Nursing Interventions ^*denotes collaborative interventions

Rationale

Place the client in a room near the nurses’ station or where the staff can observe the client closely.

The client’s safety is a priority.

Institute seizure precautions according to hospital policy (padded side rails up, airway at bedside, etc.).

Seizures can occur during withdrawal. Precautions can minimize chances of injury.

Provide only an electric shaver.

The client may be too shaky to use a razor with blades.

Monitor the client’s sleep pattern; he or she may need to be restrained if confused or if he or she attempts to climb out of bed.

The client’s physical safety is a priority.

Reorient the client to person, time, place, and situation as needed.

You provide reality orientation by describing situations, stating the date, time, and so forth.

Talk to the client in simple, direct, concrete language. Do not try to discuss the client’s feelings, plans for treatment, or changes in lifestyle when the client is intoxicated or in withdrawal.

The client can respond to simple, direct statements from you. The client’s ability to deal with complex or abstract ideas is limited by his or her condition.

Reassure the client that the bugs, snakes, and so on are not really there.

You provide reality orientation for the client.

Tell the client that you know these sights appear real to him or her, and acknowledge the client’s fears but leave no doubt about hallucinations not being real.

You can demonstrate respect for the client’s experience while still providing reality orientation.

Do not moralize or chastise the client for his or her alcoholism. Maintain a nonjudgmental attitude.

Remember that alcoholism is an illness and is out of the client’s control at this time. Moralizing belittles the client.

Nursing Interventions ^*denotes collaborative interventions

Rationale

Complete an initial client assessment; ask what and how much the client usually drinks, as well as the time and amount of the last drink of alcohol. If possible, interview family members or significant others to gain accurate information regarding alcohol intake.

This information can help you anticipate the onset and severity of withdrawal symptoms. The client’s memory may be impaired or he or she may not reveal the actual extent of alcohol intake.

^*Monitor the client’s health status based on standard parameters or rating scale. Administer medications as ordered or as indicated by alcohol withdrawal protocol. Observe the client for behavioral changes. Alert the physician to changes or when assessments exceed parameters.

Blood pressure, pulse, and the presence or absence of tongue tremors are the most reliable data to determine the client’s need for medication. Use of predetermined parameters ensures consistent assessments and reliable data on which to evaluate the client’s progress.

Monitor the client’s fluid and electrolyte balance. Intravenous therapy may be indicated for clients in severe withdrawal.

Clients with alcohol abuse problems are at high risk for fluid and electrolyte imbalances.

Offer fluids frequently, especially juices and protein shakes. Serve only decaffeinated coffee.

Caffeine will increase tremors. Protein shakes and juices offer nutrients and fluids to the client.

Provide food or nourishing fluids as soon as the client can tolerate eating; have something available at night. (Bland food usually is tolerated more easily at first.)

Many clients who use alcohol heavily experience gastritis or anorexia. It is important to reestablish nutritional intake as soon as the client tolerates food.

Administer medication to minimize the progression of withdrawal or complications and to facilitate sleep.

The client will be fatigued and needs rest. Also, he or she should be as comfortable as possible.

Encourage the client to bathe, wash his or her hair, and wear clean clothes.

Personal cleanliness will enhance the client’s sense of well-being.

Assist the client as necessary; it may be necessary to provide complete physical care, depending on the severity of the client’s withdrawal.

The client’s needs should be met with the greatest degree of independence he or she can attain, which is dependent on the severity of withdrawal symptoms.

^*After the client’s condition has stabilized, teach the client and his or her family or significant others that alcoholism is a disease that requires long-term treatment and follow-up. Refer the client to a substance dependence treatment program.

Detoxification deals only with the client’s physical withdrawal from alcohol but does not address the primary disease of alcoholism.

^*Refer the client’s family or significant others to Al-Anon, Alateen, or Adult Children of Alcoholics, as indicated.

Alcoholism is an illness that affects all family members and significant others.

Nursing Interventions ^*denotes collaborative interventions

Rationale

Place the client in a room near the nurses’ station or where the staff can observe the client closely.

The client’s safety is a priority.

It may be necessary to assign a staff member to remain with the client at all times.

One-to-one supervision may be required to ensure the client’s safety.

Institute seizure precautions as needed, according to hospital policy (padded side rails, airway at bedside).

