Alcohol withdrawal syndrome (AWS) occurs when a person suddenly stops or reduces drinking after heavy, long-term alcohol consumption. Heavy drinking is defined as five or more alcoholic beverages per day (or ≥ 15 drinks per week) for males. For females, the guideline is four drinks per day or ≥ 8 drinks in a week.
In this article:
- Overview
- Nursing Process
- Nursing Assessment
- Nursing Interventions
- Nursing Care Plans
- Acute Substance Withdrawal Syndrome
- Anxiety
- Nausea
- Risk for Injury
Overview
Alcohol is a CNS depressant. With heavy and chronic alcohol use, the body and brain will start to become dependent. When the depressant is discontinued, the brain becomes overexcited, which results in side effects of withdrawal. The severity of AWS will depend on the frequency, pattern, quantity, and duration of alcohol use. Most cases of AWS are mild, but serious and even life-threatening symptoms may occur.
Alcohol withdrawal delirium, also known as delirium tremens or “DTs,” is the most severe form of alcohol withdrawal and is considered a medical emergency. DT symptoms usually begin within 72 hours after the last drink and can result in seizures and death if not treated.
Nursing Process
The management of AWS begins with the identification of high-risk individuals. The nurse must consider that some patients admitted to the hospital for an unrelated reason may have alcohol use disorder (AUD) and are at risk for AWS due to unintentional alcohol cessation. Early detection and intervention can prevent mortality.
Treatment and other interventions will vary depending on the severity of symptoms. Medications like benzodiazepines and beta blockers are prescribed to control symptoms like seizures and to stabilize the patient’s vital signs.
A quiet, supportive environment, with soft lighting, and limited stimuli is recommended. Keeping the patient safe and preventing complications is a priority.
Nursing Assessment
The first step of nursing care is the nursing assessment, during which the nurse will gather physical, psychosocial, emotional, and diagnostic data. In this section, we will cover subjective and objective data related to alcohol withdrawal syndrome.
Review of Health History
1. Assess the patient’s general symptoms.
AWS symptoms range from mild to severe. Mild symptoms within 6-12 hours from the last drink include:
- Tremors
- Anxiety
- Nausea
- Vomiting
- Insomnia
Major withdrawal symptoms can occur 12-24 hours after the last drink and include:
- Hallucinations
- Whole body tremor
- Vomiting
- Diaphoresis
- Hypertension
- Withdrawal seizures (highest risk between 24-48 hours after the last drink)
Symptoms of delirium tremens can occur within 1-3 days after the last drink and include:
- Global confusion (hallmark symptom)
- Disorientation
- Agitation
- Hallucinations
- Fever
- Hypertension
- Tachycardia
2. Inquire about the patient’s alcohol use.
Have the patient or a reliable support person describe the patient’s history of alcohol use. Ask how many drinks they consume each day or week and the duration of their alcohol use.
3. Note the last drink.
Early signs can develop within a few hours after the last alcoholic drink. Have the patient or support person provide information on when the patient had their last alcoholic drink, which can help determine the onset and progression of symptoms. Symptoms peak around 72 hours. Knowing when the last drink was will also help plan the proper treatment for the patient.
4. Inquire about a history of alcohol withdrawal.
If the patient has a history of alcohol withdrawal that includes seizures or DT, there is an increased risk for a recurrence of these complications.
5. Determine the patient’s risk factors.
These factors increase the risk of alcohol withdrawal syndrome:
- Daily, heavy alcohol use
- Older age
- Use of other substances
- Certain medications
- Past history of AWS
6. Review the patient’s medical history.
Mental illnesses, as well as physiological conditions, such as liver disease, pancreatitis, heart failure, and neurological impairments, may complicate symptoms of AWS.
7. Check the patient’s surgical records.
Bariatric surgery may raise the risk of developing alcohol use disorder or relapsing after recovering from AUD. It may also make it more difficult for the body to absorb adequate B vitamins and other nutrients.
