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Alcohol, a central nervous system depressant, 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.
It is rapidly absorbed from the stomach and small intestine into the
bloodstream. On the other hand,alcohol withdrawal refers to symptoms
that may occur when a person who has been drinking too much alcohol
every day suddenly stops drinking alcohol.
Alcohol withdrawal symptoms usually occur within 8 hours after the last
drink, but can occur days later. Symptoms usually peak by 24 – 72 hours,
but may persist for weeks. Common symptoms include: anxiety or
nervousness, depression, fatigue, irritability, jumpiness or shakiness,
mood swings, nightmares and not thinking clearly.

Nursing Care Plans
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

TB): Depend  on general condition. Ketoacidosis may be present with/without metabolic acidosis. Encourage/support SO involvement in “Intervention” (confrontation) process. depressed immune system. and employment/support aspects. Urinalysis: Infection may be identified..  related to breakdown of fatty acids in malnutrition (pseudodiabetic condition).g. Complications prevented/resolved. 2. and amylase may be  elevated. HIV. Discharge goals 1. . and/or ischemia may be  present because of direct effect of alcohol on the cardiac muscle and/or conduction system. cardiomyopathies. Provide information about condition/prognosis and treatment needs. family/social. ketones may be present. and care setting. 2. reflecting liver or pancreatic damage. Nutritional tests: Albumin is low and total protein may be  decreased. legal. ECG: Dysrhythmias. ALT. AST. Electrolytes: Hypokalemia and hypomagnesemia are common. Nursing priorities 1. 4. 3. hepatitis. Chest x-ray: May reveal right lower lobe pneumonia  (malnutrition. psychological. reflecting malnutrition/malabsorption. indicating areas of treatment needs. Provide appropriate referral and follow-up. Liver function tests: LDH. 5. glycogen stores. Maintain physiological stability during acute withdrawal phase. including chemical. Homeostasis achieved. aspiration) or chronic lung disorders associated with tobacco use. Vitamin deficiencies are usually present. Addiction Severity Index (ASI): An assessment tool that  produces a “problem severity profile” of the patient. medical. individual risk factors. Other screening studies (e. as well as effects of electrolyte imbalance. Promote patient safety.

physiologically or environmentally Reassess level of anxiety on an caused.g. may be unable to identify and accept Explain that alcohol withdrawal what is happening. 1. identifies object of fear Desired Outcomes  Verbalize reduction of fear and anxiety to an acceptable and  manageable level. Sobriety being maintained on a day-to-day basis. apprehension Fear of unspecified consequences.3. 5. Alcoholics Anonymous. Demonstrate problem-solving skills and use resources effectively. e. Express sense of regaining some control of situation/life. and remorse Increased helplessness/hopelessness with loss of control of own life Increased tension. Condition.  Nursing Interventions Rationale Determine cause of anxiety. Plan in place to meet needs after discharge. Anxiety/Fear Nursing Diagnosis  Anxiety/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. prognosis. self-disgust. and therapeutic regimen understood. Continued alcohol toxicity ongoing basis. Ongoing participation in rehabilitation program/attending group therapy. Person in acute phase of withdrawal involving patient in the process. Anxiety may be increases anxiety and uneasiness. 4. shame. 6. will be manifested by increased anxiety and agitation as effects of ..

a significant factor. withdrawal but need to be used with pentobarbital (Nembutal). caution because they are respiratory . Include patient in Provides sense of control over self in planning process and provide choices circumstance where loss of control is when possible. diazepam (Valium). or These drugs suppress alcohol possibly secobarbital (Seconal). Barbiturates: phenobarbital. To prevent suicidal attempts. Monitor patient for signs of depression. Patient will be an accepting attitude about able to detect biased or alcoholism. Enhances sense of trust. Reduces stress. and explanation may increase Inform patient about what you plan cooperation and reduce anxiety. relax. Patient may experience periods of Reorient frequently. Administer medications as indicated: Antianxiety agents are given during Benzodiazepines: chlordiazepoxide acute withdrawal to help patient (Librium). helping to decrease honest and nonjudgmental. hallucinations and may try to harm himself and others. minimizing noise. Develop a trusting relationship Provides patient with a sense of through frequent contact being humanness. be less hyperactive. condescending attitude of caregivers. confusion. He may also experience Orient the patient to reality. Project paranoia and distrust. Maintain a calm environment. resulting in increased anxiety. and feel more in control. to do and why.Nursing Interventions Rationale medication wear off. Note: Feelings of self-worth are intensified when one is treated as a worthwhile person.

