# data[].attributes.body
S - 65 year old male presents to the emergency department.

B - Chief concern: Patient is experiencing symptoms consistent with severe alcohol withdrawal. He reports drinking heavily the past several weeks and has not had a drink in the past 24 hours.

A - Upon assessment, the patient’s vital signs are as follows:

Heart rate: 110 bpm

Blood pressure: 150/90 mmHg

Respiratory Rate: 22 breaths per minutes

Temperature: 37.5C (99.5F)

Oxygen saturation: 95% on room air.

CIWA-Ar Scale Notes:

Nausea/Vomiting: 3

Tremors: 4

Paroxysmal sweats: 3

Anxiety: 2

Agitation: 3

Tactile disturbances: 2

Auditory disturbances: 1

Visual disturbances: 0

Headache: 1

Orientation and cognition: 1

R - Recommendations are as follows:

Alcohol withdrawal - Perform CAGE questionnaire and continue CIWA protocol.

Ordering labs - CDC/diff, CMP, BAL, urine toxicology, blood glucose test.

Safety - Ensure safety and no harm to self and to others.

Continue to monitor patient vitals.

Refer patient to local AA support groups.

Educate patient on long term effects of alcohol use.

# data[].attributes.body
This is a withdrawal effect of alcohol.

Occurs 2-3 days of abstinence.

Tachycardia, sweating, flushed face, dilated pupils, elevated BP.

Fear, anxious, agitated, irritable.

Easily distracted with needing to refocus.

Impaired, pressured speech, topic to topic.

Disoriented to time, place.

Recent memory impairment.

Hallucination and illusions - common.

# data[].attributes.body
Medications for delirium tremors: Benzodiazepine - such as lorazepam or diazepam - to minimize symptoms, provide treatment, and supportive care.

# data[].attributes.body
Review the Physicians order and as previously mentioned to make sure the patient is on fall precaution and educate them on their diagnosis.

# data[].attributes.body
Seizures are likely to present 24-48 hours after the last drink.

If a patient has a seizure, medical must be ruled out before being diagnosed as an AW seizure.

Ensure patient safety by keeping the bed at the lowest position and have padded side rails.

Make sure there is suction and supplemental oxygen readily available.

Reduce stimuli if possible to reduce likelihood of an attack.

If there is a seizure, educate all staff to turn patient to side.

# data[].attributes.body
Implement physician's order's of Thiamine via either intravenously or oral route.

Implement fall precautions related to symptoms of diplopia and ataxia.

Reorient patient to setting related to confusion.

# data[].attributes.headline
Decompensation Outcome - Steps as Follow

# data[].attributes.subject
Decompensation Outcome - Steps as Follow

# data[].attributes.body
Managing Delirium Tremens and Status Epilepticus - monitor and watch for signs and symptoms of Delirium Tremens and Status Epilepticus. Assess ABCs and expect administration of medication.

# data[].attributes.body
Medical Stabilization – ensure the patient’s immediate safety by addressing any life-threatening complications and administer prescribed medication promptly to control symptoms.

# data[].attributes.body
Continuous Monitoring – implement continuous monitoring of vital signs.

# data[].attributes.body
Fluid and Electrolyte Management – assess and manage the patient’s fluid status and electrolyte balance and administer intravenous fluid as needed.

# data[].attributes.body
Psychosocial Support – provide a calm and supportive environment

# data[].attributes.body
Collaboration with healthcare team – communicate with the healthcare team to discuss the patient’s condition and the need for higher level of care.

# data[].attributes.body
Transport to higher level of care – coordinate with transportation services to facilitate the transfer of the patient to higher level of care.

# data[].attributes.body
Morgan, K. I. (2021). Davis advantage for Psychiatric Mental Health Nursing. F. A. Davis Company Publishers.