Alcohol Withdrawal Nursing Diagnosis and Nursing Care Plan

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Alcohol Withdrawal Nursing Care Plans Diagnosis and Interventions

Alcohol withdrawl NCLEX Review and Nursing Care Plans

Alcohol consumption is pervasive in society; often, it is seen as a standard beverage in celebrations, fiestas, or special occasions, but it is also evident in ceremonial and religious customs.

For therapeutic intentions, it is integrated with many over-the-counter drugs and medications. Alcohol is considered a central nervous system (CNS) depressant, and consistent exposure makes one heavily reliant on such.

As interesting as it may seem, one thing to note is its variability. Alcohol consumption relies heavily on moderation as indicated; however, uncontrolled and irresponsible drinking leads to severe complications and possibly death in a worst-case scenario.

With that said, alcohol withdrawal is the sudden discontinuance of chronic alcohol consumption after years of dependence. When alcohol is put on rapid halt, the body elicits excitatory indications—whereas signs and symptoms suggesting alcohol withdrawal manifest as delirium tremens, seizures, and mood changes.

 Causes of Alcohol Withdrawal

Alcohol withdrawal is thought to surface upon brain chemistry alteration in compensation of long-term alcohol consumption. And as the brain alters its chemical output, releasing larger quantities than usual, its dependence grows higher. Hence, the CNS becomes hyperactive or overstimulated when alcohol is abruptly withdrawn.

Signs and Symptoms of Alcohol Withdrawal

The clinical manifestations usually arise within 8 hours after the last alcohol consumption and may persist for days, peaking within 24-72 hours. Signs and symptoms may depend on the stage of alcohol withdrawal, but the most common signs and symptoms are the following:

  • Anxiety
  • Fatigue
  • Depression
  • Excitability characterized by shakiness, jitteriness, jumpiness
  • Mood changes
  • Lack of clarity in judgment and thinking. 

Related Factors to Alcohol Withdrawal

Alcohol withdrawal usually occurs in individuals with unhealthy drinking habits or who experience alcohol abuse. The risk factors include the following:

  • Period of alcohol consumption
  • History of detoxification and seizures
  • Previous episodes of delirium tremens or DT
  • Craving or urge to consume alcohol

Diagnosis of Alcohol Withdrawal

Diagnosis of alcohol withdrawal focuses on observing the signs and symptoms, usually characterized in stages. The handling physician may typically perform a thorough background and medical history checks to ascertain past, habitual drinking attributed to alcohol withdrawal syndrome (AWS), and the following tests may accompany this:

  • Blood tests
  • Liver function tests

But overall, there is no specific diagnostic test for alcohol withdrawal, and it relies heavily on clinical manifestations such as Stage I symptoms (e.g., nausea, hallucination, seizures, etc.), Stage II characterized by the presence of delirium tremens, which is the most dangerous stage, and Stage III (e.g., post-acute withdrawal symptoms).

Treatment of Alcohol Withdrawal

Mild AWS may be treated with home care and nutritional supplements. For severe cases of alcohol withdrawal characterized by DT, these may be necessary for treatment:

  • Hospitalization
  • Medications

Nursing Diagnosis for Alcohol Withdrawal

Nursing Care Plan for Alcohol Withdrawl 1

Nursing Diagnosis: Altered Perception (Sensory) related to chemical alteration, secondary to alcohol withdrawals as evidenced by the altered response to stimuli, altered behavior, unusual thinking, weakness, and visual/auditory delusions.

Desired Outcomes: 

  • The patient will regain control over one’s consciousness. 
  • The patient effectively identifies hallucinations and factors affecting sensory-perceptual capacity. 
Alcohol Withdrawl Nursing InterventionsRationale
Observe the patient’s ability to express and respond to stimuli. Assess his/her level of consciousness.It is essential to recognize the patient’s ability to respond since it can signify judgment and muscle coordination problems. A garbled, slurred, or disorganized speech can indicate incapacity to respond to commands and concentrate.  
Observe the patient’s behavioral reactions (e.g., disorientation, hyperactivity, irritability, sleeplessness, confusion, etc.) and the onset of hallucinations. Note these factors.A person’s change in demeanor is often helpful in determining impending hallucinations. Hyperactivity may indicate disturbances from the CNS, whereas sleeplessness is most commonly attributed to a decline in the sedative effect offered by alcohol.
Ensure the patient’s environment is stress and tension-free. Keep the surroundings quiet and peaceful and maintain calmness when approaching the patient.Hyperactivity can aggravate if the environment is raucous and disorderly. Changing the approach, such as modulating voice in a calmer tone, is one way to reduce the onset of hallucinations and a change in the sensory-perceptual abilities.
Encourage the patient’s family, significant other, guardians, or loved ones to remain with the patient whenever possible.Having someone reliable, the patient can depend on or find comfort from limits the risk of developing fear and negative thoughts. This instills a calming effect and may significantly reorganize the patient’s life.
Guide the patient in grasping and comprehending reality.The tendency of hallucination is always a given. The patient may try to harm himself/herself or potentially others surrounding him/her; thus, it is crucial to orient the patient from distinguishing reality and fallacies.

