Notebook

ALCOHOL

Acute Withdrawal

Alcohol is a CNS depressant. It can be harmless, enjoyable and sometimes beneficial when used in moderation.

It has a potential for abuse and is potentially fatal.

What is Alcoholism?

Alcoholism: Alcoholism is the compulsive urge to drink alcohol despite knowing the negative impact on one's health.Alcoholism: Habitual intoxication; prolonged and excessive intake of alcoholic drinks leading to a breakdown in health and an addiction to alcohol such that abrupt deprivation leads to severe withdrawal symptoms. http://www.wrongdiagnosis.com

15.1 million alcohol-abusing or alcohol-dependent individuals in our country alone!

National Institute on Alcohol Abuse and Alcoholismwww.niaaa.nih.gov

Prevalence

The patient is a 63 year old male with a past medical history of alcohol abuse and multiple cessation attempts that required acute hospital care. He has a suprapubic catheter in place for 10 years because of a botched exploratory prostate surgery. His labs were notable for transaminitis (ALT 120, AST 324) and hypokalemia (potassium 3.2).

He arrived the previous evening by ambulance stating that he was trying to quit drinking on his own but he had the shakes so bad he called 911.

Assessment findings revealed uncontrollable tremors in all four extremities. He also had nystagmus of the eyes. He reports anxiety, has a rapid heart beat (98-109 bpm), and increased blood pressure (135/92), all typical symptoms of early ETOH withdrawal.

Lab Values

WBC-5.4

HGB-13.8

HCT-42.4%

PLT-185

K+-3.2

CA++-8.1

RBC-4.45

ALT-120

AST-324

ETOH-394

Norm-5,000-10,000

Norm-13.1-17.2

Norm-42-52%

Norm- 150-400

Norm- 3.5-5.0

Norm-9.0-10.5

Norm-4.7-6.1

Norm-9-40

Norm-10-35

The presence of elevated transaminases, commonly the transaminases alanine transaminase (ALT) and aspartate transaminase (AST), may reflect liver or pancreatic damage.

Alcoholism occasionally results in hypokalemia. About one half of alcoholics hospitalized for withdrawal symptoms experience hypokalemia. This occurs in alcoholics for a variety of reasons, usually poor nutrition, vomiting, and diarrhea. Hypokalemia can result in dysrhythmias.

Hgb & Hct are on the very low end of normal, possibly r/t an iron-deficiency anemia.

Several factors account for the association between occurrence of hypocalcemia and severe alcoholism. In alcoholics, poor diet or liver disease results in diminished albumin levels, thereby limiting the amount of calcium that can remain dissolved in the blood.

Alcohol Toxicity:
Blood Alcohol Level, Classification, and Assessment Findings

80-200mg/dL (mild to moderate intoxication). Mood and behavior changes, impaired judgment, and poor motor coordination. Hypotension may occur in patients with levels >100 mg/dL.

250-400mg/dL (marked intoxication). Staggering ataxia and emotional lability. Symptoms may progress to confusion and stupor or coma.

Greater than 500 mg/dL (severe intoxication). Death is due to respiratory depression.

Ignatavicius,D. D., Workman, M. L., Medical-Surgical Nursing, Patient-Centered Collaborative Care, 6th ed.,Saunders Elsevier, Missouri, 2010, pp.83

This patients blood ETOH level upon arrival to the hospital was 394, though he states his last drink was in the morning and he arrived in the evening.

The doctor explained to the patient that if he was not serious about giving up ETOH then he would be sent home to drink. That is how serious this situation can be. The doctor further explained to me the cardiac risk factors of quitting ETOH. The patient can suffer from severe, possibly fatal dysrhythmias.

Assessment Data

Patient reports difficulty sleeping r/t his anxiety level, which he reported as a 10/10

Activity/Rest

Circulation

Peripheral pulses are rapid

Hypertension is present (commonly seen in early ETOH withdrawal, may progress to hypotension)

Tachycardia is present (common during acute withdrawal)

No dysrhythmias present at this time

Ego Integrity

Patient spoke to me about feelings of guilt r/t his drinking, states he wishes he would be satisfied with only drinking beer like his neighbor

Patient reports multiple life stressors such as his water pipes freezing, his electricity is borrowed from his neighbor by way of extension cord

He also states he is anxious all the time and when I asked how he deals with this he said he drinks to deal with it

Elimination

Patient states his last BM was the night before and it was normal

Patient had suprapubic catheter with a good output but the urine was cloudy with particulates

Bowel sounds were hyperactive

Food/Fluid

Patient drank 1600 ml of water during my 12 hour shift

He ate 50% of breakfast, 0% of lunch, and 15% of dinner

No reports of N/V/D

Neurosensory

Patient reports internal shakes and exhibits external shakes

Mood ~ anxious and depressed

Patient exhibits nystagmus

Patients reports an unsteady gait, I did not observe him out of bed

Pain

Patient reports pain 0/10

Respiration

No hx of smoking

Clear breath sounds

Safety

Hx of falls r/t unsteady gait and intoxication

Social Interaction

Only family is his mom in MI

Has a neighbor who is a good friend but also an alcoholic. They take turns making meals and he uses this neighbors electricity via extension cord

