Nursing Care Plan for Alcohol Withdrawal Syndrome / Delirium Tremens

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Outline

Pathophysiology

When a person regularly consumes large amounts of alcohol over a prolonged period of time (usually years), the body becomes physically dependent upon that substance. Alcohol withdrawal syndrome (AWS) is a set of symptoms that occur when a heavy drinker suddenly stops or significantly reduces their consumption of alcohol. The neurological and physical symptoms that ensue typically worsen over a period of 2-3 days before subsiding and mild symptoms may continue for weeks. The most severe symptom of withdrawal is delirium tremens (DT) which constitutes a medical emergency as it may be life-threatening.  Treatment for AWS and DT is geared toward initially managing symptoms and continuing with medications and counseling or psychotherapy to treat the underlying cause of alcoholism.

Etiology

 

Diagnostic Criteria:

 

Symptoms are not caused by any other medical condition or mental illness, or withdrawal from another substance.

  • Cessation or significant reduction in alcohol intake
  • Any of the 2 following symptoms developing over several hours to a few days:
    • Autonomic hyperactivity
    • Worsening tremor
    • Insomnia
    • Nausea and vomiting
    • Hallucinations
    • Psychomotor agitation
    • Anxiety
    • Generalized tonic-clonic seizures
  • Symptoms cause significant distress or impairment in social or occupational functioning

Desired Outcome

Client will maintain or regain appropriate level of consciousness with absence of hallucinations. Client will demonstrate ability to regain control of daily activities and functioning. Client will remain free from injury. Client will have vital signs that are within normal limits for that client.

Alcohol Withdrawal Syndrome / Delirium Tremens Nursing Care Plan

Subjective Data:

  • Headaches
  • Anxiety
  • Confusion
  • Heart palpitations
  • Nausea
  • Hallucinations
  • Sensory perception disturbances (visual impairment, crawling sensation on skin, hearing impairment)
  • Inability to think clearly

Objective Data:

  • Restlessness
  • Confusion
  • Seizures
  • Tremors
  • Vomiting
  • Uncontrollable sweating
  • Agitation
  • Loss of or changes in level of consciousness
  • Fever
  • Cardiac dysrhythmias
  • Hypertension
  • Tachycardia
  • Respiratory depression

Nursing Interventions and Rationales

  • Perform complete nursing assessment and assess vital signs

 

Get baseline to determine effectiveness of interventions.

The sympathetic nervous system response may cause elevated temperature, high blood pressure, tachycardia and severe respiratory depression.

 

  • Determine stage of AWS
    • Stage I – hyperactivity
    • Stage II- hallucinations and seizure activity
    • Stage III- DTs, confusion, fever and anxiety

 

Help determine appropriate interventions and prevent progression of symptoms

 

  • Perform 12-lead EKG per facility protocol

 

Monitor for cardiac dysrhythmias and irregularities.

 

  • Monitor respiratory status and administer supplemental oxygen

 

Severe respiratory depression may occur and requires immediate intervention.

 

  • Maintain patent airway and monitor for aspiration

 

Clients with vomiting and respiratory depression are at risk for aspiration. Advanced airway may be required.

 

  • Initiate IV access and administer fluids

 

Vomiting may lead to dehydration and fluid imbalance. Maintain cardiac function and cardiac output.

 

  • Monitor lab results and administer supplemental electrolytes as needed

 

Dehydration, diaphoresis  and vomiting may result in electrolyte imbalances that can cause cardiac dysrhythmias.

 

  • Initiate seizure precautions per facility protocol

 

Seizures are often contributed to low magnesium, hypoglycemia or elevated blood alcohol levels.

Antiepileptic drugs are not indicated for seizures associated with AWS as they typically resolve spontaneously.  Symptomatic treatment and safety are recommended.

 

  • Provide calm and safe environment, free from clutter, noise and shadows

 

Sensory disturbances, hallucinations and confusion can lead to severe injury. Hallucinations often occur more at night and clients in advanced stages may experience anxiety and fear.

 

  • Monitor client for signs of depression or suicidal ideation. Initiate suicide precautions as necessary per facility protocol

 

Confusion and anxiety may prompt client to attempt suicide or self-destruction.

 

  • Provide isolation or restraints as necessary per facility protocol

 

During periods of excessive psychomotor activity, hallucinations and anxiety, restraints may be required temporarily to prevent harm to client or others.

 

  • Reorient client to reality as often as needed in a calm and supportive manner

 

Confusion, anxiety and hallucinations may cause periods of delirium. Reorientation helps calm fears and relieve anxiety.

 

  • Administer medications as appropriate and required

 

Anti-anxiety medications may be given to reduce hyperactivity and promote sleep.

  • Benzodiazepines are also used to prevent seizures and manage severe tremors and withdrawal symptoms.
  • Specifically lorazepam.

Antidepressants may be given to help client regain control of daily functioning and improve ability to concentrate and participate in therapy or counseling.

 

  • Provide education and resources for client and family members

 

Resources, support groups and counseling services may help client and family members manage client’s needs going forward and help maintain relationships and daily functioning

 


References

Transcript

Hey guys, in this care plan, we will explore alcohol withdrawal syndrome in delirium tremens. 

 

So, in this alcohol withdrawal syndrome care plan, we will cover the desired outcome, the subjective and objective data along with the nursing interventions and rationales. So, our medical diagnosis is alcohol withdrawal syndrome. So, alcohol withdrawal syndrome is a set of symptoms that occurs when a person suddenly slows down or stops drinking completely.  Alcohol withdrawal includes delirium tremens, autonomic hyperactivity, nausea, vomiting, hallucinations, psychomotor, agitation, anxiety and generalized tonic clonic seizures. After consuming alcohol regularly over a long period of time, the body becomes physically dependent on that substance. So, cessation or significant reduction in alcohol results in that alcohol withdrawal syndrome and delirium tremens, which causes significant distress or impairment in their lives. 

