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alcohol withdrawalA constellation of clinical findings—e.g., CNS and autonomic nervous system excitability—which results when a person with habitual long-term or heavy alcohol use abstains therefrom, resulting in a drop in blood alcohol concentration.
• Mild 24 hours after last drink
Findings The “shakes,” insomnia, anxiety, hyperreflexia, diaphoresis, mild autonomic hyperactivity, GI upset.
• Moderate 24-36 hours after last drink
Findings Intense anxiety, tremors, insomnia, excess adrenergic symptoms.
• Severe More than 48 hours after last drink
Findings Altered senses (disorientation, agitation, hallucinations); severe autonomic hyperactivity including the “shakes,” tachycardia, tachypnoea, hyperthermia, diaphoresis.
alcohol withdrawalA constellation of clinical findings that result when a person with habitual long-term or heavy alcohol use history goes 'on the wagon' and abstains from alcohol. See Delirium tremens.
alcohol withdrawalAlcohol withdrawal syndrome.
caffeine withdrawalSee: caffeine; caffeine withdrawal headache; coffee; tea
|Mean LOS:||11.7 days|
|Description:||MEDICAL: Alcohol/Drug Abuse with Rehabilitation Therapy|
Withdrawal is a pattern of physiological responses to the discontinuation of a drug or substance such as alcohol. Tolerance occurs when consistent and long-term use of a substance leads to cellular adaptation so that increasing amounts of the substance are needed to produce the substance effect. Most central nervous system (CNS) depressants produce similar responses, but alcohol is the primary substance in which withdrawal is life-threatening, with a mortality rate of about 20% if delirium tremens (DTs) occur and are left untreated. Withdrawal symptoms should be anticipated with any patient who has been drinking the alcohol equivalent of a six-pack of beer on a daily basis for a period of 6 months; patients with smaller body sizes who have drunk less may exhibit the same symptoms. Alcohol withdrawal involves CNS excitation, respiratory alkalosis, and low serum magnesium levels, leading to an increase in neurological excitement (Table 1). The primary pathophysiological mechanism is exposure to and then withdrawal of alcohol to neuroreceptors in the brain, which changes receptor interaction with neuroreceptors, such as gamma-amionbutyric acid, glutamate, and opiates.
|Respiratory alkalosis||Alcohol produces a depressant effect on the respiratory center, depressing a person’s respirations and increasing the level of CO2. Once the person ceases the intake of alcohol, the respiratory center depressions cease, leaving an increased sensitivity to CO2. This increase in sensitivity produces an increase in the rate and depth of the person’s respirations (hyperventilation) and lowered levels of CO2 (respiratory alkalosis).|
|Low magnesium levels||Many people with chronic alcohol dependence have low magnesium intake because of inadequate nutrition. Compounding the problem is the loss of magnesium from the gastrointestinal tract caused by alcohol-related diarrhea and the loss of magnesium in the urine caused by alcohol-related diuresis. Maintaining magnesium levels in the normal range of 1.8–2.5 mEq/L decreases neuromuscular irritability during withdrawal.|
|CNS excitation||Chronic alcohol use alters cell membrane proteins that normally open and close ion channels to allow electrolytes to enter and exit the cell. With the cessation of alcohol intake, the altered proteins produce an increase in neurological excitement.|
Approximately 5% to 10% of the U.S. population is dependent on alcohol, and 30% of the patients on a general hospital unit are likely alcohol dependent; however, only 2% of them have an admitting primary or secondary diagnosis of alcohol dependence or alcoholism. The other 28% have been admitted for a variety of reasons. Illnesses such as esophagitis, gastritis, ulcers, hypoglycemia, pancreatitis, and some anemias can be attributed directly to alcohol usage. Chronic alcohol dependence is the most common cause of cardiomyopathy. There is also an increased incidence of injuries, falls, and hip fractures related to high blood alcohol levels.
