100 Substance abuse disorders
Assessment (alcoholism)
Major symptoms supportive of a diagnosis of alcohol dependency:
• Withdrawal symptoms and significant interference with psychosocial functioning in family and job relationships.
• Tolerance, as evidenced by ability to consume the equivalent of a fifth of liquor or having a blood alcohol level of 100 dL or more.
Psychological symptoms and behavior patterns:
Patient uses denial to insist that she or he does not have a problem despite concrete evidence to the contrary. Rationalization appears in the form of self-imposed rules that explain the person’s drinking habits as legitimate. Statements may be made such as, “I only drink on weekends” or “I limit myself to a beer, none of the hard stuff for me.” Projection is evidenced in the blaming of external forces for stimulating the need to drink, for example, a nagging wife or a stressful job. Blackouts occur when there is a neuronal irritability that erases the alcoholic’s memory of self-destructive behaviors while under the influence.
Physical indicators/examination:
• Cardiovascular: Peripheral pulses weak, irregular, or rapid; hypertension common in early withdrawal stage from alcohol but may become labile and progress to hypotension as withdrawal progresses; tachycardia common in early withdrawal; numerous dysrhythmias may be identified; other abnormalities depend on underlying heart disease/concurrent drug use.
• Elimination: Diarrhea, varied bowel sounds resulting from gastric complications such as gastric hemorrhage or distention.
• Nutrition and fluid intake: Nausea, vomiting, and food intolerance; difficulty chewing and swallowing food; muscle wasting; dry, dull hair; swollen salivary glands, inflamed buccal cavity, capillary fragility (malnutrition); possible generalized tissue edema resulting from protein deficiency; gastric distention, ascites, liver enlargement (seen in cirrhosis with long-term use).
• Pain/discomfort: Possible constant upper abdominal pain and tenderness radiating to the back (pancreatic inflammation).
• Respiratory: History of smoking; recurrent/chronic respiratory problems; tachypnea (with hyperactive state of alcohol withdrawal); diminished breath sounds.
• Psychiatric: Possible dual diagnoses, for example, paranoid schizophrenia, bipolar disorder, major depression.
• Level of consciousness/orientation: Confusion, stupor, hyperactivity, distorted thought processes, slurred/incoherent speech.
Withdrawal assessment:
• Stage I: Mild. Temperature, pulse, respirations (TPR) and systolic blood pressure (SBP) elevated; slight diaphoresis; oriented × 3; mild anxiety and restlessness; restless sleep; hand tremors; decreased appetite; nausea.
• Stage II: Moderate. Pulse 100-120 bpm; increased temperature; increased systolic blood pressure (SBP); obvious diaphoresis; intermittent confusion; transient visual and auditory hallucinations, primarily at night; increased anxiety and motor restlessness; insomnia; nightmares; nausea, vomiting, anorexia.
• Stage III: Severe. Pulse 120-140 bpm; increased temperature; increased diastolic blood pressure (DBP) and SBP; marked diaphoresis; marked disorientation and confusion; frightening visual, auditory, and tactile hallucinations; illusions (misinterpretation of objects); delusions; delirium tremens; disturbances in consciousness; agitation, panic states; inability to sleep; gross uncontrollable tremors, convulsions; inability to ingest any oral fluids or foods.
Suicidal assessment:
Alcoholic suicide attempts may be as much as 30% higher than the national average.
Diagnostic tests
Nursing diagnosis:
Risk for trauma
related to altered cerebral function occurring with alcohol withdrawal
Desired Outcome: Patient does not exhibit evidence of physical trauma caused by alcohol withdrawal.
| ASSESSMENT/INTERVENTIONS | RATIONALES |
|---|---|
| Assess stage of alcohol withdrawal and severity of symptoms. Monitor vital signs, gait and motor coordination, presence and severity of tremors, mental status, and electrolyte status. | The greater the severity of symptoms, the more likely the patient will experience increasing disorientation, confusion, and restlessness. As the withdrawal moves from stage I (mild) to stage III (severe), the risk for a fall or injury increases significantly. |
| Monitor for seizure activity; institute seizure precautions: bed in lowest position with side rails padded, oral airway at the bedside. | Withdrawal seizures usually occur within 48 hr following last drink. |
| Keep communication simple. | As the disease progresses, patient’s ability to comprehend complex directions and interactions diminishes greatly. Simplicity is the key to effective communication. |
| Stay with patient and provide emotional support and encouragement. | Risk of seizures is higher if patient is alone and has no one to keep him or her grounded in reality. |
| Continue to orient patient to surroundings and call light. | As blood alcohol level drops, disorientation increases and can last several days. |
| Maintain a calm, quiet environment. | Controlling the amount of external stimulation and keeping it at a minimal level promotes calm in the patient. |
| Administer IV/by mouth (PO) fluids with caution as indicated. | Careful fluid replacement corrects dehydration and facilitates renal clearance of toxins. Excessive alcohol use damages the cardiac muscle and/or conduction system. Overhydration poses significant risk to cardiac functioning. |
| Administer medications as prescribed and be alert for side effects. | |
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