Alcohol Withdrawal by

Alcohol Withdrawal Scenario #1

eddavila3 — 2023-11-11 16:33:30 UTC

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.

Complication 1: Delirium Tremors

eddavila3 — 2023-11-11 16:34:10 UTC

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.

Complication 2: Seizures

eddavila3 — 2023-11-11 16:35:08 UTC

Decompensation Outcome - Steps as Follow

2023-11-11 17:29:13 UTC

Complication 3: Wernicke-Korsakoff

2023-11-12 02:26:58 UTC

References

tonyibarra — 2023-11-12 02:57:29 UTC

Morgan, K. I. (2021). Davis advantage for Psychiatric Mental Health Nursing. F. A. Davis Company Publishers.

Nursing Intervention 3

2023-11-12 03:00:43 UTC

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.

Nursing Intervention 2

tonyibarra — 2023-11-12 03:09:49 UTC

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.

Nursing Intervention 1

tonyibarra — 2023-11-12 03:10:07 UTC

Review the Physicians order and as previously mentioned to make sure the patient is on fall precaution and educate them on their diagnosis.

Priority 1

tonyibarra — 2023-11-12 03:13:21 UTC

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.

Priority 2

tonyibarra — 2023-11-12 03:13:27 UTC

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

Priority 3

tonyibarra — 2023-11-12 03:13:31 UTC

Continuous Monitoring – implement continuous monitoring of vital signs.

Priority 4

tonyibarra — 2023-11-12 03:13:35 UTC

Fluid and Electrolyte Management – assess and manage the patient’s fluid status and electrolyte balance and administer intravenous fluid as needed.

Priority 5

tonyibarra — 2023-11-12 03:13:43 UTC

Psychosocial Support – provide a calm and supportive environment

Priority 6

tonyibarra — 2023-11-12 03:13:52 UTC

Collaboration with healthcare team – communicate with the healthcare team to discuss the patient’s condition and the need for higher level of care.

Priority 7

tonyibarra — 2023-11-12 03:13:55 UTC

Transport to higher level of care – coordinate with transportation services to facilitate the transfer of the patient to higher level of care.

Anticipatory Order

eddavila3 — 2023-11-12 04:40:52 UTC

Medications for delirium tremors: Benzodiazepine - such as lorazepam or diazepam - to minimize symptoms, provide treatment, and supportive care.