|Year : 2015 | Volume
| Issue : 1 | Page : 17-24
Alcohol withdrawal: A case report
Santhi L Johnson1, Velvizhi Theerthagiri2, Manoranjitham Sathiyaseelan3
1 Lecturer, College of Nursing, CMC, Vellore, India
2 Charge Nurse, CMC, Vellore, India
3 Professor, Dept. of Psychiatry Nursing, College of Nursing CMC, Vellore, India
|Date of Web Publication||10-Jun-2020|
Source of Support: None, Conflict of Interest: None
Alcohol withdrawal is a set of symptoms seen in an individual who reduces or stops alcohol consumption after prolonged periods of alcohol intake. Withdrawal signs and symptoms are usually minor, but they can be considerable and even fatal. Alcohol withdrawal delirium commonly known as Delirium Tremens or ‘DTs’, is the most serious manifestation of alcohol withdrawal syndrome. Nurses play a major role in early identification and management to rehabilitate these patients. A case report is presented in this article including clinical presentation, diagnostic measures and management.
Keywords: alcohol withdrawal, alcohol withdrawal syndrome, delirium tremens, nurse’s role, management, case report
|How to cite this article:|
Johnson SL, Theerthagiri V, Sathiyaseelan M. Alcohol withdrawal: A case report. Indian J Cont Nsg Edn 2015;16:17-24
| Introduction|| |
Alcohol withdrawal is a set of symptoms manifested in an individual who reduces or stops alcohol consumption after prolonged periods of alcohol intake. It can result in a range of symptoms from mild tremors to seizures. While mild withdrawal can cause discomfort, severe withdrawal may be life-threatening. Patients who drink heavily may not recognize that they have problem, or be embarrassed and minimize their drinking pattern not realizing that alcohol withdrawal can be life-threatening. The goals of treatment of alcohol withdrawal are to relieve the patient’s discomfort and prevent the occurrence of more serious symptoms. It also provides an opportunity to engage the patient in, and begin the process of de-addiction from alcohol (Jane, 2010).
Alcohol withdrawal is a clinical syndrome that affects people accustomed to regular alcohol intake who either reduce their alcohol consumption significantly or stop drinking completely. The common patterns of substance use disorders are acute intoxication, withdrawal state, dependence syndrome, and harmful use. The different terms relevant to alcohol withdrawal are alcohol abuse, alcohol dependence, alcoholism, and alcohol withdrawal syndrome (Mckay, Koranda, & Axen, 2004). The major dependence producing psychoactive substances or drugs include alcohol, opioids (e.g., opium, heroin), cannabinoids (e.g., cannabis), cocaine, amphetamine and other sympathomimetics, hallucinogens, sedatives, inhalants, nicotine, and other stimulants (e.g., caffeine) (Carson, 2000).
| Incidence|| |
Approximately 27% of people between the age of18 and 64 years meet the diagnostic criteria for alcohol dependence. About 50% of alcohol dependent patients develop clinically relevant symptoms of withdrawal, ranging from 13% to 71% (Mckeon, Frye, & Delanty, 2008).
| Pathophysiology|| |
Alcohol has a slowing effect (also called a sedating effect or depressant effect) on the brain. In a heavy, long-term drinker, the brain is almost continually exposed to the depressant effect of alcohol. Over time, the brain adjusts its own chemistry to compensate for the effect of the alcohol. It does this by producing naturally stimulating chemicals such as serotonin or norepinephrine, which is a relative of adrenaline in larger quantities than normal. If the alcohol is withdrawn suddenly, the brain is like an accelerated vehicle that has lost its brakes. Most symptoms of withdrawal are symptoms that occur when the brain is over stimulated.
