriheral neuroathies are common$ esecially
in
malnourished clients. Ataxia #!ait distur'ance( is
associated with Jernic.e@s syndrome #thiamine
de,ciency( and cere'ellar de!eneration.
Assist with am'ulation and sel"-care ;re&ents "alls with resultant in*ury.
acti&ities as needed.
;ro&ide "or en&ironmental sa"ety when indicated. Day 'e re3uired when e3uili'rium$ hand/
#>e"er to N=< Sensory/;ercetual alteration eye coordination ro'lems exist.
Fseci"yG.(
Colla3o&a"i#%
Administer II/;+ %uids with caution$ as indicated. Cautious relacement corrects dehydration and
romotes renal clearance o" toxins while reducin! ris. o" o&erhydration.
Administer medications as indicated<
Een:odia:eines such as< chlordia:eoxide
Commonly used to control neuronal
hyeracti&ity
#-i'rium($ dia:eam #Ialium($ clona:eam
that occurs as alcohol is detoxi,ed. II/;+
#Llonoin(C
administration is the route re"erred$ as
intramuscular a'sortion is unredicta'le.
Duscle-relaxant 3ualities are articularly
hel"ul
to the client in controllin! the 4sha.es$5
trem'lin!$
and ataxic 3uality o" mo&ements. Clients may
initially re3uire lar!e doses to achie&e desired
e8ect$ and then the dru!#s( may 'e taered
and
discontinued$ usually within 9M hours. No"%)
)hese a!ents must 'e used cautiously in
clients
with heatic disease$ as the a!ents are
meta'oli:ed
'y the li&er.
+xa:eam #Serax(C
Althou!h less dramatic "or control o"
withdrawal
symtoms$ this may 'e the dru! o" choice in
a
client with li&er disease 'ecause o" its shorter
hal"-li"e.
;heno'ar'italC
/se"ul in suressin! withdrawal symtoms
and
is an e8ecti&e anticon&ulsant. /se must 'e
monitored to re&ent exacer'ation o"
resiratory
deression.
Da!nesium sul"ateC
>educes tremors and sei:ure acti&ity 'y
decreasin! neuromuscular excita'ility.
)hiamine.
)hiamine de,ciency #common in alcohol
a'use(
may lead to neuritis$ Jernic.e@s syndrome$
and/or
Lorsa.o8@s sychosis.
N'&sin Dianosis S%nso&y$P%&c%+"'al al"%&a"ions -s+%ci(y0
May B% R%la"%d "o) Chemical alteration< ?xo!enous #e.!.$ alcohol
consumtion6sudden cessation( and endo!enous
#e.!.$ electrolyte im'alance$ ele&ated ammonia
and E/N(
Slee deri&ation
;sycholo!ical stress #anxiety6"ear(
Possi3ly E#id%nc%d 3y) =isorientation in time$ lace$ erson$ or situation
Chan!es in usual resonse to stimuliC
exa!!erated emotional resonses$ chan!e in
'eha&ior
Ei:arre thin.in!
>estlessness$ irrita'ility$ arehension
D%si&%d O'"com%s$E#al'a"ion C&i"%&ia4 >e!ain6maintain usual le&el o" co!nition.
Cli%n" 5ill) >eort a'sence o" auditory6&isual
hallucinations.
Identi"y external "actors that a8ect sensory-
ercetual a'ilities.
ACTIONS$INTERVENTIONS RATIONALE
Ind%+%nd%n"
Assess le&el o" consciousness$ a'ility to sea.$ Seech may 'e !ar'led$ con"used$ or slurred.
resonse to stimuli/commands. >esonse to commands may re&eal ina'ility to
concentrate$ imaired *ud!ment$ or muscle
coordination de,cits.
+'ser&e 'eha&ioral resonses #e.!.$ hyeracti&ity$ 9yeracti&ity related to CNS distur'ances
may
disorientation$ con"usion$ sleelessness$ irrita'ility(. escalate raidly. Sleelessness is common
'ecause
o" loss o" sedati&e e8ect !ained "rom alcohol
usually consumed rior to 'edtime. Slee
deri&ation may a!!ra&ate disorientation/
con"usion. ;ro!ression o" symtoms may indicate
imendin! hallucinations #Sta!e II( or =)s
#Sta!e III(.
