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Running head: ALCHOHOL WITHDRAWALS

Alcohol Withdrawals: What to Expect as a Nurse


Ashley D. Gillam & Soojin Lee
Skagit Valley College

ALCOHOL WITHDRAWALS: WHAT TO EXPECT AS A NURSE

Abstract
Alcohol withdrawal is a serious health condition that requires careful monitoring and medical
interventions. The patient will have symptoms that are debilitating, requiring a nurses help
through the withdrawal process. Tremors, insomnia, nausea or vomiting, transient visual, tactile,
or auditory hallucinations, agitation, anxiety, and seizures are some of the symptoms that can be
experienced. Symptoms generally occur 24-72 hours after the patients last drink. Delirium
tremens is a complication of untreated symptoms and can result in death. It is important to
monitor liver function and check for changes. Some of the medications given will not be as
effective, or be too effective if liver impairment is present. Benzodiazepines, barbiturates, and
anticonvulsants are commonly used for withdrawal symptoms. CIWA scores are used to identify
how much medication should be given and the severity of the withdrawal. The priority nursing
intervention for alcohol withdrawal is education, prevention of complications, and resources, so
reoccurrence does not occur.
Keywords: Alcoholism, alcoholics, withdrawal symptoms, nursing

ALCOHOL WITHDRAWALS: WHAT TO EXPECT AS A NURSE

Alcoholism is excessively prevalent in the United States and the statistics continue to
rise. The most concerning aspect of alcoholism in the clinical setting is withdrawal. A nurse
needs to have the education to recognize, care for, and educate the alcoholic patient in the
hospital. Alcohol withdrawal is something seen frequently in practice. It is important to
understand the statistics, symptoms, the Clinical Institute Withdrawal assessment for alcohol
(CIWA) scores and relation to treatment, treatment possibilities, and resources for the patient.
With this information a nurse can better construct a successful care plan for the patient.
The statistics of alcoholism show the great possibility that a registered nurse will
encounter multiple patients undergoing alcohol withdrawal during his or her career. According to
the National Institute of Alcohol Abuse and Alcoholism (2014), in 2010 17 million people
abused alcohol, and in 2012 1.4 million people were hospitalized because of that abuse. Every
year about 88,000 people die from alcohol abuse. It is important for nurses to have the education
to provide care to the patients and the ability to find resources for prevention. Recognition of
symptoms related to alcohol withdrawal will help lower the alcohol related deaths and
complications.
Alcohol withdrawal can range in severity from mild to severe. The symptoms usually
become apparent 48-72 hours after the patients last drink. As with most diseases, symptoms can
vary from patient to patient. To recognize withdrawal, the patient must exhibit two or more of the
following symptoms: tremor, insomnia, nausea or vomiting, transient visual, tactile, or auditory
hallucinations or illusions, agitation, anxiety, or seizures (Murdoch & Marsden, 2014). If these
withdrawal symptoms go untreated, it can lead to disorientation, confusion, fluctuating level of
consciousness, incontinence, and autonomic instability activity. These symptoms make up
delirium tremens (DTs), which is a life-threatening condition that occurs in 5% of patients with

ALCOHOL WITHDRAWALS: WHAT TO EXPECT AS A NURSE

alcohol withdrawal. Death occurs because of cardiovascular, metabolic, or infectious


complications (Donnelly, Kent-Wilkinson, & Rush, 2012). Prevention of serious complications,
like DTs, is a responsibility that a nurse must undertake.
Prevention of severe complications relies on the nurses ability to identify clinical
features of alcohol withdrawal. Early sedation will prevent complications and DTs (Donnelly,
Kent-Wilkinson, & Rush, 2012). Kindling, or long-term neuronal changes, occurs with multiple
withdrawals. With each withdrawal occurrence, symptoms become worse and more severe
(Cooper & Vernon, 2013). To prevent kindling, resources for prevention need to be provided for
the patient. Any patient with an alcohol disorder should have access to a nurse that is educated.
Attending classes and required meetings will help ensure that nurses have the essential
education. The CIWA scale helps to prevent complications by assessing which medications and
how much are needed for each symptom.
The CIWA is a standard set that has been reviewed and approved for assessment of
therapy effectiveness, medication dosing, and severity of withdrawal. The scale is usually used
one to three times daily, but may need to be used more frequently depending on symptoms. The
scale can be used as often as every hour if the patient needs to be medicated that often. The
nurses in clinical settings that accept withdrawal patients are educated on how to implement the
standing order set. Nurses assess for: nausea and vomiting, tremor, paroxysmal sweats, anxiety,
agitation, tactile disturbances, auditory disturbances, visual disturbances, headache, and
orientation. Based on the severity of symptoms, the nurse uses the standard order set of CIWA to
medicate the patient (Riddle, Bush, Tittle, & Dilkhush, 2010). With this standard order set, the
patients have better controlled symptoms and need less medications to control them.