No other social interactions besides this neighbor

Teaching/Learning

Patient will demonstrate an understanding of:

the need to recognize post-acute withdrawal symptoms

The basics of disease concept of alcoholism and the addictive process

The need to continue treatment in a rehabilitative program

Nursing Priorities

1. Maintain physiological stability during acute WD phase

2. Promote patient safety

3. Provide info regarding condition/prognosis and tx outcomes

4. Provide appropriate referral and follow-up

Discharge Goals

1. Homeostasis achieved

2. Complications prevented/resolved

3. Referral to AA or similar program/support group

4. Condition and therapeutic regimen understood

5. Understanding of the need for follow-up by physician

Nursing Diagnosis

Risk for injury related to abrupt withdrawal of ETOH

Nursing prioritiesMaintain patient's physical safety

Be alert for changes in status that may indicate development of complications

Desired outcomeThroughout the length of the stay, patient will remain free from injury AEB maintaining stable VS, and showing no evidence of WD, such as seizures or infection

InterventionsWhen the patient is conscious, perform a mental status evaluation

Place the patient in private room, close to nurse's station. Check on patient every 15 minutes.

RationaleThe mental status exam will determine orientation

The patients condition may change rapidly. Increased monitoring will help decrease the risk of injury.

Imbalanced nutrition: less than body requirements r/t lack of food intake AEB consumption of less than 25% of meals

Nursing PrioritiesEnsure adequate intake of nutrients

Be alert for changes in nutritional status (body weight and fluid intake)

Desired outcomesThroughout the length of stay patient will maintain body weight and fluid hydration at acceptable levels AEB eating a balanced diet, and maintaining electrolyte balance within normal limits

InterventionsAssess weight upon admission and daily while hospitalized

Assess appetite and GI tolerance. Inquire as to food preferences.

RationaleBaseline assessment is essential to determine what is normal for the patient, and facilitates determination of fluctuations

Part of baseline assessment, considering culture and background offers a holistic approach

Severe Anxiety r/t cessation of ETOH intake/physiological withdrawal AEB increased tension, apprehension

Desired outcomesThe patient will demonstrate a decrease in anxiety AEB a reduction in presenting physiological, emotional, and/or cognitive manifestations of anxiety verbalization of relief of anxiety within 24 hours.

Nursing prioritiesAssess level of anxiety

Assist client to identify feelings and begin to deal with problems

Promote wellness; teaching/discharge considerations

InterventionsInvolve patient in the process of identifying cause of anxiety. Explain that WD increases anxiety. Reassess on an ongoing basis

Develop a trusting relationship through frequent contact, being honest and non-judgmental; project an accepting attitude about alcoholism

RationalePerson in acute phase of WD may be unable to identify what is happening. Understanding of what is happening may help to decrease anxiety levels

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

GABA/Dopamine

ETOH intake represses GABA, which inhibits dopamine, keeping levels low, when ETOH is eliminated dopamine rebounds to normal level causing excitation and alterations in thought, perception and orientation

Medication

lorazepam/Ativan Short acting benzodiazapine is the drug of choice when there is known liver disease

Benzodiazapines potentiate effects of GABA, which produces a calming effect

Before I administered the Ativan I had to perform a CIWA (Clinical Institute Withdrawal Assessment) interview

CIWA

What it Measures: The CIWA can measure 10 symptoms. Scores of less than 8 to10 indicate minimal to mild withdrawal. Scores of 8 to 15 indicate moderate withdrawal(marked autonomic arousal); and scores of 15 or more indicate severe withdrawal. Theassessment requires 2 minutes to perform (Sullivan, et al, 1989).

CIWA

If CIWA score is > 0 but < 8 and vital signs are stable, no medication is required.

Repeat vital signs q 4 hours and the CIWA q 8 hours.

If CIWA is > 8 but < 15, give Lorazepam (Ativan) 2 mg PO/IM and repeat vital signs q 2 hours and the CIWA q 4 hours.

If CIWA is >15 or DBP > 110 mmHg, give Lorazepam (Ativan) 2 mg PO/IM q hour until patient has a CIWA of < 15

Support/resources at discharge

Alcoholics Anonymous - www.alcoholics-anonymous.org

National Institute on Alcohol Abuse and Alcoholism - www.niaaa.nih.gov

Al-Anon/Alateen - www.al-anon.org

Which question is most likely to predict the onset of withdrawal symptoms if client is dependent on alcohol?A. What is your experience with alcohol?B. How much alcohol do you usually have?C. When did you last have something to drink?D. How often do you usually drink?

Questions

Answer

C- this question is important since withdrawal symptoms can begin as early as 4-6 hours after substance use

Question

What priority nursing diagnosis should be addressed within 72 hours of admission?A. Ineffective copingB. Ineffective denialC. Risk for injuryD. Altered nutrition

Answer

D- nutrition is very important, because a client with alcohol dependency drinks instead of eating nourishing food, causing malabsorption of essential vitamins. Deficiency and malabsorption if vitamin B can lead to Wernicke's disease, a severe problem with decreased cognitive functioning.