FACTS - Alcohol Withdrawal

AETIOLOGY AND RISK FACTORS

- Physical dependence upon alcohol results in withdrawal symptoms if alcohol intake is suddenly stopped or reduced sharply.

- Withdrawal symptoms commence within 12 hours of stopping alcohol; these can be unpleasant even in their most minor forms.

- Most dependent drinkers will experience the minor forms of withdrawal, while some will suffer severe symptoms that require detoxification in an inpatient setting.

- Risks can include dehydration from vomiting or diarrhoea, convulsions, hallucinations and or confusion, leading to agitation and sometimes aggression.

- Minor withdrawal symptoms often peak between the second and fourth days of withdrawal and subside after this, disappearing by the eighth to tenth day.

- Major withdrawal symptoms can appear between the first and fifth days, with rapid onset. A previous history of these symptoms is the best predictor of their recurrence.

SIGNS AND SYMPTOMS

- The quantity of alcohol consumed does not necessarily dictate the severity of symptoms.

Minor symptoms

- Trembling;

- Agitation or anxiety;

- Insomnia;

- Morning retching or vomiting;

- Sweating, particularly at night;

- Frequent loose bowel motions.

Major symptoms

- Withdrawal convulsions;

- Hallucinations;

- Confusion, possible Wernickes encephalopathy or Korsakoffs psychosis;

- Delirium tremens - a serious effect of withdrawal displaying many of the above symptoms, including sweating, tachycardia, tachypnoea and pyrexia. It may also include dehydration, concurrent infection, hepatic disease or Wernicke-Korsakoff syndrome. The patient is often disorientated, with agitation, marked tremor and vivid hallucinations. The condition can be fatal if untreated.

DIAGNOSIS

- The international criteria for psychiatric diagnosis classifies alcohol withdrawal as ICD-10 (F10.3). The number 10 indicates mental illness, F10 relates to mental disorders due to alcohol, and F10.3 refers to the withdrawal state.

- The ICD states that any three of the listed symptoms are useful in making a diagnosis of alcohol dependence, in conjunction with a verbal history from the patient or relatives, a previous medical history, high blood alcohol, alcohol on the breath and deranged liver function tests (LFTs).

TREATMENT

- Sedation with appropriate benzodiazepines (often chlordiazepoxide). The regimen should dampen symptoms while avoiding over sedation and should be reduced to zero over eight to 10 days.

- Management of hallucinations with suitable neuroleptics.

- Maintenance of hydration.

- Vitamin treatment of dietary neglect, and as prophylaxis, to prevent Wernicke-Korsakoff syndrome. Where confusion is present, or if there is a history of dietary neglect, vitamins are given parenterally.

- Treatment of concurrent infections.

NURSING IMPLICATIONS

- The observation of symptoms and titration of medication accordingly (in collaboration with medical staff).

- Administration of parenteral vitamins and intravenous medications and fluids, particularly if delirium tremens is present

- Management of confusion or hallucinations, orientation via explanation, liaison with specialist services and psychiatry regarding treatment and follow-up options.

Alcohol Withdrawal

Alcohol Withdrawal

Alcohol withdrawal often occurs after moderate consumption of alcohol over a specified period of time. Excessive alcohol use is generally broken down into several categories and is considered; fifteen drinks per week or five per day in men, and eight per week or four per day in women. While alcohol withdrawal often occurs as little as five hours after the last drink, it is important to recognize alcoholism as well. Physical signs of alcoholism may include slurred speech, clumsiness, dizziness, blackouts, weight loss, redness of face, and numbness of fingers. While, other common symptoms of alcoholism may include; inability to control drinking, being presented with atypical dangerous situations, disruptions in sleep pattern, irritability, agitation, and unexplained absences of work or school.Alcohol withdrawal is relatively subjective and varies greatly with every individual.

Etiology

Etiology for alcoholism leading to withdrawal generally never has a single cause, the disorder is often more dynamic then most people are aware. The most common belief surrounding alcoholism, and all addiction for that matter, is family history, weather psychosocially or genetically, it is thought that you are at higher risk for alcohol abuse if you have a family history of addiction. Another common "cause" of addiction, which is often seen in the acute care environment, is a history of mental illness (helpguide.org). This usually leads to a dual diagnosis, where alcohol abuse worsens the other illness. Other commonplace etiologies that comprise alcoholism are peer pressure, and stressful life events. Statistically speaking nearly 14 million Americans meet diagnostic criteria for alcohol use disorders, about 18% will meet the criteria for alcohol abuse in their lifetime, and finally more than 100,000 U.S. deaths are caused by excessive alcohol consumption each year (gdcada.org). As one can see, anyone can fall victim to alcoholism and withdrawal, and it is crucial for the nurse to keep an open mind, or nose.

