The patient is a 63-year-old male with a history of alcohol abuse presenting with symptoms of acute alcohol withdrawal including tremors, anxiety, tachycardia and hypokalemia. Initial treatment involves monitoring, managing withdrawal symptoms, addressing nutritional deficits and providing counseling and referrals to support ongoing sobriety and prevent relapse.

1. ALCOHOL Acute Withdrawal

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.

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

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).

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.

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.

11. HGB-13.8

12. HCT-42.4%

13. PLT-185

14. K+-3.2

15. CA++-8.1

16. RBC-4.45

17. ALT-120

18. AST-324

20. Norm-13.1-17.2

21. Norm-42-52%

22. Norm- 150-400

23. Norm- 3.5-5.0

24. Norm-9.0-10.5

25. Norm-4.7-6.1

26. Norm-9-40

27. Norm-10-35

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.

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.

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

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.

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.

33. Assessment Data

34. Patient reports difficulty sleeping r/t his anxiety level, which he reported as a 10/10 Activity/Rest

36. Hypertension is present (commonly seen in early ETOH withdrawal, may progress to hypotension)

37. Tachycardia is present (common during acute withdrawal)

38. No dysrhythmias present at this time

40. Patient reports multiple life stressors such as his water pipes freezing, his electricity is borrowed from his neighbor by way of extension cord

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

43. Patient had suprapubic catheter with a good output but the urine was cloudy with particulates

44. Bowel sounds were hyperactive

46. He ate 50% of breakfast, 0% of lunch, and 15% of dinner

47. No reports of N/V/D

49. Mood ~ anxious and depressed

50. Patient exhibits nystagmus

51. Patients reports an unsteady gait, I did not observe him out of bed

54. Clear breath sounds

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

58. No other social interactions besides this neighbor

60. The basics of disease concept of alcoholism and the addictive process

61. The need to continue treatment in a rehabilitative program

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

64. Nursing Diagnosis

69. The patients condition may change rapidly. Increased monitoring will help decrease the risk of injury.

74. Part of baseline assessment, considering culture and background offers a holistic approach

76. Assist client to identify feelings and begin to deal with problems

77. Promote wellness; teaching/discharge considerations

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

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

83. Benzodiazapines potentiate effects of GABA, which produces a calming effect

84. Before I administered the Ativan I had to perform a CIWA (Clinical Institute Withdrawal Assessment) interview

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).

87. Repeat vital signs q 4 hours and the CIWA q 8 hours.

90. www.alcoholics-anonymous.org

91. National Institute on Alcohol Abuse and Alcoholism -

92. www.niaaa.nih.gov

93. Al-Anon/Alateen -

94. www.al-anon.org

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

97. Answer C- this question is important since withdrawal symptoms can begin as early as 4-6 hours after substance use

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

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.