8. Review the medication list.
Note the use of benzodiazepines, barbiturates, opioids, or other CNS depressants that can cause altered mental status and mimic AWS. Check for the possibility of drug interactions with alcohol use, such as acetaminophen, that can intensify liver damage.
Physical Assessment
1. Utilize clinical assessment tools.
Use the Clinical Institute Withdrawal Assessment for Alcohol revised (CIWA-Ar) tool to assess the severity of alcohol withdrawal symptoms. The nurse administers a prescribed benzodiazepine for higher scores to manage symptoms.
The Minnesota Detoxification Scale (MINDS) is a similar tool used for patients in the ICU or who are not coherent to answer questions.
The Prediction of Alcohol Withdrawal Severity Scale (PAWSS) is used to determine the risk of developing complicated (moderate to severe) AWS.
2. Monitor the vital signs.
Excessive alcohol consumption increases the risk of high blood pressure, tachycardia, and arrhythmias. Monitor for respiratory depression and hyperthermia. Cardiac arrhythmias and respiratory failure are the most common causes of death in patients with DTs.
Diagnostic Procedures
1. Send samples for testing.
The following lab tests are beneficial in monitoring and treating the patient with AWS:
- Serum alcohol level (if alcohol is still present in the blood when experiencing withdrawal, this often indicates more severe symptoms)
- Complete blood count
- Complete metabolic panel
- Electrolyte levels
- Kidney function tests
- Liver function tests
- Glucose level
- Urine drug screen
2. Prepare the patient for imaging studies.
For patients with DT who have a fever, an infectious process should be considered, as half of these patients will have an infection. Anticipate a chest X-ray initially to evaluate for pneumonia (the most common cause). Consider a CT scan of the head if trauma is suspected or if seizures occur.
3. Consider a lumbar puncture.
Consider a lumbar puncture in patients with AWS if the following apply:
- Experienced a seizure
- Continue to have a decreasing level of consciousness
- Meningitis is suspected (fever, lethargy, disorientation, headache) even without seizures
Nursing Interventions
Nursing interventions and care are essential for the patients recovery. In the following section, you will learn more about possible nursing interventions for a patient suffering from alcohol withdrawal syndrome.
1. Administer fluids and electrolytes.
Patients with moderate to severe symptoms should be treated with IV fluids. Anticipate a possible order of a “banana bag” (a cocktail of folate, thiamine, dextrose-containing fluids, and a multivitamin) to restore electrolytes and B vitamins.
2. Provide a low-stimuli environment.
Maintain a calm environment that is quiet and without harsh lighting. Reassure and orient as needed to reduce the severity of hallucinations and agitation.
3. Maintain safety.
Implement seizure precautions and place the bed in a low position with the bed alarm on to prevent falls. Restraints may be necessary if the patient becomes a safety hazard to themselves or others.
4. Administer medications as ordered.
The use of benzodiazepines (lorazepam, diazepam) is the cornerstone of treating severe withdrawal symptoms. These may be administered on a fixed schedule or as needed based on the CIWA-Ar scoring system. Adjuvant medications like haloperidol are used to manage agitation and hallucinations. Beta-blockers treat cardiovascular symptoms, and clonidine may improve the heart rate and blood pressure during withdrawal.
5. Discuss addiction treatment once stabilized.
Once the patient is stabilized and preparing for discharge, treatment for AUD should be discussed and offered. This may include options like inpatient or outpatient rehabilitation, Alcoholics Anonymous, psychological counseling, support groups, and oral medications like disulfiram and naltrexone to prevent drinking and reduce cravings.
Nursing Care Plans
Once the nurse identifies nursing diagnoses for alcohol withdrawal syndrome, nursing care plans help prioritize assessments and interventions for both short and long-term goals of care. In the following section, you will find nursing care plan examples for AWS.
Acute Confusion
Patients suffering from AWS exhibit a lack of clarity in thinking and judgment, confusion, and mood changes. They may suffer from altered sensory perception and cognition as they can exhibit distorted responses due to hallucinations and delusions.