Alcohol withdrawal is a life-threatening condition. It can begin within 12 to 24 hours of admission or as late as 2 weeks after a person stops drinking. Early-stage withdrawal usually occurs within 48 hours of the patient’s last drink, with generally mild symptoms. Late-stage alcohol withdrawal, or alcohol withdrawal delirium, usually begins 72 to 96 hours after the patient’s last drink but can occur up to 2 weeks later. It occurs in approximately 5% of all patients hospitalized with alcohol dependence and is the most acute phase of alcohol withdrawal.
When a heavy drinker takes a drink, there is a calming effect, a sense of tranquility. As alcohol consumption continues, the CNS is increasingly depressed, leading to a sleep state. The brain (reticular activating system) attempts to counteract sleepiness and the depression with a “wake-up” mechanism. The reticular activating system works through chemical stimulation to keep the body and mind alert. The individual who drinks on a daily basis builds up a tolerance to the alcohol, requiring increasing amounts to maintain the calming effect. If no alcohol is consumed for 24 hours, the reticular activating system nonetheless continues to produce the stimulants to maintain alertness, which leads the individual to experience an overstimulated state and the development of alcohol withdrawal symptoms after 48 hours.
Susceptibility to alcohol abuse appears to run in families and is the subject of vigorous ongoing investigations to locate genes that contribute. It is probable that the effects of multiple genes and environment are involved in alcoholism. Twin studies have shown a stronger concordance between identical than between nonidentical twins (55% or greater concordance for monozygotic twins and 28% for same-sex dizygotic twins). Genetic differences in alcohol metabolism may result in higher levels of a metabolite that produces pleasure for those with a predisposition to alcohol abuse. Associations between alcoholism and certain alleles of alcohol dehydrogenase (ADH2, ADH3, and ADH7) have been documented. Polymorphisms in SNCA, GABA-A, NPY, TAS2R16, CHRM2, DRD2, ALDH2, ANKK1, SLC6A4, and COMT genes have also been associated with alcohol abuse.
Gender, ethnic/racial, and life span considerations
Overuse and abuse of alcohol are seen in all age groups and in females and males. More and more teens are identified as alcohol dependent and should have their drug or alcohol usage assessed on admission to the hospital or clinic. Binge drinking (more than five drinks at one time for males and four for females) is a persistent problem among college students. Approximately 70% of people who are alcohol dependent are males, but women are more likely to hide their problem. Of growing concern is the number of elderly who are abusing alcohol as a way to deal with their grief, loneliness, and depression. Ethnicity and race have no known effects on alcohol withdrawal.
Global health considerations
Alcohol consumption has increased greatly in developing countries and is a health concern because, first, it is occurring in countries without a tradition of alcohol use, and second, these countries have few strategies for prevention or treatment. Alcohol causes approximately 20% and 30% of the following diseases and conditions: esophageal and liver cancer, cirrhosis of the liver, epilepsy, homicide, and motor vehicle collisions. Alcohol causes 1.8 million deaths each year and a significantly shortened life span in millions of others worldwide. Motor vehicle collisions and other unintentional injuries account for almost one-third of the alcohol-related deaths.
Determine when the patient had his or her last drink to assess the risk of alcohol withdrawal. Do not ask “Do you drink?” but rather, “When did you have your last drink?” Asking the patient’s significant others about her or his alcohol use may be another way to establish a history of alcohol abuse; however, the significant others may also be unwilling to answer potentially embarrassing questions honestly.
Use the CAGE questionnaire, an alcoholism screening instrument. CAGE is an acronym for key words in the questions that follow. Affirmative answers to two or more of the CAGE screening questions identify individuals who require more intensive evaluation:
- Have you ever felt the need to CUT down on drinking?
- Have you ever felt ANNOYED by criticisms of your drinking?
- Have you ever had GUILTY feelings about drinking?
- Have you ever taken a morning EYE opener?
Determine if the patient has a history of poor nutrition or an illness or infection that has responded poorly to treatment; these are possible signs of alcohol dependence. Ask the patient if he or she has experienced any agitation, restlessness, anxiety, disorientation, or tremors in the past few hours, which are signs of the onset of early-stage alcohol withdrawal. Determine if the patient has been sweating excessively; feeling weak in the muscles; or experiencing rapid breathing, vomiting, or diarrhea.
