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Alcohol Withdrawal - Nursing Quick Help

Alcohol Withdrawal - Nursing Quick Help - Clinical Hub, Nursing Hub, Nursing Practice Guidelines, Quick Help for Nurses, Resources


Hello Nurses, I am Dr. Brown, the Director of
The Center for Addictive Disorders here at UW. I
am here to give you some help and answer
some questions you may have about alcohol
withdrawal. To your left you will find quick topics
to help you.
Just click on the pictures to the left to
learn more.
Quick Help for Nurses:
Alcohol Withdrawal
Nursing Practice Innovation, 2017

Quick Help for Nurses:
Alcohol Withdrawal
Nursing Practice Innovation, 2017

Questions on CIWA-Ar
HOME
Question: Are there unique aspects of
CIWA-Ar that I should be aware of related to
alcohol withdrawal?
Answer: Yes, tremors, sweating, visual
hallucinations and nausea/vomiting are often key
aspects common with alcohol withdrawal. Anxiety
and agitation are less specific.
Question: Is it ok to do a CIWA-Ar on
someone who can not answer questions or
interact with the nurse?
Answer: Ideally no, CIWA-Ar is validated in
patients who can talk to you and answer questions,
if they can't, CIWA-Ar is not ideal to use. In those
cases the provider should be notified.
Question: I think someone is faking the
tremor, what should I do?
Answer: An alcohol tremor is fine tremor,
usually faster than someone can fake. Also you may
look at the patient’s tongue to see if the tongue is
tremoring, it is difficult to fake a tongue tremor.
Nursing Practice Innovation, 2017

Timing of Alcohol Withdrawal:
• Please note this is from last drink, not admission
• Stages can be skipped or patients may come in already in
delirium tremors or having had a seizure
HOME
Timing: Onset after
last drink
Within hours 24-48 hours 24-48 (rarely before
12 hours)
24-96 hours (usually
72-96 hours)
Four Stages of
Alcohol Withdrawal
Syndrome
Stage 1
Autonomic
Activation
Stage 2
Alcoholic
Hallucinosis
Stage 3
Alcohol Withdrawal
Seizure
Stage 4
Delirium Tremens
Clinical
Manifestations
Tremors, anxiety,
sweats, agitation,
sleep
disturbances,
nausea/vomiting,
headache
Often begins as
vague perceptual
disturbance,
visual is most
common, tactile
and auditory may
occur
Generalized tonic
clonic seizure
Disorientation,
confusion, severe
agitation, marked
autonomic activation,
sleep/wake
disturbance
Mental Status Intact
Orientation
Intact Orientation Varies Orientation is not
intact
Nursing Practice Innovation, 2017

Recommending
a Higher Level of
Care
1. Hoffman, R., Weinhouse, (2014) Management of moderate and severe alcohol withdrawal syndromes. UpToDate. Retrieved from UpToDate.com.
2. Kraemer, K. L., Mayo-Smith, M. F., & Calkins, D. R. (2003). Independent clinical correlates of severe alcohol withdrawal. Substance Abuse, 24, 197e209.
3. Monte, R., Rabuñal, R., Casariego, E., Bal, M., & Pértega, S. (2009). Risk factors for delirium tremens in patients with alcohol withdrawal syndrome in a hospital setting. European Journal
HOME
Consider
recommending
a transfer to a
higher level of
care
Change in
orientation in the
context of AWS.
CIWA can no longer
be performed
accurately due to
patient’s inability to
reliably answer
questions (delirium)
1
.
Pt has a known hx
of complex AWS
(seizures, DTs)
with escalating
symptoms
(CIWAs)1,2,3.
Increased
oxygenation
needs, work of
breathing,
respiratory rate 1.
Nursing care
requirements exceed
general level of care
level. Nurse cannot
provide care safely
to their patient
assignment.
CIWA Scores above
20 x 2, with no
decrease in
symptoms in spite of
adequate treatment
with CIWA orders 1.
Nursing Practice Innovation, 2017

Is the Patient Exaggerating
Symptoms to Get Medications?
HOME
Exaggerating symptoms is a common concern among nurses. Here
are five points to consider. Always get the provider involved.
Patients who know CIWA-Ar may not be drug seeking,
they may just have gone through withdrawal before, this
is a risk factor.
Remember get the provider involved if you believe they
are exaggerating symptoms: untreated withdrawal is very
dangerous.
Patients with alcohol withdrawal need outside help, in
the inpatient setting your goal is to keep them safe.
Recognize that a few days of benzos will not lead to
physical dependence.
Tremor: check the tongue for tremor. it is a good indicator
and can not be faked.
In general a patient who just scores high on CIWA-Ar for
only agitation and anxiety are less likely to have severe
withdrawal.
Nursing Practice Innovation, 2017