Alcohol withdrawal syndrome is mediated by a variety of mechanisms. The brain maintains neurochemical balance through inhibitory and excitatory neurotransmitters. The main inhibitory neurotransmitter is g-amino-butyric acid (GABA), which acts through the GABA-alpha (GABA-A) neuroreceptor. One of the major excitatory neurotransmitters is glutamate, which acts through the N-methyl-D-aspartate (NMDA) neuroreceptor. Alcohol enhances the effect of GABA on GABA-A neuroreceptors, resulting in decreased overall brain excitability. Chronic exposure to alcohol results in a compensatory decrease of GABA-A neuroreceptor response to GABA, evidenced by increasing tolerance of the effects of alcohol. Alcohol inhibits NMDA neuroreceptors, and chronic alcohol exposure results in up-regulation of these receptors. Abrupt cessation of alcohol exposure results in brain hyperexcitability, because receptors previously inhibited by alcohol are no longer inhibited. Brain hyperexcitability manifests clinically as anxiety, irritability, agitation, and tremors. Severe manifestations include alcohol withdrawal seizures and delirium tremens (Bayard. Mcintyre, Hill, Woodside, & James, 2004).
| Clinical Manifestations|| |
The signs and symptoms of alcohol withdrawal usually appear between 6 and 48 hours after heavy alcohol consumption decreases. Initial symptoms may include the following (Elliott, Geyer, Lionetti, & Doty, 2013).
- Nausea and vomiting
- Craving for alcohol
- Poor concentration
- Elevated temperature
- Increased blood pressure
- Mood swings
The most severe form of alcohol withdrawal is DT, a medical emergency which usually occurs 2 to 4 days after the last use of alcohol. While only about 5% of patients with alcohol withdrawal progress to DTs, about 5% of these patients die.
DT’s are characterized by:
- severe anxiety or agitation
- clouding of consciousness and confusion
- hallucinations (visual, auditory, tactile)
- fearfulness and suspicions
- diaphoresis, tachycardia, hypertension
Seizures may occur in some people with alcohol withdrawal and usually begin within the first 24 hours after cessation of alcohol use. [Table 1] shows the timings of alcohol withdrawl syndrome (Gordon, 2011).
| Diagnosis/Assessment of Alcohol Withdrawal|| |
History: A careful history is essential, eliciting the details of the amount and pattern of use, history of complications presently or in the past, and the time of last drink. Patients who have a long history of intoxication and withdrawals and those who develop withdrawal syndrome more than 2 days after their last drink are more likely to experience severe symptoms. A history of seizures, delirium, and tachycardia further increase the risk of more severe withdrawal symptoms (Burns, Price, & Lekawa, 2010).
Physical Examination: Patients withdrawing from alcohol must be carefully examined for injuries, vitamin deficiency and medical conditions after the vital signs (pulse, respiration, blood pressure), hydration, level of consciousness have been checked and stabilized. General examination should focus on cardiac functioning, liver disease (e.g., alcoholic hepatitis), pancreatic disease (e.g., alcoholic pancreatitis), infectious diseases (e.g.. tuberculosis), bleeding within the digestive system and nervous system impairment (Burns et al., 2010).
Standardized Tools: Scales such as the Clinical Institute Withdrawal Assessment for Alcohol (CIAW-Ar) scale may be used to assess the severity of the withdrawal and plan management strategies (Sullivan, Sykora, Schneiderman, Naranja, & Sellers, 1989). Assessment includes nausea and vomiting, tactile disturbances, tremor, auditory disturbances, paroxysmal sweats, visual disturbances, anxiety, head ache, fullness in head, agitation, disorientation, and clouding of sensorium. Each aspect of the assessments is rated from zero to a maximum of four to seven. A part of the scale is given in Box 1.
| Management|| |
The goals of treatment include reducing withdrawal symptoms, preventing complications of alcohol use, and therapy to stop drinking (abstinence). Management includes supportive care and pharmacological management (Jarris & Blad, 2010)
1. Supportive Care
- Comorbid medical conditions: These should be treated if present. Metabolic derangements must be corrected with oral or intravenous fluids. Vital signs and other clinical parameters must be frequently reassessed. The environment must be quiet and non- stimulating.
