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 considerations:
DRG projected mean length of inpatient stay: 4.9 days
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.
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 considerations:
DRG projected mean length of inpatient stay: 4.9 days
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.
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