” change mind or restructure and strengthen denial systems. Motivation decreases as well-being increases and person again feels able to control the problem.Nursing Interventions Rationale depressants and REM sleep cycle inhibitors. Process wherein SO and family members. last drinking episode. supported by staff. Sensory-Perceptual Alterations Nursing Diagnosis  Sensory-Perceptual Alterations May be related to . provide information about how patient’s Arrange “Intervention” drinking and behavior have affected (confrontation) in controlled setting each one of them. Decreases time for patient to “think about it. Patient is more likely to contract for treatment while still hurting and experiencing fear and anxiety from Provide consultation for referral to detoxification and crisis center for ongoing treatment program as soon as medically stable (oriented to reality). helps patient acknowledge that drinking is a problem and has resulted in current situational crisis. 2. Direct contact with available treatment resources provides realistic picture of help.

confused. Sleep deprivation may aggravate disorientation and confusion.g. sleeplessness. apprehension. commands. irritability. Hyperactivity related to CNS disturbances may escalate rapidly. exaggerated emotional  responses. Identify external factors that affect sensory-perceptual abilities. change in behavior Bizarre thinking Listlessness.. or situation Changes in usual response to stimuli. Report absence of/reduced hallucinations. elevated ammonia and BUN) Sleep deprivation Psychological stress (anxiety/fear) Possibly evidenced by   Disorientation to time. irritability. of sedative effect gained from alcohol usually consumed before bedtime. electrolyte imbalance. activity associated with  visual/auditory hallucinations Fear/anxiety  Desired Outcomes    Regain/maintain usual level of consciousness.g. impaired judgment. . Progression of symptoms may indicate impending hallucinations (stage II) or DTs (stage III).. Response to commands may to speak. disorientation. alcohol consumption/sudden cessation) and endogenous (e. Nursing Interventions Rationale Speech may be garbled. confusion. ability slurred. or Assess level of consciousness. response to stimuli and reveal inability to concentrate. or muscle coordination deficits. place.   Chemical alteration: Exogenous (e. person. Sleeplessness is common due to loss Observe behavioral responses such as hyperactivity.

Avoid restraining the patient unless necessary. and often include insects. prevent and time. To protect patient and others. place. tactile. which may reduce fear. and surrounding environment limit misinterpretation of external as indicated. Auditory hallucinations are reported to be more frightening and threatening to patient. Promotes recognition of caregivers and a sense of consistency. or Document as auditory. and faces of friends and enemies. Reorient frequently to person. Patients are frequently observed “picking the air. Visual hallucinations occur more at night Note onset of hallucinations. and hallucinations. Avoid bedside discussion about Patient may hear and misinterpret . May reduce confusion. To reduce the incidence of delusions minimizing noise and shadows.” Yelling may occur if patient is calling for help from perceived threat (usually seen in stage III AWS). Patient may calm. Reduces external stimuli during Provide quiet environment. and may whenever possible.Nursing Interventions Rationale Provide calm environment. Provide care by same personnel whenever possible. darkened room. Speak in hyperactive stage. attempts of suicide. Turn off radio and TV surroundings cannot be seen. stimuli. quiet voice. provide a reorienting influence. visual. some respond better to quiet. animals. Monitor patient for signs of To avoid harming himself and depression. Encourage SO to stay with patient May have a calming effect. Regulate lighting become more delirious when as indicated. but during sleep.

imbalance is common. violent behavior. perceptual deficits. magnesium levels.Nursing Interventions patient or topics unrelated to the patient that do not include the patient. Ketoacidosis is sometimes present without glycosuria. leave doors in full open or closed position. ABGs. He may experience hallucinations Orient the patient to reality. Provide environmental safety (place bed in low position. requiring protection from self. and ammonia intoxication can occur if the liver is unable to convert ammonia to urea. Restraints are usually ineffective and add to patient’s agitation. which can aggravate hallucinations. BUN. necessary. but occasionally may be required to prevent self-harm. observe frequently. hyperglycemia or hypoglycemia may occur. Patients with excessive psychomotor activity. place call light or bell within reach. Monitor laboratory studies: Changes in organ function may electrolytes. and suicidal gestures may Provide seclusion. suggesting pancreatitis or impaired gluconeogenesis in the . severe hallucinations. however. liver precipitate or potentiate sensory- function studies. Liver function is often impaired in the chronic alcoholic. Rationale conversation. Electrolyte glucose. remove articles that Patient may have distorted sense of reality or be fearful or suicidal. can harm patient). ammonia. and may try to harm himself and others. restraints as respond better to seclusion.