Signs and Symptoms

Many people do not arrive at the hospital complaining of "alcohol withdrawal", they usually show up demonstrating secondary symptoms. This is where it becomes important for the nurse to properly identify the signs and symptoms and provide the best care possible. Alcohol withdrawal is a very unpleasant experience and can range from mild symptoms, to a life threatening event. Medline Plus divides signs and symptoms into three categories; psychological, physical, and severe. Mild to moderate psychological symptoms will usually present first and include; jumpiness or nervousness, shakiness, anxiety, irritability or easy excitability, rapid emotional changes, depression, fatigue, difficulty thinking clearly, and bad dreams. Likewise physical symptoms, are typically indicative of more severe with withdrawal and manifest as; headache, sweating, nausea and vomiting, anorexia (loss of appetite), insomnia, pallor, tachycardia, dilated pupils, tremors, and involuntary spasms of the eyelids. Finally the nurse needs to especially be on alert for severe symptoms, even after a diagnosis has been made. Severe symptoms include; delirium, fever, convulsions, black outs and sever agitation. Once the nurse is able to identify a patient suffering through alcohol withdrawal they can begin proper treatment.

Diagnosis

Diagnosis according to the Diagnostic and statistical manual of mental disorders 4th edition, text revision (DSM- IV-TR) is multifaceted and is broken down into four points.The DSM-IV-TR is what is used diagnose, but is not necessarily required to start treatment for alcohol withdrawal.

Pharmacological Treatment

Pharmacological treatment of Alcohol withdrawal is often used in conjunction with non-pharmacologic methods, and has shown great success. Medications used to treat alcohol withdrawal must not be potentiated, or altered by alcohol, as to become intolerable. The most common used class of medication are benzodiazepines, which include; alprazolam, chlordiazepoxide, clorazepate, diazepam, and lorzepam to name a few. The choice of drug often varies depending on the situation, but long-acting agents are frequently used (American Family Physician). The long acting benzodiazepines diazepam (Valium) and chlordiazepoxide (Librium) are effective because of their long half-life, "smoother" withdrawal, and rebound withdrawal symptoms are less likely to manifest. Intermediate acting benzodiazepines (lorazepam and oxazepam) are beneficial for the elderly and patients with liver failure. Lorazepam is also the only medication in this category that can be administered intramuscularly, which is important if a patient in unable to swallow or is NPO. Other medications, haloperidol (Haldol) and atenolol (Tenormin), can be used along with benzodiazepines but not by themselves in the treatment of alcohol withdrawal. Haloperidol is helpful in managing agitation and hallucinations, and atenolol has shown to improve vital signs and reduce alcohol cravings in adjunct with oxazepam. It is also advised that medications used to treat underlying conditions are compatible with benzodiazepines before administration, and modifications be made as necessary.

Non-pharmacologic Treatment

The nurse will likely be responsible for monitoring blood pressure, temperature, breathing, heart rate, and fluid and electrolyte level. Also the nurse should monitor lab values, and frequently assess other body systems for abnormalities. Generally speaking, when the vital signs are stable, and within normal limits, there is no immediate physical threat to the patient and the nurse can focus on mental state. Although initial treatment for alcohol withdrawal may be short term inpatient, the long term care and detoxification more often occurs on an outpatient basis. Common belief is inpatient setting provides the safest most effective setting, but is usually reserved for severe cases. Many studies agree that withdrawal is best treated with supportive care. According to Myrick and Anton, supportive care consists of providing patients with a quiet environment, reduced lighting, limited interpersonal interaction, nutrition and fluids, reassurance, and positive encouragement. Many experts emphasize that regardless of how mild the withdrawal may seem pharmacologic treatment must be used in adjunct with supportive care. A commonly known program, Alcoholics Anonymous (AA), is a support group used as long term therapy for recovering alcoholics after severe physical symptoms have subsided. Many patients are encouraged to attend meetings at AA or other groups along with one-on-one therapy. Alternative therapies may also include natural and herbal remedies, one in particular that is popular

