Halter: Varcarolis' Foundations of Psychiatric Mental Health Nursing, 7th Edition

Chapter 22: u!stance "elated#$ddicti%e &isorders

Case tudies and Nursing Care Plans: u!stance $!use#$lcohol 'ithdra(al
Mike, a 45-year-old car technician, is admitted to the alcohol unit of the hospital because of his declining
physical health. For the past 2 days, he has been confused and unable to take care of himself. His sister, who
accompanied him to the hospital, states that he had a stable life until 5 years ago, when his wife left. fter that,
he began to drink increasingly larger amounts of alcohol! currently, he drinks a case of beer a day, as well as any
other li"uor he can get his hands on. He often misses work, has blackouts, and goes on drinking binges!
conse"uently, he has been fired from many #obs. Mike$s sister lets him stay with her occasionally, but she limits
his %isits because she feels he is a bad role model for her children.
Mike is alternately confused and lucid when he speaks to the nurse, Marie. His hands are tremulous, and his
forehead is sweaty. His %itals are& '( )5*+)**, pulse )2*, respirations ),, and temperature )**.- F. .hile
talking with Marie, he picks at bugs that he says are on the sheets of his hospital bed. He states that he hasn$t
slept for 2 days and is cra%ing a drink. t first he recogni/es Marie as his nurse, but then he identifies her as his
sister.
$ssess)ent
*!+ecti%e &ata
0 1itals& '( )5*+)**, ( )2*, 2esp ),, 3emp )**.-
0 (icks at bugs he says are on the sheets
0 Hasn$t slept for 2 days
0 4rinks a case of beer a day and any li"uor he can get
0 4rinking increasingly larger amounts of li"uor 5 5 years
0 Misses work, has blackouts, goes on drinking binges
0 lternati%ely confused and lucid
0 Hands are tremulous
0 6onfused and delirious
u!+ecti%e &ata
0 6ra%ing a drink
0 2ecogni/es nurse at first, then identifies her as his sister
Nurse,s Personal Perspecti%e
Marie is concerned about this client$s health and dismayed that he had turned to drink after his wife left. 7he
reali/es that this is a #udgmental statement and that e%eryone has uni"ue perceptions of e%ents and a uni"ue
coping style. Marie hopes that Mike reco%ers from alcohol withdrawal without complication and enters
rehabilitation. 7he feels optimistic about the possibility of this happening, because her brother had a similar
history and has been in remission from alcohol dependence for )2 years.
&iagnosis
"is- for in+ury related to altered cere!ral functioning as )anifested !y
0 8le%ated %itals
0 6onfusion
0 7igns of alcohol withdrawal& perspiration, tremulousness, ele%ated %itals
6opyright 9 2*)4, 2*)*, 2**, by 7aunders, an imprint of 8lse%ier :nc.
6ase 7tudies and ;ursing 6are (lans 22-2
$ltered thought process related to alcohol (ithdra(al as )anifested !y
0 (icking at bugs on the bed
0 7peaking lucidly and confused
ensory perceptual alterations related to deliriu) as )anifested !y
0 6onfusion
0 :llusions
0 :neffecti%e coping
.neffecti%e health )aintenance related to alcohol a!use as )anifested !y
0 <oss of #ob
*utco)es .dentification
Marie$s goal is to ensure Mike$s physiological safety, so that he will remain in#ury free during deto=ification
and after discharge will participate in rehabilitation.
Planning
Marie plans to assess Mike$s withdrawal progress and to pro%ide inter%entions, including
an=iolytic medications to ensure his safe withdrawal from alcohol. fter this, she plans to address his
rehabilitation from alcoholism.
.)ple)entation
hort/0er)
1oals
.nter%ention "ationale E%aluation
Client
e2periences no
in+ury during
(ithdra(al3
Monitor %ital signs during withdrawal. change in %ital signs
indicates withdrawal
progression and the need for
medication.
Mike$s
withdrawal
proceeds
without any
physical
conse"uences.
He returns to
normal
physiological
stability by 5
days.
Monitor electrolytes, )ental status, and
sei4ure acti%ity3
lterations may portend a
more se%ere withdrawal stage.
;otify the physician about any
une=pected changes.
Create safe en%iron)ent5sei4ure
precautions3
(ad side rails to pre%ent in#ury
during a sei/ure.
2educe en%ironmental stimuli >e.g., lights,
sounds, noises, mo%ement?.
2educing stimuli decreases the
client$s an=iety.
dminister )edications,
anticon%ulsants, antisei4ure drugs, and
!en4odia4epines to relie%e withdrawal
symptoms and pre%ent further symptoms.
Medications relie%e symptoms
and pre%ent sei/ures.
ssess fluid and electrolyte status. client in withdrawal is at risk
for fluid and electrolyte
imbalance.
@eep suction, $)!u !ag, and oral
air(ay at !edside3
:n case they are needed for
respiratory function after a
sei/ure
Monitor client$s sleep pattern3 confused client may climb
out of bed and in#ure himself.
6opyright 9 2*)4, 2*)*, 2**, by 7aunders, an imprint of 8lse%ier :nc.
6ase 7tudies and ;ursing 6are (lans 22--
Client
de)onstrates
orientation to
person, place,
and ti)e3
ssess client$s thought process, including
hallucinations.
ssessments determine
appropriate inter%entions.
Mike is
oriented to
person, place,
and situation
by the third
day.
2e-orient client to person, place, and time. (romotes reality
8ducate client about all procedures. ssists in reality orientation
and decreases an=iety
$d)inister Haldol prn for agitation or
hallucinations per order3
Haldol reduces agitation and
hallucinations.
Maintain a well-lighted en%ironment with
minimal clutter.
2educes illusions and
enhances reality orientation
2eassure the client that !ugs are not
present3
(ro%ides reality orientation
Client
%er!ali4es ris-s
of continuing
to drin-
alcohol3
4e%elop a trusting nurse-client
relationship.
3rust is the basis of a
therapeutic relationship.
Mike admits
that alcohol
has
temporarily
affected his
health, but he
feels that
continuing to
drink will not
ha%e any
long-term
effects.
2e%iew client$s current withdrawal
e=perience.
2eminds the client of his
negati%e e=perience related to
alcohol withdrawal
Ha%e client list the effects of alcohol on
himself and family.
3he client must recogni/e the
conse"uences of drinking to
decrease denial.
4o not critici/e client for drinking
alcohol.
lcoholism is a disease and
out of the client$s control.
4emonstrate a non#udgmental manner. 6on%eys respect for the client
but not for the beha%ior.
E%aluation
Mike is discharged from the hospital with medical and mental health follow-up appointments. Howe%er, he fails
to attend the meetings. His sister is contacted, but she says that Mike left the state in search of a #ob and that she
has not heard from him in months.
6opyright 9 2*)4, 2*)*, 2**, by 7aunders, an imprint of 8lse%ier :nc.