- Nutrition: Supplemental Thiamine and multivitamins in oral and parenteral forms must be given. Injection Neurobion must be given daily for 5 days along with 100 mg of oral Thiamine thrice a day and oral Multivitamin tablets.
- Complications: Patients with, or at risk for Wernicke’s encephalopathy must be given parenteral Thiamine. If injuries are present, Tetanus Toxoid may be required.
- The patient must be provided with support and reassurance.
2. Pharmacological Treatment
- Benzodiazepines: Benzodiazepines are a class of sedative medications that are used in alcohol withdrawal to control psychomotor agitation and prevent progression to more severe withdrawal. Longer acting benzodiazepines such as Diazepam or Chlordiazepoxide provide a smoother and safer withdrawal than other preparations. Shorter acting preparations such as Lorazepam are indicated when elimination time for benzodiazepines is prolonged, such as in patients with significant liver disease. Initially high doses of the drug are administered based on the severity of the withdrawal symptoms and the dose gradually tapered as the symptoms subside. For example, Chlordiazepoxide 20 mg may be given three or four times a day; one or two extra doses may be given on the first day if the patient is jittery or has increasing tremors. On every consecutive or alternate day, the dose may be decreased by 10 to 20 mg as the withdrawal symptoms resolve so that the patient is off the benzodiazepines in 5 to 10 days.
- Antipsychotics: Antipsychotic medication is sometimes used as an adjunct to benzodiazepines to help control the agitation of alcohol withdrawal delirium.
- Anticonvulsants: The overwhelming majority of seizures from alcohol withdrawal are self-limited and do not require treatment with anticonvulsants.
3. Nursing Management
Nursing management of alcohol withdrawal syndrome is discussed based on a case report.
Mr. X, a 43 years old married male was brought to acute care room in psychiatry department, with the history of irritability, abusive, and assaultive behaviour, restlessness, breaking house hold articles, expressing hearing of voices that someone is calling him and threatening him, someone is standing in front of him, expressing fear, severe anxiety, sweating, headache, tremors, vomiting, memory impairment, disorientation, expressing death desires, poor sleep and appetite for 3 days. He also had a history of consuming alcohol for 5 years and for past two years consuming alcohol in dependence pattern. He consumed all varieties of alcohol about 360ml/day. The last drink was a week ago with 360ml of Brandy.
At the time of admission, he was not oriented to time, place, and person, very restless, agitated, talking irrelevantly, had palpitation, sweating, tremors, expressing hearing of voices that threatens him. He was diagnosed to have alcohol withdrawal syndrome with DT and impending Wernicks. Blood investigations were done including liver function test (LFT) and electrolytes.
The following are the patient picture and the pharmacological treatment during hospitalization:
On the 24th day of admission patient was educated about the deterrent agent and he was started on Tab. Disulfiram 250 mg OD after obtaining consent. He was kept in the ward for 3 days after starting Tab. Disulfiram, and observed for complications. He was discharged with no notable complications.
The nursing care of Mr. X is discussed using nursing process approach (Watling, Fleming, Casey, & Yanos, 1995).
1.Nursing diagnosis: Risk for injury related to alcohol withdrawal as evidenced by memory impairment, disorientation, assaultive behaviour, and ataxia
Expected outcome: Injury is prevented
- Mr. X was kept in acute care room for close monitoring
- Provided side railed cot
- Provided calm atmosphere with low stimulation
- Assessed the level of disorientation and orientation chart was maintained
- Assisted for self care activities
- Administered medication Tab. Lorazepam as per order to improve sleep and as well as to reduce agitation and Tab. Risperidone to reduce psychosis
Evaluation: Mr. X was prevented from injury.