reduced muscle and hand/eye  coordination Desired Outcomes   Demonstrate absence of untoward effects of withdrawal. Hypoxemia and hypercarbia are common manifestations in chronic alcoholics who are also heavy smokers. which has previously been suppressed by alcohol use. Experience no physical injury. promoting relaxation and sleep.Nursing Interventions Rationale liver. Drugs that have Administer medications as indicated: Antianxiety agents as indicated little effect on dreaming may be desired to allow dream recovery (REM rebound) to occur. Nursing Interventions Identify stage of AWS (alcohol Rationale Prompt recognition and intervention . 3. Risk for Injury Nursing Diagnosis  Risk for Injury 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. Reduces hyperactivity.

Peripheral neuropathies are common. Assist with ambulation and self-care Prevents falls with resultant injury. hypertension). disturbance) is associated with Wernicke’s syndrome (thiamine deficiency) and cerebellar degeneration.. stage I is associated with signs and symptoms of hyperactivity (tremors. absent. Monitor and document seizure activity. insomnia. Maintain patent airway. or history of head trauma and preexisting seizure disorder. Note: In absence of history and other pathology causing seizures. diaphoresis. hypoglycemia. fever. Stage II is manifested by increased hyperactivity plus hallucinations and seizure activity. Provide environmental safety (padded side rails. elevated blood alcohol. or hyperactive. especially Check deep-tendon reflexes. nausea and vomiting. if possible. Reflexes may be depressed. In addition. Note: Antiepileptic drugs are not indicated for alcohol withdrawal seizures. Stage III symptoms include DTs and extreme autonomic hyperactivity may halt progression of symptoms and enhance recovery or improve prognosis. Ataxia (gait gait. with profound confusion. . bed in low position). Assess in malnourished patient. they usually stop spontaneously. sleeplessness. requiring only symptomatic treatment. recurrence or progression of symptoms indicates need for changes in drug therapy and more intense treatment to prevent death. tachycardia. Grand mal seizures are most common and may be related to decreased magnesium levels. i.e.Nursing Interventions Rationale withdrawal syndrome). anxiety.

hand and eye coordination problems exist. Muscle- chlordiazepoxide (Librium). and ataxic (Tranxene). and then drugs may be tapered and discontinued. although Serax has a shorter half-life. Provide for environmental safety when indicated. clonazepam (Klonopin). Studies have also shown that these drugs can prevent progression to more severe states of withdrawal. IV and PO administration is preferred route because IM Benzodiazepines (BZDs): absorption is unpredictable. BZDs for patients experiencing hallucinations. May be used in conjunction with Haloperidol (Haldol). quality of movements.” trembling. clorazepate shakes.Nursing Interventions Rationale activities as needed. May be required when equilibrium. diazepam relaxant qualities are particularly (Valium). usually within 96 hr. Note: These agents are used cautiously in patients with known hepatic disease because they are metabolized by the liver. Thiamine. Patient may initially require large doses to achieve desired effect. Administer medications as indicated: BZDs are commonly used to control neuronal hyperactivity because of their minimal respiratory and cardiac depression and anticonvulsant properties. Thiamine deficiency (common in . helpful to patient in controlling “the oxazepam (Serax).

by decreasing neuromuscular excitability. absence  of/reduced frequency of dysrhythmias. and Korsakoff’s psychosis. conduction Desired Outcomes  Display vital signs within patient’s normal range. 4. BP may become labile and progress to hypotension. Wernecke’s syndrome. accompanied by catecholamine release and increased Monitor vital signs frequently during acute withdrawal. Reduces tremors and seizure activity Magnesium sulfate. Note:Patient may have underlying cardiovascular disease. rhythm. raises BP and heart rate. . however.Nursing Interventions Rationale alcohol abuse) may lead to neuritis. Demonstrate an increase in activity tolerance. Extreme hyperexcitability. peripheral vascular resistance. Nursing Interventions Rationale Hypertension frequently occurs in acute withdrawal phase. which is compounded by alcohol withdrawal. Risk for Decreased Cardiac Output Nursing Diagnosis  Risk for Decreased Cardiac Output Risk factors may include    Direct effect of alcohol on the heart muscle Altered systemic vascular resistance Electrical alterations in rate.