Nursing Care Plan for Alcohol Withdrawl 2

Nursing Diagnosis: Anxiety / Fear related to a perceived threat of harm or death, secondary to alcohol withdrawal as evidenced by helplessness, feelings of remorse, panic attacks, increased BP, and heart rate. 

Desired outcome: The patient will verbalize his/her fear and anxiety and effectively express control over his/her own life.  

Alcohol Withdrawl Nursing InterventionsRationale
Assess the possible cause of anxiety or fear.The patient may have trouble identifying and comprehending the events happening around him/her. Therefore, inquiries might be difficult considering the lack of awareness. Determining the cause is critical to ascertain whether environmental or physiologic factors cause anxiety.
Reexamine the patient’s anxiety level now and then.To identify the stage of anxiety or fear and to mitigate it when alarming signs are observed.
Educate the patient on the consequences of alcohol withdrawal.Perpetual alcohol intoxication can lead to anxiety and over apprehension, and this is made possible when the effect of alcohol slowly wears off. Educating the patient would lead to awareness of the situation, thereby giving him/her a sense of control.
Inform the patient of the nurse’s duties and responsibilities.It builds a rapport of mutual trust between the patient and nurse.
During the planning process, ensure the patient’s inclusion and, if possible, provide options he/she can choose from.Including the patient in the planning process will likely reduce his/her stress and anxiety level.
Establish a trusting bond with the patient by approaching him/her with a non-judgmental attitude and projecting acceptance instead.To promote compassion and humanness. Accepting the patient despite the matter of alcoholism will reduce their sense of distrust and paranoia.  
Frequently reinstruct and reorient the patient.The patient may have occasional periods of confusion and hallucination; thus, reorientation whenever this instance alarmingly arises is equally essential as checking up the patient.
Monitor the patient for signs of depression.The patient’s demeanor will likely show signs of depression, and recognizing these red flags should be pivotal to mitigate the patient’s suicidal tendencies.

Nursing Care Plan for Alcohol Withdrawl 3

Nursing Diagnosis: Risk for Decreased Cardiac Output related to a compromised heart function secondary to alcohol withdrawal

Desired Outcome: The patient’s vital signs will normalize with a marked decrease of dysrhythmias. 

Alcohol Withdrawl Nursing InterventionsRationales
During acute withdrawal, frequently monitor the patient’s vital signs.In the acute withdrawal phase, a serious potentiating indication to observe is the development of hypertension. The increase in BP and heart rate is attributable to extreme hyperactivity. On another side, BP fluctuations may also arise due to disease progression. It is important to note that patients suffering from alcohol withdrawal are often compounded with another complication, an underlying cardiovascular disease; therefore, hypotension is induced.  
Monitor the patient’s cardiac rhythm and cardiac rate, noting aberrations and irregularities in the heart rhythm.When there is long-term alcohol abuse, it potentiates the risk of developing cardiomyopathy or heart failure. Other irregularities such as dysrhythmias arise from a shift in the electrolyte balance, therefore deterring cardiac function and heart output. Additionally, tachycardia may also occur due to a sympathetic output (e.g., hypoxia) and an increased catecholamine release.
Monitor the intake and output of the patient’s fluid and electrolytes—document the 24 hours fluid and electrolyte balance.In an alcoholic patient, hydration is usually assessed (albeit unreliable) to determine an implicated cardiac function. Dehydration, diaphoresis, and fever are common markers indicating cardiac disease. Untreated overhydration is another risk to be wary of as it arises from electrolyte imbalance in the presence of a compromised cardiac output.
Administer the required fluids and electrolytes as prescribed.Chronic alcohol abuse predisposes the patient to fluid loss and electrolyte imbalances (e.g., magnesium, potassium, glucose), as mandated by fever, vomiting, and cold sweats.
Evaluate and monitor the patient’s laboratory results, such as the electrolyte panel.To monitor electrolyte imbalances (e.g., magnesium, potassium) that could translate to the patient’s risk of developing CNS hyperactivity and dysrhythmias.

Nursing Care Plan for Alcohol Withdrawl 4

Nursing Diagnosis: Risk for Ineffective Breathing Pattern related to hypoxia, secondary to alcohol withdrawal.

Desired Outcome: The patient will demonstrate normal breathing pattern, respiratory rate with the absence of clinical manifestations of hypoxia.