2.Nursing diagnosis: Disturbed visual and auditory sensory perception related to inability to differentiate real from unreal stimuli evidenced by visual and auditory hallucinations
Expected outcome: Mr. X maintains normal sensory perceptions
- Assessed the hallucinatory behaviours. He expressed that he hears voices threatening him and someone is standing in front of him
- Provided calm environment and provided dim light
- Observed the behavioural responses for hyperactivity, disorientation, confusion, sleeplessness, agitation
- Same nurses were assigned to provide care to reduce confusion
- Bed side discussions about him was avoided
- Maintained non threatening environment with a non judgemental and firm-kind attitude
- Periodically reoriented him to time, place, and person and presented reality
- Administered Tab. Lorazepam 2 mg QID and Tab. Risperidone 1mg BD to reduce hyperactivity and promote sleep
- Monitored blood investigations e.g.,serum potassium
- Administered Syr. KCl 10 ml TID as the potassium level was low (2.3 mEq/L)
- Administered Inj. Thiamine 200mg IV TID in 100 ml Normal Saline along with Tab. Thiamine and Inj. Neurobion to reduce Wernicke’s encephalopathy
- Frequent ECG monitoring was done
- Provided potassium rich diet with constant supervision
Evaluation: Mr. X had ataxia, disorientation, and auditory hallucination at the time of admission. On 10[th] day of his admission he did not report of any auditory hallucination.
3. Nursing diagnosis: Anxiety related to altered sensory perception such as hallucination and withdrawal symptoms
Expected outcome: Mr. X’s anxiety is reduced
- Identified and acknowledged his perceptions of the situation
- Encouraged him to ventilate his feelings
- Explained to him that alcohol withdrawal would increase anxiety and uneasiness
- Reassessed the level of anxiety on an ongoing basis
- Developed trusting relationship through frequent contactsand being non-judgemental
- Conveyed an accepting attitude about his dependence pattern
- Reoriented to time, place, and person
- Advised his relative not to criticise his alcohol use behavior
- Provided cotton ball to plug both his ears to avoid hearing voices
- Administered Tab. Lorazepam as per order
Evaluation: Mr. X looked relaxed and verbalized that he was not having fear and did not express the distress due to auditory hallucination.
4. Nursing diagnosis: Hypokalemia related to inadequate fluid intake and vomiting as evidenced by serum potassium level 2.9 mEq/L and restlessness
Expected outcome: Normal fluid and electrolyte balance is maintained
- Monitored vital signs frequently and documented
- Monitored for signs and symptoms of electrolyte imbalance
- Monitored serum potassium level on daily basis
- Monitored him for adequate intake and output
- Maintained strict intake and output chart
- Ensured adequate fluid intake under constant supervision
- Provided potassium rich food and fluids such as beans, dark leafy greens, potatoes, and bananas
- Administered Syr. KCl as per order
Evaluation: Mr. X maintained normal fluid and electrolyte balance. His serum potassium increased to 5 mEq/L from 2.9 mEq/L.
5.Nursing Diagnosis: Imbalanced nutrition less than body requirement related to vomiting, poor intake and loss of appetite evidenced by decreased weight and inability to perform activities
Expected Outcome: Mr. X maintains normal nutritional status as evidenced by weight gain and participation in activities
- Assessed the weight, height, and activity level
- Provided clean environment
- Assessed his likes and dislikes and provided food according to his preferences
- Provided Vitamin B and potassium rich diet everyday
- Provided positive re-inforcements and appreciated him even for small efforts to take food
- Monitored weight weekly
- Provided with small frequent diet to overcome nausea and vomiting
Evaluation: Mr. X maintained normal nutritional status as evidenced by weight gain from 48 kg to 52 kg.
6. Nursing diagnosis: Low self esteem related to guilt feeling as evidenced by anger and fighting with family members
Expected outcome: Mr. X demonstrates optimistic view of life and gains confidence
- Provided opportunity to verbalize his feelings
- Performed mental status examination periodically
- Spent time with him
- Observed the family interactions and level of support
- Encouraged him to express his feeling of craving for alcohol
- Provided necessary medication to overcome craving
- Helped him to acknowledge that use of alcohol is the problem and it can be dealt without use of alcohol
- Encouraged him to list and review past accomplishments and positive happenings to raise self esteem
- Psycho-education about stress management and coping strategies was given
- Helped him to gain insight into cue management on his own
- Encouraged him to participate in group therapy of Alcoholic Anonymous (AA) group
- Administered Neurovitamins as per order
- Advised the relatives not to be judgemental about his alcohol behaviors
Evaluation: Mr. X gained self esteem and assured that he will not take alcohol in future and use the adaptive coping mechanism during stress.