Nursing Diagnosis: Acute Confusion
Related to:
- Biochemical alterations
- Psychological stress
- Sleep deprivation
- Sensory deprivation
As evidenced by:
- Changes in the usual responses to stimuli
- Disorientation to time, person, place, or situation
- Irritability
- Exaggerated emotional responses and alterations in behavior
- Auditory or visual hallucinations
- Fear or anxiety
- Inability to follow commands
Expected outcomes:
- Patient will not experience auditory or visual hallucinations.
- Patient will be alert and oriented x 4 at discharge.
Assessment:
1. Monitor laboratory values.
Ammonia levels, electrolyte imbalances, glucose levels, and liver function tests can lend objective data to support symptoms of confusion and disorientation.
2. Assess and observe behavioral responses.
AWS symptoms like disorientation, sleeplessness, confusion, irritability, and hyperactivity can worsen, indicating impending delirium tremens or hallucinations.
Interventions:
1. Provide a consistent environment.
Continual interruptions by different healthcare workers can worsen disorientation. Try to limit interactions and staff members.
2. Restrain the patient as needed.
Restraints are a last resort for a patient experiencing confusion as physical restraints can worsen symptoms of agitation. Restraints may be required to keep the patient and staff safe.
3. Reduce stimulation.
Loud sounds, the beeping of machines, music, lights, and TV can worsen confusion. Do not overwhelm the patient with too many sources of stimulation.
4. Encourage family support.
Family members and familiar faces may help diffuse situations and aid in reorientation.
Acute Substance Withdrawal Syndrome
With heavy alcohol use, the brain and the body become accustomed to the sedating effects of the substance. When alcohol use is reduced or stopped, excitatory symptoms occur.
Nursing Diagnosis: Acute Substance Withdrawal Syndrome
Related to:
- Excessive alcohol use over time
- Dependence on alcohol
- Sudden cessation of alcohol
As evidenced by:
- Anxiety
- Headache
- Tremors
- Insomnia
- Nausea
- Vomiting
- Confusion
- Tachycardia
- Fever
- High blood pressure
- Sweating
- Agitation
Expected outcomes:
- Patient will maintain vital signs and mental status within normal limits.
- Patient will not experience seizure activity from alcohol withdrawal.
Assessment:
1. Monitor for the progression of alcohol withdrawal symptoms.
Mild symptoms may include tremors, anxiety, and nausea. If the patient begins to display signs of confusion, altered vital signs, and an increasing CIWA-Ar score, the nurse should suspect delirium tremens and initiate interventions immediately.
2. Review lab values.
Patients with a chronic history of alcohol abuse are at risk for nutrient deficiencies, specifically B vitamins like folate and thiamine. Severe deficiencies can cause neurological complications.
3. Assess for previous episodes of alcohol withdrawal.
It’s important for the nurse to ask if the patient has experienced previous withdrawal episodes, as repeated occurrences lower the threshold for seizures and increase the risk for more severe symptoms.
Interventions:
1. Administer medications as indicated.
Benzodiazepines are often prescribed for patients with acute alcohol withdrawal syndrome as this can help reduce hyperactivity, promote relaxation and sleep, and help manage the patient’s withdrawal symptoms. Research recommends the use of benzodiazepines PRN (as needed) instead of scheduled, as this reduces the duration of treatment and the overall use of benzodiazepines.
2. De-escalate agitation.
Implement de-escalation techniques to reduce agitation and prevent unsafe situations in patients experiencing acute substance withdrawal symptoms. These include:
- Maintaining a calm demeanor
- Communicating clearly and respectfully
- Setting realistic boundaries
- Moving them to a quiet location away from others
3. Replace vitamins and electrolytes.
If the patient is deficient in B vitamins, glucose, and electrolytes, replace via IV infusion as ordered to prevent malnutrition, seizures, dehydration, and other complications.
