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Alcohol Withdrawal

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This is a presentation of one of my patients that I had to do for class...hope it helps!

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Alcohol Withdrawal

  1. 1. ALCOHOL Acute Withdrawal
  2. 2. 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.
  3. 3. 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>
  4. 4. 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
  5. 7. 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).
  6. 8. 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.
  7. 9. 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.
  8. 10. Lab Values <ul><li>WBC-5.4
  9. 11. HGB-13.8
  10. 12. HCT-42.4%
  11. 13. PLT-185
  12. 14. K+-3.2
  13. 15. CA++-8.1
  14. 16. RBC-4.45
  15. 17. ALT-120
  16. 18. AST-324
  17. 19. ETOH-394 </li></ul><ul><li>Norm-5,000-10,000
  18. 20. Norm-13.1-17.2
  19. 21. Norm-42-52%
  20. 22. Norm- 150-400
  21. 23. Norm- 3.5-5.0
  22. 24. Norm-9.0-10.5
  23. 25. Norm-4.7-6.1
  24. 26. Norm-9-40
  25. 27. Norm-10-35 </li></ul>
  26. 28. 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.
  27. 29. 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.
  28. 30. 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
  29. 31. 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.
  30. 32. 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.
  31. 33. Assessment Data
  32. 34. Patient reports difficulty sleeping r/t his anxiety level, which he reported as a 10/10 Activity/Rest
  33. 35. Circulation <ul><li>Peripheral pulses are rapid
  34. 36. Hypertension is present (commonly seen in early ETOH withdrawal, may progress to hypotension)
  35. 37. Tachycardia is present (common during acute withdrawal)
  36. 38. No dysrhythmias present at this time </li></ul>
  37. 39. Ego Integrity <ul><li>Patient spoke to me about feelings of guilt r/t his drinking, states he wishes he would be satisfied with only drinking beer like his neighbor
  38. 40. Patient reports multiple life stressors such as his water pipes freezing, his electricity is borrowed from his neighbor by way of extension cord
  39. 41. He also states he is anxious all the time and when I asked how he deals with this he said he drinks to deal with it </li></ul>
  40. 42. Elimination <ul><li>Patient states his last BM was the night before and it was normal
  41. 43. Patient had suprapubic catheter with a good output but the urine was cloudy with particulates
  42. 44. Bowel sounds were hyperactive </li></ul>
  43. 45. Food/Fluid <ul><li>Patient drank 1600 ml of water during my 12 hour shift
  44. 46. He ate 50% of breakfast, 0% of lunch, and 15% of dinner
  45. 47. No reports of N/V/D </li></ul>
  46. 48. Neurosensory <ul><li>Patient reports “internal shakes” and exhibits “external shakes”
  47. 49. Mood ~ anxious and depressed
  48. 50. Patient exhibits nystagmus
  49. 51. Patients reports an unsteady gait, I did not observe him out of bed </li></ul>
  50. 52. Pain <ul><li>Patient reports pain 0/10 </li></ul>
  51. 53. Respiration <ul><li>No hx of smoking
  52. 54. Clear breath sounds </li></ul>
  53. 55. Safety <ul><li>Hx of falls r/t unsteady gait and intoxication </li></ul>
  54. 56. Social Interaction <ul><li>Only family is his mom in MI
  55. 57. 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
  56. 58. No other social interactions besides this neighbor </li></ul>
  57. 59. Teaching/Learning <ul>Patient will demonstrate an understanding of: <li>the need to recognize post-acute withdrawal symptoms
  58. 60. The basics of disease concept of alcoholism and the addictive process
  59. 61. The need to continue treatment in a rehabilitative program </li></ul>
  60. 62. 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>
  61. 63. 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
  62. 64. Nursing Diagnosis
  63. 65. Risk for injury related to abrupt withdrawal of ETOH <ul>Nursing priorities <li>Maintain patient's physical safety
  64. 66. 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>
  65. 67. <ul>Interventions <li>When the patient is conscious, perform a mental status evaluation
  66. 68. 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
  67. 69. The patients condition may change rapidly. Increased monitoring will help decrease the risk of injury. </li></ul>
  68. 70. 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
  69. 71. 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>
  70. 72. <ul>Interventions <li>Assess weight upon admission and daily while hospitalized
  71. 73. 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
  72. 74. Part of baseline assessment, considering culture and background offers a holistic approach </li></ul>
  73. 75. 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
  74. 76. Assist client to identify feelings and begin to deal with problems
  75. 77. Promote wellness; teaching/discharge considerations </li></ul>
  76. 78. <ul>Interventions <li>Involve patient in the process of identifying cause of anxiety. Explain that WD increases anxiety. Reassess on an ongoing basis
  77. 79. 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
  78. 80. 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>
  79. 81. 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
  80. 82. Medication lorazepam/Ativan <ul><li>Short acting benzodiazapine is the drug of choice when there is known liver disease
  81. 83. Benzodiazapines potentiate effects of GABA, which produces a calming effect
  82. 84. Before I administered the Ativan I had to perform a CIWA (Clinical Institute Withdrawal Assessment) interview </li></ul>
  83. 85. 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).
  84. 86. CIWA <ul><li>If CIWA score is > 0 but < 8 and vital signs are stable, no medication is required.
  85. 87. Repeat vital signs q 4 hours and the CIWA q 8 hours.
  86. 88. 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>
  87. 89. Support/resources at discharge <ul><li>Alcoholics Anonymous -
  88. 90. www.alcoholics-anonymous.org
  89. 91. National Institute on Alcohol Abuse and Alcoholism -
  90. 92. www.niaaa.nih.gov
  91. 93. Al-Anon/Alateen -
  92. 94. www.al-anon.org </li></ul>
  93. 96. 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
  94. 97. Answer C- this question is important since withdrawal symptoms can begin as early as 4-6 hours after substance use
  95. 98. 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
  96. 99. 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.

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