7. Nursing diagnosis: Ineffective individual coping related to depletion of coping strategies and use of alcohol to cope with life stressors as evidenced by crying spells and expressing decreased self esteem
Expected outcome: Mr. X demonstrates positive coping during treatment
- Determined his understanding of current situations and other methods of coping with life’s problems
- Encouraged verbalization of feelings, fear, and anxiety
- Explored alternative coping strategies
- Encouraged him to do deep breathing exercise, and relaxation techniques
- Encouraged him to get involved in group therapy and occupational therapy
- Discussed with him the ill effects of alcohol
- Discussed the plan for living without alcohol
- Encouraged him to participate in AA meetings regularly to increase self esteem and to remain abstinent from alcohol
- Gave positive reinforcement for even the small effort that he made to participate in activities
Evaluation: Mr. X verbalised that he will use the coping strategies taught to him and will not drink alcohol for stress reduction.
8. Nursing diagnosis: Knowledge deficit regarding disease condition, prognosis, treatment, and discharge needs related to lack of information
Expected outcome: Mr. X gains adequate knowledge about illness and treatment
- Assessed the knowledge of him and his family members regarding alcoholism and its prevention
- Encouraged the family members to ventilate their feelings
- Discussed the relationship of alcohol and the current situation
- Discussed the ill effects of alcohol
- Along with therapist assisted him to bring awareness about the availability of deterrents
- Discussed the importance of continuation of drugs
- Taught him about the side effects of drugs
- Taught him about the relaxation technique
- Taught him about the stress reduction techniques and life style modification
- Encouraged the family to be supportive and not to criticize his behaviour
- Provided psycho-education about the precautions while using deterrents
Evaluation: Mr. X verbalized that he understood about relapse prevention, follow the teaching given to him and come for regular follow up.
Mr. X was on intravenous Thiamine infusion, oral Benzodiazepines, and mild dose of Anti-psychotics. In the next few days, his orientation improved, ataxia and confusion were reduced and psychotic symptoms disappeared. Benzodiazepines were titrated and stopped. Motivational interview was conducted, individual and family psychotherapy was given and was engaged in group activities. He was then started on a deterrent agent during the 4th week of inpatient stay after informed consent. He was discharged with relevant home care advice.
| Nurses Role in Therapy|| |
Nurses play a significant role in supportive therapeutic interventions during controlled alcohol detoxification. These include providing frequent reassurance, reality orientation and other physical and emotional nursing care as needed. Patients seem to do best when they are kept in an evenly lit, quiet room, avoiding dark shadows, bright lights, loud noises, and other excessive stimuli. Liberal intake of non-caffeinated fluids can prevent dehydration. The purpose of alcohol detoxification is to prepare the person for entry into a rehabilitation program with the hope of long-term abstinence. Most patients choose long-term involvement with self-help programs such as AA. Others do better with the addition of cognitive-behavior therapy and family therapy. Patients whose families were involved in their care were significantly more likely to enter a continuing care program after detoxification.
| Conclusion|| |
It is also important to treat other conditions that may occur after successful detoxification. Many individuals in the early stages of recovery experience depression which generally can be treated with counseling. Some patients benefit from the addition of antidepressants especially those who have a history of depression prior to their alcohol dependence, and those who experience symptoms of depression that continue despite ongoing counseling. Comprehensive nursing care also includes educating the patient about precautions to take after sobriety is achieved. Through the nurse-patient relationship many nurses are able to assist the individual using the controlled alcohol detoxification process, as well as encourage them to continue treatment and maintain sobriety.
Conflict of Interest: The authors have declared no conflicts of interest.
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