Nursing Diagnoses

There are a wide array of nursing diagnoses that would suffice for Alcohol withdrawal, and will vary greatly depending on the presenting signs and symptoms. A nurse will often include a diagnosis from the Ego Integrity category from NANDA, as alcohol withdrawal is considered a mental disorder. Impaired adjustment, Anxiety, and Ineffective Coping are a few often used in relation to the underlying cause of alcoholism and ultimately why they ended up in treatment. Altered thought process and sensory perception alterations are frequently seen in withdrawal, especially in the earlier stages. Safety is another huge aspect of care the nurse needs to address, especially in the acute treatment of a person going through a withdrawal. Safety diagnoses include; risk for injury, risk for violence directed at self/others, hyperthermia, impaired physical mobility, and many others. It is also vital the nurse monitor respiratory status, as alcohol can depress respirations, in which case the nurse would formulate a nursing diagnosis based on ineffective breathing pattern. Caring for an alcohol withdrawal patient requires a dynamic approach by the nurse, and no aspect of care should be overlooked. Once the severe signs and symptoms have been cared for, the nurse must identify and treat the underlying cause, psychological symptoms.

Conclusion

Alcohol withdrawal is a common problem in society today, and with such high numbers of people abusing alcohol it is an issue that needs to be addressed. Identifying that they have a problem is the first step to becoming better. It is important that people are able to identify signs of alcoholism and alcohol withdrawal, weather for themselves, a family member or a friend. The earlier someone seeks treatment and is diagnosed, the more successful they will be. Fortunately with advances in medicine, treatment starts at a pharmacological level, relieving physical symptoms in a brisk manner, allowing the underlying cause to be addressed. With education and awareness, one can hope we can reduce the incidence of alcoholism and withdrawal.

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Alcohol Withdrawal

Alcohol Withdrawal

Alcohol withdrawal often occurs after moderate consumption of alcohol over a specified period of time. Excessive alcohol use is generally broken down into several categories and is considered; fifteen drinks per week or five per day in men, and eight per week or four per day in women. While alcohol withdrawal often occurs as little as five hours after the last drink, it is important to recognize alcoholism as well. Physical signs of alcoholism may include slurred speech, clumsiness, dizziness, blackouts, weight loss, redness of face, and numbness of fingers. While, other common symptoms of alcoholism may include; inability to control drinking, being presented with atypical dangerous situations, disruptions in sleep pattern, irritability, agitation, and unexplained absences of work or school.Alcohol withdrawal is relatively subjective and varies greatly with every individual.

Etiology

Etiology for alcoholism leading to withdrawal generally never has a single cause, the disorder is often more dynamic then most people are aware. The most common belief surrounding alcoholism, and all addiction for that matter, is family history, weather psychosocially or genetically, it is thought that you are at higher risk for alcohol abuse if you have a family history of addiction. Another common "cause" of addiction, which is often seen in the acute care environment, is a history of mental illness (helpguide.org). This usually leads to a dual diagnosis, where alcohol abuse worsens the other illness. Other commonplace etiologies that comprise alcoholism are peer pressure, and stressful life events. Statistically speaking nearly 14 million Americans meet diagnostic criteria for alcohol use disorders, about 18% will meet the criteria for alcohol abuse in their lifetime, and finally more than 100,000 U.S. deaths are caused by excessive alcohol consumption each year (gdcada.org). As one can see, anyone can fall victim to alcoholism and withdrawal, and it is crucial for the nurse to keep an open mind, or nose.

Signs and Symptoms

Many people do not arrive at the hospital complaining of "alcohol withdrawal", they usually show up demonstrating secondary symptoms. This is where it becomes important for the nurse to properly identify the signs and symptoms and provide the best care possible. Alcohol withdrawal is a very unpleasant experience and can range from mild symptoms, to a life threatening event. Medline Plus divides signs and symptoms into three categories; psychological, physical, and severe. Mild to moderate psychological symptoms will usually present first and include; jumpiness or nervousness, shakiness, anxiety, irritability or easy excitability, rapid emotional changes, depression, fatigue, difficulty thinking clearly, and bad dreams. Likewise physical symptoms, are typically indicative of more severe with withdrawal and manifest as; headache, sweating, nausea and vomiting, anorexia (loss of appetite), insomnia, pallor, tachycardia, dilated pupils, tremors, and involuntary spasms of the eyelids. Finally the nurse needs to especially be on alert for severe symptoms, even after a diagnosis has been made. Severe symptoms include; delirium, fever, convulsions, black outs and sever agitation. Once the nurse is able to identify a patient suffering through alcohol withdrawal they can begin proper treatment.