You should be prepared for the possibility of withdrawal seizures.

Restraints may be necessary to keep the client from harming himself or herself.

If the client cannot be protected from injury in any other manner, restraints may be necessary. Remember, restraints are not to be used punitively.

Decrease environmental stimuli (lights, television, visitors) when the client is agitated. Avoid lengthy interactions; keep your voice soft; speak clearly.

Your presence and use of soft voice tones can be calming to the client. He or she is not able to deal with excessive stimuli.

Do not moralize or chastise the client for substance use. Maintain a nonjudgmental attitude.

Remember that substance use and abuse is an illness and out of the client’s control at this time. Moralizing belittles the client.

Talk with the client using simple, concrete language. Do not attempt to discuss the client’s feelings, plans for treatment, or changes in lifestyle while the client is influenced by the drug or in acute or severe withdrawal.

The client’s ability to process abstractions is impaired during withdrawal. You and the client will be frustrated if you attempt to address interpersonal or complex issues at this point.

Reorient the client to person, time, place, and situation as indicated when the client is confused or disoriented.

Presentation of concrete facts facilitates the client’s reality contact.

Nursing Interventions ^*denotes collaborative interventions

Rationale

^*Obtain the client’s history, including the kind, amount, route, and time of last drug use. Consult the client’s family or significant others to obtain or validate the client’s information if necessary.

Baseline data can help you anticipate the onset, type, and severity of physical withdrawal symptoms. The client may report an inaccurate estimate of drug use (either minimized or exaggerated).

Be aware of PRN medication orders to decrease physical symptoms. Do not allow the client to be needlessly uncomfortable, but do not use medications too liberally.

Judicious use of PRN medications can decrease the client’s discomfort, but must be used cautiously, as the client is already experiencing drug effects.

You may need to obtain blood or urine specimens for drug screening on admission, per physician order and client consent. Stress that this information is needed to treat the client and is not for legal or prosecution purposes. Note: Clients involved in vehicular accidents or charged with criminal activity may be an exception in some states.

Drug screens can positively identify substances the client has ingested. Often other substances are included in illegal drugs, of which the client has no knowledge. The client and family must be reassured that treatment is separate from legal issues. However, depending on state laws, information from laboratory tests may need to be surrendered to authorities.

Remain nonjudgmental in your approach to the client and significant others.

Your nonjudgmental approach can convey acceptance of the client as a person, which is separate from drug-taking behavior.

Monitor the client’s intake and output and pertinent laboratory values, such as electrolytes.

The client in withdrawal is at risk for fluid and electrolyte imbalances.

Encourage oral fluids, especially juice, fortified supplements, or milk. If the client is vomiting, intravenous therapy may be necessary.

Milk, juice, and supplements provide a maximum of nutrients in a small volume. Fluids usually are tolerated best by the client initially.

Talk with the client quietly in short, simple terms. Do not chatter or make social conversation. Be comfortable with silence.

Excessive talking on your part may be irritating to the client in withdrawal. The client’s ability to deal with stimuli may be impaired.

You may touch or hold the client’s hand if these actions comfort or reassure the client.

Your physical presence conveys your acceptance of the client.

Encourage the client to bathe, wash his or her hair, and wear clean clothes.

Personal cleanliness will enhance the client’s sense of well-being.

Assist the client as necessary; it may be necessary to provide complete physical care depending on the severity of the withdrawal symptoms.

You should attend to the client’s hygiene only to the extent that he or she cannot do so independently.

^*Teach the client and his or her family or significant others that substance dependence is an illness and requires long-term treatment and follow-up. Refer the client to a substance dependence treatment program.

Substance withdrawal deals only with the client’s physical dependence. Further therapy is needed to address the primary problem of substance dependence.

^*Refer the client’s family or significant others to Alanon, Alateen, or Adult Children of Alcoholics as indicated.

Family and significant others are affected by the client’s substance use and also need help with their own issues.

Teach the client about the prevention of hepatitis and HIV transmission.

Clients who use intravenous drugs are at increased risk for hepatitis and HIV transmission by sharing needles and by sexual activity, especially when judgment is impaired.

^*If the client is HIV positive, refer him or her for medical treatment and counseling related to HIV disease.

Clients who are HIV positive face the risk of AIDS as well as related social problems. Clients may be unaware of available medical treatment and supportive resources.