Withdrawal Syndrome

Topics: Delirium tremens, Alcohol withdrawal syndrome, Addiction Pages: 8 (2009 words) Published: February 13, 2013
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Nursing Care of Patients with Alcohol Withdrawal Syndrome

Sabrina D. Jarvis, DNP, ACNP-BC
Brigham Young University
Provo, Utah, USA

Kent D. Blad, DNP, ACNP-BC, FCCM
Brigham Young University
Provo, Utah, USA

Alcoholism is prevalent in up to 20% of inpatient adults,(1) presenting a significant challenge when providing nursing care for the critically ill patient who develops acute alcohol withdrawal syndrome (AWS). Many of these patients are already compromised by underlying medical conditions, so alcohol withdrawal symptoms often complicate the clinical picture. These symptoms, which can be seen as early as 6 to 12 hours after the patient’s last drink, can range from mild to severe, can be mistaken for other serious medical conditions – such as stroke, sepsis, hypoglycemia and hypoxia – and can increase the associated risk of morbidity and mortality.(2)

If left untreated, mortality rates from severe alcohol withdrawal and delirium tremens (DTs) have been shown to be as high as 20%.(3) If AWS is recognized early and improved treatment is instituted, mortality rates have been reduced to 1% to 5%.(3) Nurses and other care providers must be able to recognize early and severe signs of AWS. They must quickly and efficiently assess the patient and initiate proper treatment, while instituting supportive care beyond medications and monitoring.

Clinical Features of AWS
The patient experiencing AWS can manifest a wide range of signs and symptoms.(4) Mild withdrawal symptoms can include insomnia, anxiety, nausea and vomiting, hyperreflexia, diaphoresis and mild autonomic hyperactivity. More moderate symptoms are intense anxiety, tremors and excessive adrenergic symptoms. Severe symptoms are characterized by alterations of sensorium, such as disorientation, agitation and hallucinations, along with severe autonomic hyperactivity, such as tachycardia, hypertension, seizures, tachypnea, hyperthermia, diaphoresis, and DTs.(3) Typically, the latter begin within 48 to 96 hours of the patient’s last drink and can last up to a week. DTs or seizures have been shown to develop in up to 20% of inpatients experiencing AWS if not treated promptly and adequately.(4)

Many of the presenting signs and symptoms of AWS are nonspecific and can be confused with other clinical problems, such as electrolyte imbalances, pain and infections. The nurse must understand these symptoms usually manifest within 24 hours of the patient’s last drink, peak in two to seven hours, and terminate in two to seven days.

Clinical Assessment for AWS
Consistent and precise patient assessment is necessary to identify AWS. Different assessment tools have been used over the years, but the 10-item revised Clinical Institute Withdrawal Assessment for Alcohol Scale (CIWA-Ar) is the most common tool for initial assessment and ongoing monitoring within the intensive care unit (ICU).(6) Although creating the perfect tool for the critical care setting has been difficult, this scale has been widely used and examined for validity and reliability. In recent years, the CIWA-Ar score has been used in individualized, symptomtriggered therapy (STT) to...
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