 

So, the patient will maintain or regain an appropriate level of consciousness, have stable vital signs and the absence of hallucinations, the patient will remain free of injury and regain control of daily activities in functioning. This is all that we want when they leave the hospital. 

 

Now, let’s take a look at our care plan for alcohol withdrawal syndrome, starting with the subject of data. So, your patient is not going to be feeling very well ,at all. They’re going to be having headaches. They’re going to feel anxious. They might feel really confused. They might have some nausea or heart palpitations. All of this occurs because the body is so used to having the alcohol regularly depressing their CNS system. And so with the sudden withdrawal, the body is reacting very severely. Sometimes when the alcohol leaves the system, that confusion doesn’t get any better. This is super concerning because they’re lacking many vitamins that we usually get. Um, and they need that for their brain, right? So, the excessive alcohol intake was kind of preventing those nutrients from getting to the brain like it needed to. 

 

So, we’ll talk about interventions that will help with this later. Now, let’s talk about the objective data. So, the lack of CNS depression can cause the patient to become really restless, agitated, and they might have tremors, which you usually can see. And if you can’t, you can ask them to hold their hands out or even just kind of gently touch their hands and you’ll feel the shakiness in their hands. Often the person detoxing is going to experience uncontrollable sweating, so you might have to change their sheets often. You might see some cardiac dysrhythmias on the EKG or telemetry as the body reacts to that lack of alcohol. Their vital signs are probably going to show some tachycardia and hypertension, which is usually treated with medications that actually treat the withdrawal, which we’ll talk about later. So, seizures are a serious, serious side effect of withdrawal that some might have because of the effects on the brain. 

 

Now, let’s talk about the nursing interventions for alcohol withdrawal syndrome. So, you need to perform a complete assessment on this patient, including the vital signs. Pay really close attention to the patient’s respiratory system. You want to make sure they’re still breathing. You want to pay attention to their neurologic system, like that confusion or agitation, and you want to pay attention to their cardiac status, like that high blood pressure and that high heart rate, right? 

 

So, these can all be severely affected with this withdrawal. Include any withdrawal questions that your organization uses per protocol. We’ll talk about the CIWA Protocol later. So, this is going to help you to obtain a baseline and determine the stage and severity. Reassessing often, usually every three hours, will help you determine the effectiveness of the interventions. 

 

There’s different stages. So, stage one would include hyperactivity. Stage two includes hallucinations and seizure activity. Stage three includes DT’S, confusion, fever, and anxiety. So, you might think of this as mild, moderate, and severe. Maintain a patent airway and initiate oxygen as needed if their pulsox levels drop depending on what the doctor’s orders say or the protocols. Be sure to ask questions per your facility protocol regarding the suicidal ideation. Why? Well, sometimes when these patients are coming off alcohol, they feel confused. They feel anxious, um, they just feel really not themselves, so they might start to have some suicidal ideations and experience some self-destructing ideas. So provide isolation as needed or restraints if necessary per facility protocol, to keep that patient and others safe. 

 

So, it’s really, really important to monitor the patient’s heart for cardiac dysrhythmias and irregularities. First, initiate a 12 lead EKG to obtain a baseline, then put the patient on telemetry per doctor order or protocol, so that you can watch their heart on a regular basis. 

 

Remember how I mentioned prolonged confusion in some patients after the alcohol wears off? So, this is called Wernicke Korsakoff Syndrome, and it’s because of the lack of thiamine. So, this has to be treated immediately, or prevented by providing an IV banana bag, which is called the banana bag because it’s yellow. It’s actually full of vitamins that the brain needs. This is so that that confusion does not remain permanent. This can be really scary for family members because the patient is not usually confused. So, they’re like what is going on? So, of course also consider IV hydration because this patient is probably dehydrated and you don’t want to, um, promote any cardiac dysrhythmias. You should initiate seizure precautions, um, per protocol. This is so that you can prevent anything dangerous from occurring, like falling out of bed or choking on their own saliva, so, keep that suction at the bedside. If you need to, you can even provide a camera in the room. If they’re known to have seizures a lot that way, you know, when to get in there and help. So, you want to provide a really calm and safe environment for these patients and reorient them as you need to. If they’re confused, this is going to help decrease their anxiety and increase the safety of them. They already feel really sick and not themselves, so you want to help them to not feel so overstimulated. So, administer medications as appropriate and as ordered by the doctor. 

 

So, my organization uses the CIWA Protocol, which I think many do. So this is to determine the dose of either the lorazepam or the diazepam, depending on which they choose based on the scores that we get after going through the questions. So, let me give you some examples of questions that we might ask the patient:

 

Do you feel anxious? And if so, how would you rate your anxiety from zero to 10? 

 

Are you seeing, or hearing or feeling anything, um, unusual? 

 

Do you feel restless? 

 

Other parts of the CIWA Protocol are really just kind of objective. You can see them, for example, how badly are they sweating or shaking? Are there, um, vital signs off the charts? They have high blood pressure, you know, high heart rate. Um, so medications that we would use are going to help to reduce the hyperactivity. We’re going to prevent seizures hopefully and promote their sleep. They also help to decrease the blood pressure and heart rate. 

 

So, our last intervention is to provide education and resources for that patient and family, if they’re there. So this is so important you guys, you need to help this patient with moving forward. What’s going to happen when they leave the hospital? It’s scary and it’s hard for them. It’s so, so hard for them to stop drinking for good. They need that support and guidance. 

 

We love you guys! Now go out and be your best self today and as always, happy nursing.