What are manifestations of alcohol withdrawal that the nurse should monitor for?

Helping a patient through alcohol withdrawal is, hands down, one of the most challenging things you will encounter as a nurse. It requires patience, empathy, a strong backbone and high vigilance to keep both you and the patient safe. It is absolutely heartbreaking to witness, especially when symptoms are severe. My hope for you is that you approach these situations with compassion and grace. 

For some patients, symptoms can be quite mild, maybe tremors or nausea…and for others it can be severe. I think the reality of what alcohol withdrawal is like is very eye-opening for people. Just because alcohol use is common, does not mean that the effects of it are benign. I remember with a heavy heart a patient who for days lied in bed, grunting and moaning…sounds I’ve heard no human being make before or since. It was disturbing and heartbreaking to watch. I cannot imagine what that poor patient was going through but it looked like they were living through their worst nightmare. Whenever I work with a patient going through withdrawal, I hope so much that they come out the other side and never drink again. Sadly, though, many patients return to alcohol as it is a very difficult addiction to beat. We do what we can, and in that moment, we are there to keep the patient safe without judgment of any kind.

The patient going through alcohol withdrawal is at risk for serious complications, including: 

Delerium tremens (DT): This severe consequence of alcohol withdrawal can be life threatening for the patient. The patient will have hallucinations, hyperventilation resulting in alkalosis, tachycardia, hypertension, severe agitation, confusion/delirium, hyperthermia and diaphoresis. This condition can be life threatening and has a mortality rate of approximately 5%.

Wernicke’s encephalopathy: This is a neurological disorder that results from chronic thiamine (B-1) deficiency. Key symptoms of this life-threatening condition are nystagmus, ataxia, and confusion.

Seizure: Patients going through withdrawal area at high risk or seizures. To learn more about patient safety as it relates to seizures, this blog post is for you!

As you can see, alcohol withdrawal can be complex. So, let’s streamline our thinking with the Straight A Nursing LATTE method. Not familiar with this strategy? Learn about it here.

L: How will the patient LOOK? 

How the patient looks, or presents, really depends on how long it’s been since they last had alcohol of any kind. To determine this, it’s important to assess when the patient had their last alcoholic drink. Though all patients experience withdrawal differently, you can use this as a general guideline: 

• 6 to 36 hours after last drink: minor withdrawal symptoms such as nsomnia, tremors, mild anxiety, headache, GI upset, palpitations, diaphoresis, and anorexia.
• 6 to 48 hours after last drink: seizure risk is high during this period; usually are self-limiting generalized tonic-clonic seizures
• 12 to 24 hours after last drink: hallucinations that are tactile, auditory or visual in nature (alcoholic hallucinosis)
• 48-96 hours after last drink: delirium tremens (aka alcohol withdrawal delirium), severe hallucinations, disorientation, hypertension, tachycardia, hyperthermia, diaphoresis, agitation, hyperventilation; these symptoms will typically peak at 5 days after last drink taken.

A: How will you ASSESS the patient? 

One way you’ll likely assess the patient going through alcohol withdrawal is through the CIWA score (CIWA stands for Clinical Institute Withdrawal Assessment for Alcohol). This assessment tallies up the severity of the patient’s symptoms and assigns them a score, ranging from 0 to 67 points. How the patient scores on this scale helps the MD guide therapy.

As you are calculating the patient’s CIWA score you’ll be assessing a lot of different factors such as tremors, diaphoresis, hallucinations, and anxiety (to see a full CIWA assessment, check out this CIWA calculator here).

You’ll assess for any signs of withdrawal as outlined above, get full sets of vital signs and always, always, assess the patient’s risk for harm to self or others. 

Once the patient is past their crisis, you’ll probably conduct a CAGE assessment as well, and it is typically always conducted in cases where trauma occurred and the patient’s blood alcohol level tested above the legal limit.  It is a screening tool that is used when you suspect the individual may have an addiction to alcohol. 

C=Cut Down: Have you ever had someone suggest that you cut down on your drinking?

A= Annoyed: Have people annoyed you by criticizing your drinking?

G= Guilty: Have you ever felt guilty for behaviors related to drinking?

E= Eye Opener: Do you need something to get going in the morning, to steady your nerves or to help with a hangover?

T: What TESTS will be ordered?

