02.14 Alcohol Withdrawal (Addiction)

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Addiction – Behavioral Problems (Mnemonic)
Alcoholism – Outcomes (Mnemonic)
Alcohol Abuse Interventions (Picmonic)

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Let’s talk about Alcohol Withdrawal. Now, technically the withdrawal portion of this is a medical condition, not mental health. But alcohol use disorder is a mental health condition that can cause some pretty serious medical issues, so we’re going to kind of touch on all of it here.

So what is Alcohol Withdrawal - it is a set of symptoms that results after someone attempts to quit or abruptly stops consuming alcohol after regular long-term consumption. With Alcohol Use Disorder, someone drinks compulsively, can’t control how much they drink, and tends to be super anxious or irritable when they aren’t drinking. When you consume that much alcohol for a long period of time, your brain starts to get used to it and it changes some of your brain chemistry. So when someone stops drinking - their brains can go haywire. Now keep in mind, this might not be someone who is trying to quit - this might be someone who was in a car accident and is now hospitalized and can’t drink like they usually would.

So, we always want to ask the question and be very specific - how much do you drink on a daily basis and when was your last drink? This helps us to start to establish a timeline and be able to predict when their symptoms will progress. Symptoms of withdrawal can occur as early as 6 hours after the last drink and usually involve tremor, anxiety, nausea and vomiting, and trouble sleeping - THIS feeling is usually what drives someone with alcohol use disorder to take another drink. This is what makes it really hard to quit. These symptoms will peak at about 48-72 hours and will get worse and worse before they start to get better - including a severe version of these initial symptoms plus hypertension, diaphoresis, hallucinations and even seizures. Left untreated, these symptoms can progress to what’s known as Withdrawal Delirium or Delirium Tremens.

Delirium Tremens, also sometimes called “DT’s” is a medical emergency. It usually comes on about 3 or more days after their last drink. They’ll have all the previous symptoms at severe levels - so severe tremors, diaphoresis, nausea, hypertension, etc. PLUS global confusion and disorientation, which is the hallmark sign. They’ll also have agitation, a high fever, autonomic instability, and seizures. This condition CAN and WILL kill someone if left untreated. So, even if you have a client come in for something completely unrelated, like a car accident - it’s SO important to ask them if they drink regularly and when their last drink was - that way we can get them some treatments early and monitor them closely to prevent it from getting this bad.

So when we are assessing a client who is at risk for alcohol withdrawal, there is usually a protocol to follow. We’ve attached a couple of examples to the lesson under references - the MINDS score and the CIWAA score. So our primary intervention will always be anything having to do with safety - that might include airway protection, seizure precautions, and possibly even a sitter or restraints if they’re super agitated. Then we’re going to assess the symptoms and give them a score based on the method we’re using. Most protocols then have a guideline as to how to intervene based on that score. For example, at one facility I’ve worked at, we would assess the CIWAA score every 2 hours and if their score was over 25, we would give 1 mg of Lorazepam and reassess in 1 hour. Again, you just need to know YOUR facility’s specific protocols and make sure you’re following them.

We want to assess frequently, institute seizure and fall precautions, and reorient them as needed. Again, maintain safety at all times, and perform a self-harm assessment. With alcohol use disorder, clients may be so dependent on the alcohol for their coping strategies that it can be very difficult not to have that. And we definitely want to encourage them to seek long-term therapy or support, including things like Alcoholics Anonymous meetings. Expressing their feelings can be very therapeutic. As far as medications for Alcohol Withdrawal, we use Benzodiazepines almost every time - I already mentioned Lorazepam is common. We’ll also use antiemetics for the nausea and we’ll give Vitamin replacements. Those who overuse alcohol tend to be quite deficient in B12 and Thiamine and other micronutrients so we will give them something called a Banana Bag or a Rally Pack that’s full of vitamins like Thiamine and electrolytes and can prevent encephalopathy. Check out the neuro lesson on encephalopathies to learn more about why that occurs. Another medication we can give for someone trying to quit drinking is called Disulfiram or Antabuse. Essentially if they take this medication and then get even one sip of alcohol in their system, it makes them violently ill. This includes things like mouthwash or over-the-counter cough medicine - so make sure you educate your patient that they shouldn’t start the Antabuse until they haven’t had alcohol for 12 hours and that the effects can last for days after taking it. So no alcohol!

Priority nursing concepts for a patient with Alcohol Withdrawal are safety, nutrition, and coping.

Okay, so let’s recap - Alcohol Withdrawal occurs after someone who uses alcohol chronically or excessively for an extended period of time stops abruptly or attempts to quit. Make sure you’re assessing the timeline because symptoms can start as soon as 6 hours after the last drink and will peak at about 48-72 hours. We need to monitor them closely and assess them frequently to intervene and prevent Withdrawal Delirium or Delirium Tremens, which is a medical emergency and can be deadly. So we give benzodiazepines and vitamins to manage the symptoms to get them through the dangerous period of withdrawal, and we always prioritize safety, including fall and seizure precautions. If they have severe agitation, they may even require a sitter or restraints, so just make sure you’re following your facility’s protocol for those things.

So that’s it for Alcohol Withdrawal. Make sure you check out the resources attached to this lesson to learn more. Now, go out and be your best self today. And, as always, happy nursing!
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