Diagnosis

Diagnosis according to the Diagnostic and statistical manual of mental disorders 4th edition, text revision (DSM- IV-TR) is multifaceted and is broken down into four points.The DSM-IV-TR is what is used diagnose, but is not necessarily required to start treatment for alcohol withdrawal.

Pharmacological Treatment

Pharmacological treatment of Alcohol withdrawal is often used in conjunction with non-pharmacologic methods, and has shown great success. Medications used to treat alcohol withdrawal must not be potentiated, or altered by alcohol, as to become intolerable. The most common used class of medication are benzodiazepines, which include; alprazolam, chlordiazepoxide, clorazepate, diazepam, and lorzepam to name a few. The choice of drug often varies depending on the situation, but long-acting agents are frequently used (American Family Physician). The long acting benzodiazepines diazepam (Valium) and chlordiazepoxide (Librium) are effective because of their long half-life, "smoother" withdrawal, and rebound withdrawal symptoms are less likely to manifest. Intermediate acting benzodiazepines (lorazepam and oxazepam) are beneficial for the elderly and patients with liver failure. Lorazepam is also the only medication in this category that can be administered intramuscularly, which is important if a patient in unable to swallow or is NPO. Other medications, haloperidol (Haldol) and atenolol (Tenormin), can be used along with benzodiazepines but not by themselves in the treatment of alcohol withdrawal. Haloperidol is helpful in managing agitation and hallucinations, and atenolol has shown to improve vital signs and reduce alcohol cravings in adjunct with oxazepam. It is also advised that medications used to treat underlying conditions are compatible with benzodiazepines before administration, and modifications be made as necessary.

Non-pharmacologic Treatment

The nurse will likely be responsible for monitoring blood pressure, temperature, breathing, heart rate, and fluid and electrolyte level. Also the nurse should monitor lab values, and frequently assess other body systems for abnormalities. Generally speaking, when the vital signs are stable, and within normal limits, there is no immediate physical threat to the patient and the nurse can focus on mental state. Although initial treatment for alcohol withdrawal may be short term inpatient, the long term care and detoxification more often occurs on an outpatient basis. Common belief is inpatient setting provides the safest most effective setting, but is usually reserved for severe cases. Many studies agree that withdrawal is best treated with supportive care. According to Myrick and Anton, supportive care consists of providing patients with a quiet environment, reduced lighting, limited interpersonal interaction, nutrition and fluids, reassurance, and positive encouragement. Many experts emphasize that regardless of how mild the withdrawal may seem pharmacologic treatment must be used in adjunct with supportive care. A commonly known program, Alcoholics Anonymous (AA), is a support group used as long term therapy for recovering alcoholics after severe physical symptoms have subsided. Many patients are encouraged to attend meetings at AA or other groups along with one-on-one therapy. Alternative therapies may also include natural and herbal remedies, one in particular that is popular

Nursing Diagnoses

There are a wide array of nursing diagnoses that would suffice for Alcohol withdrawal, and will vary greatly depending on the presenting signs and symptoms. A nurse will often include a diagnosis from the Ego Integrity category from NANDA, as alcohol withdrawal is considered a mental disorder. Impaired adjustment, Anxiety, and Ineffective Coping are a few often used in relation to the underlying cause of alcoholism and ultimately why they ended up in treatment. Altered thought process and sensory perception alterations are frequently seen in withdrawal, especially in the earlier stages. Safety is another huge aspect of care the nurse needs to address, especially in the acute treatment of a person going through a withdrawal. Safety diagnoses include; risk for injury, risk for violence directed at self/others, hyperthermia, impaired physical mobility, and many others. It is also vital the nurse monitor respiratory status, as alcohol can depress respirations, in which case the nurse would formulate a nursing diagnosis based on ineffective breathing pattern. Caring for an alcohol withdrawal patient requires a dynamic approach by the nurse, and no aspect of care should be overlooked. Once the severe signs and symptoms have been cared for, the nurse must identify and treat the underlying cause, psychological symptoms.

Conclusion

Alcohol withdrawal is a common problem in society today, and with such high numbers of people abusing alcohol it is an issue that needs to be addressed. Identifying that they have a problem is the first step to becoming better. It is important that people are able to identify signs of alcoholism and alcohol withdrawal, weather for themselves, a family member or a friend. The earlier someone seeks treatment and is diagnosed, the more successful they will be. Fortunately with advances in medicine, treatment starts at a pharmacological level, relieving physical symptoms in a brisk manner, allowing the underlying cause to be addressed. With education and awareness, one can hope we can reduce the incidence of alcoholism and withdrawal.

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