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? <ul>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 </ul>
15.1 million alcohol-abusing or alcohol-dependent individuals in our country alone! National Institute on Alcohol Abuse and Alcoholism www.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.
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, 6 th 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.
Safety <ul><li>Hx of falls r/t unsteady gait and intoxication </li></ul>
Social Interaction <ul><li>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 </li></ul>
Teaching/Learning <ul>Patient will demonstrate an understanding of: <li>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 </li></ul>
Nursing Priorities <ul>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 </ul>
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
Risk for injury related to abrupt withdrawal of ETOH <ul>Nursing priorities <li>Maintain patient's physical safety
Be alert for changes in status that may indicate development of complications </li></ul><ul>Desired outcome <li>Throughout 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 </li></ul>
<ul>Interventions <li>When 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. </li></ul><ul>Rationale <li>The mental status exam will determine orientation
The patients condition may change rapidly. Increased monitoring will help decrease the risk of injury. </li></ul>
Imbalanced nutrition: less than body requirements r/t lack of food intake AEB consumption of less than 25% of meals <ul>Nursing Priorities <li>Ensure adequate intake of nutrients
Be alert for changes in nutritional status (body weight and fluid intake) </li></ul><ul>Desired outcomes <li>Throughout 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 </li></ul>
<ul>Interventions <li>Assess weight upon admission and daily while hospitalized
Assess appetite and GI tolerance. Inquire as to food preferences. </li></ul><ul>Rationale <li>Baseline 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 </li></ul>
Severe Anxiety r/t cessation of ETOH intake/physiological withdrawal AEB increased tension, apprehension <ul>Desired outcomes The 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. </ul><ul>Nursing priorities <li>Assess level of anxiety
Assist client to identify feelings and begin to deal with problems
<ul>Interventions <li>Involve 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 </li></ul><ul>Rationale <li>Person 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 </li></ul>
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 <ul><li>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 </li></ul>
CIWA What it Measures: The CIWA can measure 10 symptoms. Scores of less than 8 to 10 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. The assessment requires 2 minutes to perform (Sullivan, et al, 1989).
CIWA <ul><li>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. </li></ul><ul><li>If CIWA is >15 or DBP > 110 mmHg, give Lorazepam (Ativan) 2 mg PO/IM q hour until patient has a CIWA of < 15 </li></ul>
Support/resources at discharge <ul><li>Alcoholics Anonymous -
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 coping B. Ineffective denial C. Risk for injury D. 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.