Use caution in the amount of information you document regarding a patient's alcohol use history. The information is more appropriately placed in a confidential file that is not a part of the formal patient record to protect the patient’s confidentiality. Patients have lost medical coverage when insurance agents or attorneys have obtained access to written confidential information on the patient record. Recommend strategies for care in writing, but do not detail a confidential patient drinking history in the legal patient record.
Although many people with alcohol dependence appear normal, look for clues of alcohol use, particularly if the patient has not been forthcoming during the history taking. Note the odor of alcohol on the breath or clothing. Inspect arms and legs for bruising or burns that may have been caused by injury. Inspect for edema around the eyes or tibia and a flushed face from small vessel vasodilation. Observe general appearance, noting if the patient appears haggard or older than the stated age.
The first symptoms of alcohol withdrawal can appear as soon as 4 hours after the last drink. Note any comments made by the patient about drinking, even in jest. Observe any defensiveness or guarded responses to questions about drinking patterns. Note if the patient requests sedation. If you suspect that a patient may have been abusing alcohol, assess the vital signs every 2 hours for the first 12 hours. If the patient remains stable, vital signs can be assessed less frequently; however, monitor the patient carefully for signs of mild anxiety or nervousness that could indicate alcohol withdrawal. Temperature, blood pressure, and heart rate begin to elevate. Hyperalertness and irritability increase. The patient may remark that she or he feels “trembly” or nervous on the “inside” (internal tremors). Temperature, blood pressure, and heart rate continue to elevate. Mild disorientation and diaphoresis are present. External tremors are visible. DTs is the name associated with the symptoms of confusion and tremors. If the brain is still not sedated, the patient can have seizures, cardiac failure, and death unless medication protocols are instituted.
Patients who have previously experienced active withdrawal may have little trust or confidence that the nurse will treat them any differently. Individuals who are alcohol dependent may be in denial or very embarrassed at having their drinking exposed. Maintain a nonjudgmental, supportive approach. The patient needs to feel secure that you will be there to keep him or her safe. Assess the patient’s coping mechanisms and support system.
|Test||Normal Result||Abnormality With Condition||Explanation|
|Blood alcohol concentration||Negative (< 10 mg/dL or 0.01 g/dL)||Positive (> 10 mg/dL or 0.01 g/dL)||Legal intoxication in most states is 80 mg/dL|
|Liver function gamma-glutamyl transpeptidase||4–25 units (females); 7–40 units (males)||Elevated above normal||Evidence of liver disease or alcoholism|
|Aspartate aminotransferase||8–20 units/L||Elevated above normal||Evidence of liver disease or alcoholism|
|Alanine aminotransferase||8–10 units/L||Elevated above normal||Evidence of liver disease or alcoholism|
Other Tests: Blood glucose levels: Elevated or low blood glucose levels without a family history of diabetes mellitus indicate chronic alcohol use. Chest x-ray: Approximately 50% of patients with DTs who have fever will also have an infection and, in particular, pneumonia.
Primary nursing diagnosis
DiagnosisFluid volume deficit related to water loss
OutcomesFluid balance; Circulation status; Cardiac pump effectiveness; Hydration; Nutrition management; Nutrition therapy
InterventionsFluid/electrolyte management; Fluid monitoring; Shock management: Volume; Medication administration; Circulatory care
Planning and implementation
Upon assessment of a pattern of heavy drinking, the patient is often placed on prophylactic benzodiazepines. These medications are particularly important if the patient develops early signs of withdrawal, such as irritability, anxiety, tremors, restlessness, confusion, mild hypertension (blood pressure > 140/90), tachycardia (heart rate > 100), and a low-grade fever (temperature > 100°F). Keeping the patient safe during the withdrawal process depends on managing the physiological changes, the signs and symptoms, and the appropriate drug protocols. The goal is to keep the patient mildly sedated or in a calm and tranquil state but still allow for easy arousal.
Although sedation should prevent withdrawal, if withdrawal occurs, patients will often require intravenous hydration, with fluid requirements ranging from 4 to 10 L in the first 24 hours. Hypoglycemia is common, and often a 5% dextrose solution in 0.90% or 0.45% saline will be used. Monitor and replace electrolytes as necessary because people with alcohol dependence often have low calcium, magnesium, phosphorous, and potassium.
