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Group # 7 Topic 3

Names: Alyssa Marlow, Jasmine Romero, Madison Lebo, Ashley Alfaro, Manisha Budha, Payton Murray, Raven White, Morgan Krupp

A 35-year-old female was brought to the ER with severe alcohol withdrawal, scoring 25 on the CIWA scale. She has a history of chronic alcohol use and past delirium tremens, presenting with tremors, agitation, sweating, and tactile disturbances, along with elevated vitals. Treatment includes benzodiazepines or antipsychotics, a blood panel to check for complications, close monitoring for delirium tremens, seizure precautions, and supportive care with fluids and food.

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Situation: 35y/o female presented to the ER by ambulance with severe alcohol withdrawal according to the CIWA scale.

Background: last alcohol consumption was 18 hours ago. She has a history of chronic alcohol use and pervious delirium tremens episodes within the past year.

Assessment: CIWA score of 25. Her blood pressure is 165/101, Respirations: 22 breaths / min temperature: 99.5°F, HR: 110 bpm, oxygen saturation: 98% on RA. Presenting with withdrawal of: tremors, paroxysmal sweats, agitation, and tactile disturbances, and sweating profusely. She is physically and verbally intrusive behavior.

Recommendation: medication to calm the patient down like benzodiazepine and or antipsychotics. Getting a blood panel to check levels for life threatening complications (anemia: folate / b12, Wernicke: thiamine) monitor for delirium tremens and potentially transferring to ICU. Place in a quiet environment and place patient on a 1:1 for close monitoring since she is high risk, seizure precautions, and fall risk. Continue with the CIWA assessment and titrate benzodiazepines per hospital protocol. Give IV fluids and food.

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1)    One potential complication the patient can have is delirium tremens. The patient has a greater risk of developing DT, due to the history of Delerium Tremens within the last year. The patient has signs/and symptoms that could indicate delirium tremens such as A heart rate of 110, an elevated blood pressure of 165/101, and has diaphoresis. The patient is also having tactile, auditory hallucinations, and severe alcohol withdrawal according to CIWA. If unmanaged the patient could have seizures that can lead to status epilepticus.

2)    Patient is at risk of developing Wernicke's encephalopathy related to patients' history of alcohol abuse. Long term alcohol abuse can lead to a thiamine deficiency (vitamin B1). Signs and symptoms are ataxia, vision problems, and confabulations, and the patient can appear agitated.

3)    Due to the patient's blood pressure of 165/101 and a heart rate of 110, the patient's cardiac status is unstable. Severe hypertension and tachycardia increases the patients' risk of developing cardiovascular problems such as a myocardial infarction or developing a stroke.

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1.        Administer benzodiazepines as prescribed

a.        Rationale: Benzodiazepines are first line treatments for automatic instability related to delirium tremens. The patient has a history of delirium tremens, as well as having a high CIWA score and hallucinations. This intervention is extremely critical to prevent the patient from further damage.

2.        Administer thiamine (Vitamin B1) to prevent Wernicke’s encephalopathy

a.        Rationale: Our patient is at risk of developing Wernicke’s encephalopathy because of their long-term alcohol abuse which has led to a thiamine (vitamin B1) deficiency. This condition is irreversible if untreated, so administration of thiamine early is a crucial intervention.

3.        Monitor vital signs and manage autonomic instability

Rationale: Our patient is at a high risk of developing cardiovascular complications such as MI or stroke due to his hypertension and tachycardia. As nurses, we must continuously monitor this patient’s vital signs to determine if this patient needs further treatment or medications to prevent these complications.

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I think the highest priority complication would be delirium tremens, due to severe alcohol withdrawal. This is a huge concern because the patient’s CIWA score is 25, with symptoms such as tremors, sweating, anxiety, agitation, and tactile disturbances. The patient also has a previous history of delirium tremens within the past year, which raises more concern about her potentially developing them again. I think to combat this; a benzodiazepine would be ordered to help manage the alcohol withdrawal. Benzodiazepines such as diazepam, lorazepam, and chlordiazepoxide help to relax and calm the CNS and work in GABA. Benzodiazepine has the ability to reduce the risk for seizures and help to regulate the patient’s vital signs such as tachycardia and elevated blood pressure. There is also risk for dehydration and fluid electrolyte imbalance, therefore I think that close monitoring of fluid electrolyte balance should be ordered. Reassessing the CIWA score and closely monitoring the patient’s tachycardia and elevated blood pressure would also be advised to ensure that the patient’s status is improving.

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1.        Assess and stabilize the patient while initiating the emergency response- and notify the provider immediately.

a.        Rationale: Since the patient has exhibited physical and/or mental decompensation, we need to act quickly to stabilize and notify the team. The patient could deteriorate rapidly. Survival and safety comes first.

2.        Seizure precautions

a.        Rationale: Since the patient has a history of DT and is declining physically and mentally, precautions need to be in place. Patients at risk for delirium tremens are also at risk for seizures. Bed pads to be added to the side rails, suctions placed next to the bed, and oxygen available next to the bed to ensure safety.

3.        Limit Environmental Stimuli

a.        Rationale: Due to the fact that our patient is suffering from alcohol withdrawal and is declining mentally in spite of previous nursing interventions, the patient has an increased chance of developing hallucinations, and increased agitation. To help limit sensory overload, have the lights lowered, quiet room, and fall precautions in place.