ALCOHOL WITHDRAWALS: WHAT TO EXPECT AS A NURSE

The treatment set for alcohol withdrawal can vary at each facility. Some common
medications used are benzodiazepines, barbiturates, and anticonvulsants. Benzodiazepines
reduce the risk of delirium and seizures. The most commonly used benzodiazepines are
Diazepam and chlordiazepoxide because of their long half-life. Barbiturates are a sedativehypnotic that have a long half-life, are cost-effective and have a low street value. In addition,
barbiturates are easier on the liver than benzodiazepines. Anticonvulsants decrease the
probability of experiencing seizures and blocks kindling effect by blocking sodium channels.
Anticonvulsants have a low abuse potential and minimal cognitive impairment. The potential
liver damage from excessive alcohol could affect dosages and types of medication given. It is
important for the nurse to know what damage could be done to the liver and how to identify liver
dysfunction in the hospital setting.
Alcohol is a leading cause of liver disease. The liver cannot store alcohol, which results
in ethanol being converted into acetaldehyde to be excreted in the urine. Alcohol dehydrogenase
and aldehyde dehydrogenase are two enzymes responsible for the conversion. Excess of these
enzymes causes inflammation of the liver cells, increased fat deposited in the liver, and low
blood sugars. Over time the inflammation will lead to cell death if alcohol use is not decreased.
Lab increases of aspartate aminotransferase (AST) and alanine aminotransferase (ALT) will help
to diagnosis liver problems (Fullwood, 2014). If liver damage is present, benzodiazepines may
not be a treatment option due to the increase in side effects. There could be increased respiratory
depression, sedation, and memory issues (Cooper & Vernon, 2013). This is why it is important to
monitor liver enzymes and the patients status holistically to help alleviate more complications
that can occur. Prevention and education are key in preventing long term liver damage.

ALCOHOL WITHDRAWALS: WHAT TO EXPECT AS A NURSE

When caring for a patient with alcohol abuse issues, finding resources for prevention are
going to be the number one nursing intervention after managing any withdrawal. Nurses will be
the motivational force that could drive the patient into recovery. Nurses need to educate their
patient on effects of alcohol, treatment options, social support, counseling, support groups, and
treatment programs that are available for the disease (Donnelly, Kent-Wilkinson, & Rush, 2012).
Nurses can print a local Alcoholics Anonymous pamphlet, contact social services, and look
online for further resources. Preventing recurrent withdrawals is essential to prevent long-term
complications. The patient needs to know the long-term effects of alcohol on their body as this
may motivate them to change.
It is clear that alcohol withdrawal is an ongoing problem that needs the attention as
nurses. Nurses will provide better care to patients with education and knowledge of the
withdrawal symptoms and treatment possibilities. Providing resources and education to the
patients on what to expect will help the process go smoother and will strengthen the relationship
with them. Seeking knowledge and necessary classes is one of the most important nursing tasks
in order to help these patients.

ALCOHOL WITHDRAWALS: WHAT TO EXPECT AS A NURSE

References
Cooper, E., & Vernon, J. (2013). The effectiveness of pharmacological approaches in the
treatment of alcohol withdrawal syndrome (AWS): A literature review. Journal of
Psychiatric and Mental Health Nursing , 20, 601-612. doi:10.1111/j.13652850.2012.01958.x
Donnelly, G., Kent-Wilkinson, A., & Rush, A. (2012). The alcohol-dependent patient in hospital:
Challenges for nursing. MEDSURG Nursing, 21, 9-14.
Fullwood, D. (2014). Alcohol-related liver disease . Nursing Standard, 28(46), 42-47.
Murdoch, J., & Marsden, J. (2014). A 'symptom-triggered' approach to alcohol withdrawal
management . British Journal of Nursing , 23, 198-202.
National Institute on Alcohol Abuse and Alcoholism. (2014, July). Alcohol facts & statistics.
Retrieved from http://www.niaaa.nih.gov/alcohol-health/overview-alcoholconsumption/alcohol-facts-and-statistics
Riddle, E., Bush, J., Tittle, M., & Dilkhush, D. (2010). Alcohol withdrawal: Development of a
standing order set . CriticalCareNurse, 30, 38-47. doi:10.4037/ccn2010862

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