Once the patient’s nausea and vomiting have been controlled, encourage a well-balanced diet. Monitor the patient continually for signs of dehydration, such as poor skin turgor, dry mucous membranes, weight loss, concentrated urine, and hypotension. Record intake and output. If the patient’s blood pressure drops below 90 mm Hg, a significant fluid volume loss has occurred; notify the physician immediately.
|Medication or Drug Class||Dosage||Description||Rationale|
|Thiamine; multivitamin supplements||100 mg IV; 1 amp multivitamin||Vitamin supplement||Counters effects of nutritional deficiencies|
|Benzodiazepines||Varies by drug||Anti-anxiety||Manages alcohol withdrawal; prescribed for their sedating effect and to control the tremors or seizures, which can be life-threatening|
Other Drugs: Electrolyte replacement, phenobarbital, carbamazepine, and midazolam; clonidine and beta blockers may be administered to suppress the cardiovascular signs of withdrawal. It is not appropriate to administer alcohol in any form to manage DTs or withdrawal.
Managing fluid volume deficit is a top priority in nursing care. Encourage the patient to drink fluids, particularly citrus juices, to help replace needed electrolytes. Caution the patient to avoid caffeine, which stimulates the CNS. Maintain a quiet environment to assist in limiting sensory or perceptual alterations and sleep pattern disturbance.
An appropriately sedated patient should not undergo acute withdrawal. If symptoms occur, however, stay at the bedside during episodes of extreme agitation to reassure the patient. Avoid using restraints. However, if they become necessary, position the patient to prevent aspiration. Use soft rather than leather restraints to reduce the risk for skin abrasions and circulatory insufficiency. During restraint, check the patient’s circulation every 2 hours or more often.
When the patient is awake, alert, and appropriately oriented, discuss her or his drinking and the effect of drinking on the patient’s illness. Encourage the patient to seek help from Alcoholics Anonymous (AA) or to see a counselor or attend a support group. Refer the patient to a clinical nurse specialist if appropriate.
Evidence-Based Practice and Health Policy
Pecoraro, A., Ewen, E., Horton, T., Mooney, R., Kolm, P., McGraw, P., & Woody, G. (2013). Using the AUDIT-PC to predict alcohol withdrawal in hospitalized patients. Journal of General Internal Medicine, August 20. Advanced online publication. doi 10.1007/s11606-013-2551-9
- The AUDIT-PC screening tool, originally designed to identify problem drinkers in outpatient primary care settings, evaluates the frequency and amount of alcohol consumption, ability to stop drinking once alcohol consumption has begun, the effects of alcohol consumption on the ability to meet normal behavioral expectations, and external concern about alcohol consumption habits.
- In one study, which compared 223 patients who developed alcohol withdrawal syndrome (AWS) during hospitalization to 466 randomly selected patients without AWS, an AUDIT-PC score ≥ 4 at admission provided 91% sensitivity and 89.7% specificity for predicting the development of AWS during hospitalization.
- In this study, each point increase in the AUDIT-PC score was associated with a 1.68 increased risk of developing AWS (p < 0.001).
- Physical findings: Vital signs, fluid intake and output, skin turgor, presence of tremors or seizures
- Mental status: Anxiety level, auditory-visual hallucinations, confusion, violent behavior
- Reactions to the alcohol withdrawal experience
Discharge and home healthcare guidelines
teaching.Teach the patient to eat a well-balanced diet with sufficient fluids. Emphasize the value of exercise and adequate rest. Encourage the patient to develop adequate coping strategies.
follow-up.Following an alcohol withdrawal experience, the patient may be able to accept that he or she has a problem with alcohol abuse. Discharge plans may include behavior modification programs, sometimes in conjunction with disulfiram (Antabuse) or participation in AA. Families must also be involved in the treatment planning to gain an understanding of the part that family dynamics play in people who are alcohol dependent.
Patient discussion about alcohol withdrawal
Q. ALCOHOL WITHDRAWAL what are the symtoms of it?