Note onset o" hallucinations. =ocument as Auditory hallucinations are reorted to 'e more
auditory$ &isual$ and/or tactile. "ri!htenin!/threatenin! to client. Iisual
hallucinations occur more at ni!ht and o"ten
include insects$ animals$ or "aces o"
"riends/enemies. Clients are "re3uently o'ser&ed
ic.in! the airC yellin! may occur i" client is
callin!
"or hel "rom ercei&ed threat #usually seen in
Sta!e III(.
;ro&ide 3uiet en&ironment. Sea. in calm$ >educes external stimuli durin! hyeracti&e
sta!e.
3uiet &oice. >e!ulate li!htin! as indicated. Client may 'ecome more delirious when
)urn o8 radio/)I durin! slee. surroundin!s cannot 'e seen$ althou!h some
resond 'etter to 3uiet$ dar.ened room.
;ro&ide care 'y same ersonnel whene&er ossi'le. ;romotes reco!nition o" care!i&ers and a
sense o"
consistency that may reduce "ear.
>eorient "re3uently to erson$ lace$ time$ and Day reduce con"usion/misinterretation o"
surroundin! en&ironment as indicated. external stimuli.
A&oid 'edside discussion a'out client or toics Client may hear and misinterret con&ersation$
unrelated to the client that do not include the client. which can a!!ra&ate hallucinations.
;ro&ide en&ironment sa"ety #e.!.$ lace 'ed in low Client may ha&e distorted sense o" reality$
'e
osition$ lea&e doors in "ull oen or closed osition$ "ear"ul$ or 'e suicidal$ re3uirin! rotection
"rom
o'ser&e "re3uently$ lace call li!ht/'ell within reach$ sel"-harm.
remo&e articles that can harm client(.
Colla3o&a"i#%
;ro&ide seclusion$ restraints as necessary. Clients with excessi&e sychomotor acti&ity$
se&ere hallucinations$ &iolent 'eha&ior$ and/or
suicidal !estures may resond 'etter to
seclusion.
>estraints are usually ine8ecti&e and add to
client@s a!itation 'ut occasionally may 'e
re3uired
"or short eriods to re&ent sel"-harm.
Donitor la'oratory studies #e.!.$ electrolytes$ Chan!es in or!an "unction may reciitate or
ma!nesium le&els$ li&er "unction studies$ ammonia$ otentiate sensory-ercetual de,cits.
?lectrolyte
E/N$ !lucose$ AEHs(. im'alance is common. -i&er "unction is o"ten
imaired in the chronic alcoholic$ and ammonia
intoxication can occur i" the li&er is una'le to
con&ert ammonia to urea. Letoacidosis is
sometimes resent without !lycosuriaC howe&er$
hyer!lycemia or hyo!lycemia may occur$
su!!estin! ancreatitis or imaired
!luconeo!enesis in the li&er. 9yoxemia and
hyercar'ia are common mani"estations in
chronic
alcoholics who are also hea&y smo.ers.
Administer medications as indicated$ e.!.<
Antianxiety a!ents #>e"er to N=< Anxiety Fse&ere/ >educes hyeracti&ity$ romotin! relaxation/
anicG/2ear(C slee. =ru!s that ha&e little e8ect on dreamin!
may 'e desired to allow dream reco&ery #>?D
re'ound( to occur$ which has 'een suressed 'y
alcohol use.
)hiamineC &itamins C N E comlex$ multi&itaminsC Iitamins may 'e deleted 'ecause o"
insu7cient
Stressta's. inta.e and mala'sortion. Iitamin de,ciency
#esecially thiamine( is associated with ataxia$
loss
o" eye mo&ement and uillary resonse$
alitations$ ostural hyotension$ and
exertional dysnea.
