·       Heart rate: 110 bpm

·       Blood pressure: 165/101 mmHg

·       Respiratory rate: 22 breaths/minute

·       Temperature: 37.5°C (99.5°F)

·       Oxygen saturation: 98% on room air

Clinical Institute Withdrawal Assessment for Alcohol Scale-Revised (CIWA-Ar):

·       Nausea and vomiting: 3

·       Tremors: 4

·       Paroxysmal sweats: 4

·       Anxiety: 3

·       Agitation: 5

·       Tactile disturbances (e.g. "bugs crawling on skin"): 3

·       Auditory disturbances (e.g. ringing in the ears): 1

·       Visual disturbances (e.g. "halos" around lights): 0

·       Headache: 1

·       Orientation and cognition (ability to remember the date and place): 1

Total: 25/67

• A severe and life-threatening form of alcohol withdrawal.

• This patient is high risk due to her history of DTs, high CIWA-Ar score (25), agitation, and elevated vitals.

• Symptoms can include confusion, hallucinations, and unstable vital signs.

• Typically occurs 48–72 hours after the last drink.

• Requires urgent treatment with benzodiazepines and close monitoring.

2.) Withdrawal Seizures

• Seizures can occur within 6–48 hours of stopping alcohol.

• This patient’s tremors and past DTs suggest a high risk.

• Seizures can be sudden and lead to dangerous complications like status epilepticus.

• Prevention includes scheduled or symptom-triggered benzodiazepine therapy.

3.) Acute Psychosis or Psychiatric Decompensation

• Severe withdrawal can lead to hallucinations, paranoia, or aggression.

• This patient has tactile disturbances and high anxiety/agitation, which may progress.

• Risk of harm to self or others if symptoms worsen.

• Requires psych assessment, calm environment, and possibly antipsychotic support.

The priority complication would be delirium tremens. The doctor may order IV benzodiazepines (e.g., lorazepam) as needed per CIWA-AR protocol, and baseline labs (CBC, BMP, electrolyte levels).

Rationale:

Delirium Tremens is a severe and potentially life-threatening emergency. IV benzodiazepines help subdue neuronal activity by boosting the effect of GABA. Benzodiazepines can help control the shaking, confusion, increased blood pressure, and risk of seizures.

As the nurse was leaving the room, the patient then screams, “AHHH! THEY'RE UNDER MY SKIN” in a panic and rips out her IV. She starts flailing, knocks over a monitor, and collapses to the ground. A tonic-clonic seizure ensues, lasting nearly a minute. Afterwards, she is disoriented, diaphoretic, nonverbal, and attempting to crawl under the bed, screaming about fire and insects.

BP: 198/113 mmHg

RR: 28

Temp: 38.6°C (101.5°F)

CIWA-Ar now ≥ 25

IT'S TIME TO ACT FAST!

1) Delirium Tremens:

Administer medications as ordered based on CIWA-AR score, monitor vital signs frequently, provide a low-stimulation environment.

Rationale:

Benzodiazepines can prevent progression of delirium tremens. Frequent VS checks allow early detection of autonomic hyperactivity and a calm environment reduces sensory overload and agitation.

2) Withdrawal Seizures:

Initiate seizure precautions, continue medication therapy per protocol, and monitor neurological status and LOC regularly.

Rationale:

Seizure precautions reduce the risk of injury during seizures, medications can reduce neuronal excitability, and ongoing neuro checks help detect early signs of seizures or worsening withdrawal.

3) Acute Psychosis or Psychiatric Decompensation:

Request a psychiatric consult and assess mental status frequently, use a calm, non-confrontational approach with de-escalation techniques, and ensure close supervision or initiate a sitter, if needed.

Rationale:

Psych evaluations and monitoring can identify worsening psych symptoms so they can be treated appropriately. A calm approach reduces anxiety and risk of aggression, supervision ensures safety if the patient becomes a danger to self or others.

Rationale: Ensure patient survival and prevent aspiration or prolonged CNS complications due to the seizure and delirium.

Rationale: The patient requires ICU-level care for continuous IV sedation, close neurologic and cardiovascular monitoring (telemetry), seizure control, and potential airway support. Prompt and thorough handoff ensures safe transition and prevents further deterioration.

Rationale: A medically and behaviorally unstable patient presents a risk to themselves and others. Ensuring proper documentation and secure transport supports safe handoff and uninterrupted continuity of care in the ICU.