oversedation. Preexisting dehydration. response to increased circulating Document irregularities and catecholamines. to assess in the alcoholic patient because the usual indicators are not reliable. dehydration. Note: Hydration is difficult balance. and overhydration is a risk in the presence of compromised cardiac function. Be prepared and assist in Causes of death during acute cardiopulmonary resuscitation. and diaphoresis may result in decreased circulating volume that can compromise cardiovascular Monitor I&O. and infections. Monitor body temperature. All of these may have an adverse effect on cardiac function and output. excessive psychomotor activity. causing vasodilation and compromising venous return and cardiac output. Tachycardia is common because of sympathetic Monitor cardiac rate and rhythm. Irregularities and dysrhythmias. Note 24-hr fluid function. dysrhythmias may develop with electrolyte shifts and imbalance. withdrawal stages include cardiac dysrhythmias. vomiting. and massive infections. fever.Nursing Interventions Rationale Long-term alcohol abuse may result in cardiomyopathy or HF. respiratory depression and arrest. severe dehydration or overhydration. Elevation may occur because of sympathetic stimulation. Mortality for unrecognized and untreated delirium tremens (DTs) may be as high as .

Risk for Ineffective Breathing Pattern Nursing Diagnosis  Risk for Ineffective Breathing Pattern Risk factors may include  Direct effect of alcohol toxicity on respiratory center and/or sedative drugs given to decrease alcohol withdrawal symptoms . Note: Administer medications as indicated: Atenolol and other b-adrenergic Clonidine (Catapres). and body temperature. especially potassium. Corrects deficits that can result in life-threatening dysrhythmias. cardiac dysrhythmias and CNS excitability. 5. blood pressure. Monitor laboratory studies: serum magnesium. Electrolyte imbalance: potassium. as well as lower the heart rate. indicated diaphoresis. as losses (associated with fever. atenolol blockers may speed up the (Tenormin).Potassium. withdrawal process and eliminate tremors.Nursing Interventions Rationale 25%. potentiate risk of electrolyte levels. some patients may require more specific therapy. and glucose. and vomiting) and electrolyte imbalances. Severe alcohol withdrawal causes the patient to be susceptible to fluid Administer fluids and electrolytes. Although the use of benzodiazepines is often sufficient to control hypertension during initial withdrawal from alcohol. magnesium.

Note presence of adventitious sounds: rhonchi. . Elevate head of bed.   Tracheobronchial obstruction Presence of chronic respiratory problems. marked respiratory depression can occur because of CNS depressant effects of alcohol if acute intoxication is present. inflammatory process Decreased energy/fatigue Desired Outcomes  Maintain effective breathing pattern with respiratory rate within normal range. Cheyne-Stokes vomiting and malnutrition. Patient is at risk for atelectasis related to hypoventilation and Auscultate breath sounds. lowers diaphragm. Hyperventilation is common during acute withdrawal phase. Right lower lobe pneumonia is common in alcoholdebilitated patients and is often due to chronic aspiration. Note acidotic state associated with periods of apnea. Kussmaul’s respirations are Monitor respiratory rate and depth sometimes present because of and pattern as indicated. be free of cyanosis and other signs/symptoms of hypoxia. Chronic lung diseases are also common: emphysema. enhancing lung inflation. Nursing Interventions Rationale Frequent assessment is important because toxicity levels may change rapidly. lungs clear. wheezes. pneumonia. This may be compounded by drugs used to control alcohol withdrawal symptoms (AWS). However. bronchitis. respirations. Decreases potential for aspiration.

requiring intervention to prevent respiratory arrest. ABGs complications such as atelectasis and and pulse oximetry as available and pneumonia. evaluates effectiveness indicated of respiratory effort. respiratory depression. adjuncts available. . Have suction equipment.Nursing Interventions Rationale Encourage cough and deep-breathing Facilitates lung expansion and exercises and frequent position mobilization of secretions to reduce changes. risk of atelectasis and pneumonia. identifies therapy needs. Monitors presence of secondary Review serial chest x-rays. Sedative effects of alcohol and drugs potentiates risk of aspiration. airway relaxation of oropharyngeal muscles. and respiratory depression. Administer supplemental oxygen if Hypoxia may occur with CNS and necessary.