• Blood alcohol level: Blood test to determine the level of alcohol in the patient’s system.
• Urine tox screen: Will show us the presence of alcohol and other substances such as opioids, benzodiazepines, and marijuana.
• Electrolytes: Many times patients with alcoholism will have alterations in electrolytes such as magnesium and potassium due to nutritional deficiencies. Patients with pancreatitis (link to podcast about pancreatitis) may have an associated hypocalcemia.
• BUN and creatinine: An elevated creatinine will indicate kidney disease, which is common in patients with alcoholism. You’ll also want to look at the BUN:Cr ratio. It’s usually between 10:1 and 20:1; if it’s increased this is a sign of dehydration. A low BUN is often present in liver disease associated with alcoholism. 
• Liver function tests (LFTs): These are often elevated in patients with alcoholism due to liver damage.
• Amylase and lipase: Elevations here reveal pancreatitis, which is common with alcohol abuse.
• Ammonia: This will be elevated in patients experiencing hepatic encephalopathy, which is a neurological manifestation of liver disease. 
• Glucose: Patients with alcoholism may also have liver impairment which can play a key role in putting the patient at risk for hypoglycemia due to impaired gluconeogenesis.
• CBC: The patient may be anemic due to myelosuppression related to long-term alcohol use, so watch for anemia and thrombocytopenia. Platelets are also often low due to liver disease. A lot of patients with alcoholism have GI bleeds, which is another reason the Hgb would be low. Also, dietary deficiencies of B-12 and folate lead to megaloblastic anemia in patients with alcoholism.
• Urinalysis: Watch for ketones, which would be present in alcoholic ketoacidosis.  ABG: may reveal alcoholic ketoacidosis
• CT or MRI: These imagine studies may be necessary if the patient has a seizure.

T: How will you TREAT the patient?

Protocols for treating a patient with acute alcohol withdrawal will vary, but the general standard of care is to:

• Reduce symptoms: Medications used to reduce the severity of alcohol withdrawal symptoms include benzodiazepines (often lorazepam/Ativan or librium) and sometimes dexmedetomidine hydrochloride. Often the benzodiazepine dose will be based off the severity of the patient’s CIWA score. Most of the time patients will be able to take their benzodiazepine PO, but IV therapy may be needed for patients having severe symptoms, or who are not safely swallowing. Dexmedetomidine hydrochloride (Precedex) is a continuous infusion that is sometimes used to treat severe symptoms in the critical care setting.
• Monitor for seizures: Patients at risk for seizure will be on “seizure precautions” (link to seizure post). Most seizures with alcohol withdrawal are self-limiting and, according to UpToDate, the use of prophylactic therapy is not typically part of the plan of care.
• Replace key vitamins and nutrients: Thiamine supplementation will help prevent Wernicke’s encephalopathy. Folic acid and multivitamins are also given to patients with alcoholism as they are usually severely undernourished. If the patient cannot take PO medication, you will often see these three medications combined together in an IV bag often referred to as a “banana bag” because of the yellow hue of the liquid.
• Replace and optimize electrolytes.
• Optimize nutrition: Once the patient is safe from aspiration, s/he should be started on nutrition; not only are these patients usually malnourished, they also have high metabolic demands due to the excited autonomic state that occurs in withdrawal. While the patient is NPO, the patient may very well be on a dextrose infusion to help meet this metabolic demand, provide some calories, and prevent hypoglycemia.
• Keep the patient safe from harm: The patient may need 1:1 observation, restraints or even both. 
• Provide resources: Speak to the MD about a social work consult for this patient as they may need a lot of support once this crisis has passed. 

E: How will you EDUCATE the patient/family?

Witnessing a loved one going through withdrawal is incredibly distressing for family members. Ensure them that the symptoms the patient is experiencing are expected and that measures are in place to help alleviate them as much as possible. Once the patient gets through the initial crisis, s/he will need education about alcohol cessation and the risks associated with continued use. 

If your facility is lucky enough to have social workers, they will be providing the patient with information about support groups in the area such as Alcoholics Anonymous. Family members may benefit from support groups as well, so please don’t overlook an opportunity to help, even if the patient states they have no intention of stopping their alcohol use. 
The patient may need education on maintaining their nutrition, recognizing signs of dehydration, what to do if they notice excessive bleeding…essentially, any other potential problems they could have related to their alcohol use. It is also helpful to provide these patients with the SAMHSA (Substance Abuse and Mental Health Services Administration) national helpline number and website: https://www.samhsa.gov and 1-800-662-HELP (4357).

Get this on audio in Episode 75 on the Straight A Nursing Podcast.

References

Bråthen, G., Ben – Menachem, E., Brodtkorb, E., Galvin, R., Garcia – Monco, J. C., Halasz, P., … Young, A. B. (2010). Alcohol-Related Seizures. In N. E. Gilhus, M. P. Barnes, & M. Brainin, European Handbook of Neurological Management (pp. 429–436). https://doi.org/10.1002/9781444328394.ch29

Hoffman, R. S., & Weinhouse, G. L. (2019). Management of moderate and severe alcohol withrawal symptoms. Retrieved from UpToDate website: https://www.uptodate.com/contents/management-of-moderate-and-severe-alcohol-withdrawal-syndromes#H25

Lab Tests Online. (n.d.). Blood Urea Nitrogen (BUN)—Understand the Test & Your Results. Retrieved September 28, 2019, from https://labtestsonline.org/tests/blood-urea-nitrogen-bunVasan, S., & Kumar, A. (2019). Wernicke Encephalopathy. In StatPearls. Retrieved from http://www.ncbi.nlm.nih.gov/books/NBK470344/