NURSING DIAGNOSIS NUTRITION) al"%&%d/ l%ss "han 3ody
&%8'i&%m%n"s
May B% R%la"%d "o) ;oor dietary inta.e #relaced 'y alcohol
consumtion(
?8ects o" alcohol on or!ans in&ol&ed in di!estion
#e.!.$ stomach$ ancreas$ li&er(C inter"erence with
a'sortion and meta'olism o" nutrients and
amino acidsC and increased loss o" &itamins in the
urine
Possi3ly E#id%nc%d 3y) >eorts o" inade3uate "ood inta.e$ altered taste
sensation$ lac. o" interest in "ood$ a'dominal ain
Eody wei!ht 201 or more under ideal
;ale con*uncti&a and mucous mem'ranesC sore$
in%amed 'uccal ca&ity6cheilosis
;oor muscle tone$ s.in tur!or
9yeracti&e 'owel sounds$ diarrhea
)hird sacin! o" circulatin! 'lood &olume #e.!.$
edema o" extremities$ ascites(
;resence o" neuroathies
-a'oratory e&idence o" decreased red cell count
#anemias($ &itamin de,ciencies$ reduced serum
al'umin le&el$ or electrolyte im'alance
D%si&%d O'"com%s$E#al'a"ion C&i"%&ia4 Ier'ali:e understandin! o" e8ects o" alcohol
Cli%n" 5ill) in!estion and reduced dietary inta.e on
nutritional status and !eneral well-'ein!.
=emonstrate 'eha&iors$ li"estyle chan!es to
re!ain6maintain aroriate wei!ht.
Daintain sta'le wei!ht or ro!ressi&e wei!ht !ain
toward !oal with normali:ation o" la'oratory
&alues and a'sence o" si!ns o" malnutrition.
ACTIONS$INTERVENTIONS RATIONALE
Ind%+%nd%n"
?&aluate resence/3uality o" 'owel sounds. Note Irritation o" !astric mucosa is common and may
a'dominal distension$ tenderness. result in ei!astric ain$ nausea$ and hyeracti&e
'owel sounds. Dore serious e8ects o" HI system
may occur secondary to cirrhosis and heatitis.
Note resence o" nausea/&omitin!$ diarrhea. Nausea and &omitin! are o"ten amon! the ,rst
si!ns o" alcohol withdrawal and may inter"ere
with achie&in! ade3uate nutritional inta.e.
Assess a'ility to "eed sel". )remors$ altered mentation$ or hallucinations may
inter"ere with in!estion o" nutrients and indicate
need "or assistance.
;ro&ide small$ easily di!ested$ "re3uent meals/ Day limit !astric distress and enhance inta.e and
snac.s$ and ad&ance as tolerated. toleration o" nutrients. As aetite and a'ility to
tolerate "ood increase$ diet should 'e ad*usted to
ro&ide the necessary calories and nutrition "or
cellular reair and restoration o" ener!y.
Colla3o&a"i#%
>e&iew la'oratory tests #e.!.$ AS)$ A-)$ -=9$ Assesses li&er "unction$ ade3uacy o" nutritional
serum al'umin/real'umin$ trans"errin(. inta.eC in%uences choice o" diet and need "or/
e8ecti&eness o" sulemental theray.
>e"er to dietitian/nutritional suort team. /se"ul in esta'lishin! and coordinatin! indi&idual
nutritional re!imen.
;ro&ide diet hi!h in rotein with at least hal" o" Sta'ili:es 'lood su!ar$ there'y reducin! ris. o"
calories o'tained "rom car'ohydrates. hyo!lycemia$ while ro&idin! "or ener!y needs
and cellular re!eneration.
Administer medications as indicated$ e.!.<
Antacids$ antiemetics$ antidiarrhealC >educes !astric irritation and limits e8ects o"
symathetic stimulation.
Iitamins$ >elace losses. No"%) All clients should recei&e
thiamine. thiamine and &itamins$ 'ecause de,ciencies
#clinical or su'clinical( exist in most$ i" not all$
clients with chronic alcoholism.
Institute/maintain N;+ status as indicated. ;ro&ides !astrointestinal rest to reduce harm"ul
e8ects o" !astric/ancreatic stimulation in
resence o" HI 'leedin! or excessi&e &omitin!.
