Nursing Care Plan for Alcohol Withdrawal Syndrome / Delirium Tremens

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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

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