Alcohol Withdrawl Nursing InterventionsRationale
Frequently assess the patient’s respiratory rate, depth, and pattern of inhalation.Monitoring these vital signs and aspect is essential due to the shifting motion of toxicity levels. During the withdrawal phase, hyperventilation is one of the most typical signs in the acute withdrawal phase. Similarly, marked hypoventilation is associated with the depression effect of alcohol during acute intoxication. And to control alcohol withdrawal symptoms, the usage of drugs is synthesized.
Perform lung auscultation to monitor the patient’s breath sounds. Observe the presence of respiratory noises like rhonchi and wheezing.Patients exemplifying withdrawal symptoms are at risk of developing atelectasis due to respiratory depression and pneumonia. Atelectasis is unilateral; therefore, lung collapse may set in. For alcohol debilitated patients, pneumonia in the right lower lobe is common and is attributable to chronic aspiration. Other lung diseases may also come about, such as bronchitis and emphysema.
Encourage the patient to perform deep-breathing exercises and recurrent position changes; likewise, suggest coughing when necessary.The patient may develop complications when there is limited lung expansion. And doing such exercises and position changes would promote lung expansion. Coughing is also one way to reduce the risk of atelectasis and pneumonia since this will mobilize secretions and improve ventilation.
Ensure that the patient’s head is elevated.To decrease the risk of aspiration as it depresses the diaphragm, increasing the chance of lung inflation.
Always have a piece of available suction equipment, airway adjuncts, and supplemental oxygen.Alcohol and drugs have sedative effects, and this adverse influence heightens the risk of hypoventilation, aspiration, and oropharyngeal muscle relaxation, all of which are grounds for intervention as they will potentiate respiratory arrest. Another risk is hypoxia as it simultaneously arises with CNS and hypoventilation; hence, supplemental oxygen may be necessary if the situation needs so.
Monitor the patient’s series of chest x-rays, pulse oximetry, and arterial blood gasses as indicated.Reviewing and monitoring the patient’s serial test results can identify possible grounds or suspicions of secondary complications (e.g., pneumonia and atelectasis). It will also help evaluate respiratory effort effectiveness and denote therapy necessity.

Nursing Care Plan for Alcohol Withdrawl 5

Nursing Diagnosis: Risk for Injury related impaired motor and sensory function, secondary to alcohol withdrawal

Desired outcome: The patient will not be subject to harm or physical injury.

Alcohol Withdrawl Nursing InterventionsRationale
Assess the patient’s stage of alcohol withdrawal syndrome (AWS); for instance: stage I is characterized by absence of signs and symptoms of hyperexcitability and hyperactivity (e.g., sleeplessness, vomiting, tremors, nausea, tachycardia, cold sweats, and vomiting), whereas stage II is characterized by signs and symptoms of delirium tremens, severe autonomic hyperactivity along with anxiety, sleeplessness, and anxiety.It is essential to distinguish the stage of AWS as it recognizes the need for immediate intervention. Likewise, prevention improves prognosis and moderate the progression of the disease, thereby increasing the chance of recovery. It will also provide information on the possible relapse of the disease that could indicate the need for treatment modifications.
Monitor and record the patient’s seizure episodes. Ensure that the airway is free of obstructions and there are padded coverings in the bed’s side rails.The most common type of seizure linked to elevated blood alcohol levels and decreased glucose and magnesium levels is generalized tonic-clonic seizures. Careful observation of the patient’s seizure activity, particularly grand mal seizures, and the use of protective covering or material would ensure the patient’s safety during such episodes. These seizures are usually self-limiting (as long as they are absent in the patient’s medical history), requiring only palliative or systematic treatment.
Support the patient during ambulatory and self-aid activities.To assist and prevent the patient from falling or injuring himself/herself.
Ensure that the patient’s environment is secure and safe by promoting healthy and protective practices.To promote the patient’s safety and wellness, especially if there is poor hand-eye coordination.

Nursing References

Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). Nursing diagnoses handbook: An evidence-based guide to planning care. St. Louis, MO: Elsevier.  Buy on Amazon

Gulanick, M., & Myers, J. L. (2017). Nursing care plans: Diagnoses, interventions, & outcomes. St. Louis, MO: Elsevier. Buy on Amazon

Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2018). Medical-surgical nursing: Concepts for interprofessional collaborative care. St. Louis, MO: Elsevier.  Buy on Amazon

Silvestri, L. A. (2020). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier.  Buy on Amazon

Disclaimer:

Please follow your facilities guidelines, policies, and procedures.

The medical information on this site is provided as an information resource only and is not to be used or relied on for any diagnostic or treatment purposes.

This information is intended to be nursing education and should not be used as a substitute for professional diagnosis and treatment.

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