NURSING DIAGNOSIS AN1IET7 9s%#%&%$+anic:$!EAR
May B% R%la"%d "o) Cessation o" alcohol inta.e6hysiolo!ical
withdrawal
Situational crisis #hositali:ation(
)hreat to sel"-concet$ ercei&ed threat o" death
Possi3ly E#id%nc%d 3y) 2eelin!s o" inade3uacy$ shame$ sel"-dis!ust$ and
remorse
Increased hellessness6hoelessness with loss o"
control o" own li"e
Increased tension$ arehension
2ear o" unseci,ed conse3uencesC identi"yin!
o'*ect o" "ear
D%si&%d O'"com%s$E#al'a"ion C&i"%&ia4 Ier'ali:e reduction o" "ear and anxiety to an
Cli%n" 5ill) acceta'le and mana!ea'le le&el.
?xress sense o" re!ainin! some control o"
situation6li"e.
=emonstrate ro'lem-sol&in! s.ills and use
resources e8ecti&ely.
ACTIONS$INTERVENTIONS RATIONALE
Ind%+%nd%n"
Identi"y cause o" anxiety$ in&ol&in! client in the Clients in acute hase o" withdrawal may 'e
rocess. ?xlain that alcohol withdrawal increases una'le to identi"y and/or accet what is
anxiety and uneasiness. >eassess le&el o" anxiety haenin!. Anxiety may 'e hysiolo!ically
or
on an on!oin! 'asis. en&ironmentally caused. Continued alcohol
toxicity will 'e mani"ested 'y increased anxiety
and a!itation as e8ects o" medications wear o8.
=e&elo a trustin! relationshi throu!h "re3uent ;ro&ides client with a sense o" humanness$
helin!
contact$ 'ein! honest and non*ud!mental. ;ro*ect to decrease aranoia and distrust. Client
will 'e
an accetin! attitude a'out alcoholism. a'le to detect 'iased or condescendin! attitude
o"
care!i&ers.
In"orm client what you lan to do and why. Include ?nhances sense o" trust$ and exlanation
may
client in lannin! rocess and ro&ide choices increase cooeration/reduce anxiety. ;ro&ides
when ossi'le. sense o" control o&er sel" in circumstances where
loss o" control is a si!ni,cant "actor. No"%)
2eelin!s
o" sel"-worth are intensi,ed when one is treated
as
a worthwhile erson.
>eorient "re3uently. #>e"er to N=< Sensory/ Client may exerience eriods o" con"usion$
;ercetual alterations Fseci"yG.( resultin! in increased anxiety.
Colla3o&a"i#%
Administer medications as indicated$ e.!.<
Een:odia:eines< chlordia:eoxide #-i'rium($ Antianxiety a!ents are !i&en durin! acute
dia:eam #Ialium(C withdrawal to hel client relax$ 'e less
hyeracti&e$ and "eel more in control.
Ear'iturates< heno'ar'ital$ or ossi'ly )hese dru!s suress alcohol withdrawal 'ut
seco'ar'ital #Seconal($ ento'ar'ital #Nem'utal(. need to 'e used with caution as they are
resiratory deressants and >?D slee cycle
inhi'itors.
Arran!e Inter&ention #con"rontation( in controlled )he rocess o" Inter&ention$ wherein S+s/"amily
!rou settin!. mem'ers$ suorted 'y sta8$ ro&ide in"ormation
a'out how the client@s drin.in! and 'eha&ior
ha&e
a8ected each one o" them$ hels the client to
ac.nowled!e that drin.in! is a ro'lem and has
resulted in current situational crisis.
;ro&ide consultation "or re"erral to reco&ery/ Client is more li.ely to contract "or treatment
reha'ilitation ro!ram "or on!oin! treatment as while still hurtin! and exeriencin! "ear and
soon as medically sta'le #e.!.$ oriented to reality(. anxiety "rom last drin.in! eisode.
Doti&ation
decreases as well-'ein! increases and erson
a!ain
"eels a'le to control the ro'lem. =irect contact
with a&aila'le treatment resources ro&ides
realistic icture o" hel. =ecreases time "or client
to
4thin. a'out it5/chan!e mind or restructure and
stren!then denial systems.