4. Refer to substance abuse treatment at discharge.
Once stabilized, the patient should be provided with resources for continued treatment for alcohol use disorder. This may include inpatient or outpatient drug rehabilitation, counseling, and medications.
Anxiety
Anxiety is one of the symptoms of AWS. Long-term anxiety and stress reduction are vital parts of the management of AWS.
Nursing Diagnosis: Anxiety
Related to:
- Situational crisis
- Discontinuation of alcohol
- Physiological withdrawal
- Threat to self-concept
- The perceived threat of death
- Life stressors
As evidenced by:
- Increased tension and apprehension
- Increased helplessness with loss of control
- Feelings of inadequacy, shame, and guilt
- Expresses anguish
- Expresses anxiety about life event changes
- Expresses distress
- Expresses insecurity
Expected outcomes:
- Patient will express a reduction of fear and anxiety to a manageable level.
- Patient will demonstrate problem-solving skills and make use of available resources.
Assessment:
1. Assess the cause and level of anxiety.
Determining the patient’s anxiety level and causes can help formulate the most appropriate treatment regimen.
2. Implement CIWA assessments.
The Clinical Institute Withdrawal Assessment for Alcohol scale (CIWA) is the most important tool for monitoring alcohol withdrawal symptoms and management. It measures nausea/vomiting; tremors; sweating; anxiety; agitation; tactile, auditory, and visual disturbances; headaches; and orientation. The nurse performs this assessment every 1-4 hours per facility orders.
Interventions:
1. Reorient as needed.
A person who is suffering from alcohol withdrawal is often unable to identify and recognize what is happening which increases anxiety. Reorientation is necessary until symptoms resolve.
2. Develop a trusting relationship with the patient.
A trusting relationship can be achieved through honest and nonjudgemental interactions with the patient to help decrease fear and distrust of the healthcare team.
3. Maintain a calm environment.
A calm and quiet environment can reduce the patient’s stress and promote an effective atmosphere for healing.
4. Provide resources for addiction.
Once the patient has been stabilized, they may have fear and anxiety about experiencing future relapses and withdrawal symptoms. If the patient requests help, provide referrals to Alcoholics Anonymous and other resources.
5. Administer medications as indicated.
Benzodiazepines are the gold standard treatment for AWS. They also help the patient relax, feel more in control, and reduce agitation.
Nausea
With alcohol withdrawal, the body becomes hyperactive and sensitive, resulting in withdrawal symptoms including nausea and vomiting.
Nursing Diagnosis: Nausea
Related to:
- Unpleasant sensory stimuli
- Anxiety
- Gastrointestinal irritation
- Withdrawal from a dependent substance
As evidenced by:
- Increased salivation
- Food aversion
- Gagging sensation
- Increased swallowing
- Sour taste
- Loss of appetite
Expected outcomes:
- Patient will state relief from nausea.
- Patient will utilize interventions that can help reduce nausea and vomiting.
Assessment:
1. Assess the patient’s timeline of nausea and vomiting.
Nausea can occur within six hours after the last drink. Prepare the patient that nausea may worsen within the next few days, but then should subside.
2. Assess the severity of nausea.
An assessment tool like the CIWA-Ar scale can help assess the severity of alcohol withdrawal symptoms like nausea and determine the appropriate treatment regimen.
Interventions:
1. Encourage sips of water as tolerated.
Hydration is vital in patients experiencing withdrawal symptoms, especially nausea and vomiting. If not NPO, encouraging smaller sips of water may help keep the patient hydrated if they are vomiting.
2. Record emesis.
If the patient is vomiting, record the amount of emesis if possible to monitor intake and output.
3. Administer fluids and electrolytes as indicated.
Fluid and electrolyte loss due to nausea and vomiting from alcohol withdrawal can increase the risk of dehydration. Administering intravenous fluids promotes fluid and electrolyte balance and prevents dehydration.
4. Offer a BRAT diet as tolerated.
Patients suffering from acute alcohol withdrawal symptoms are advised to remain NPO. A BRAT (bananas, rice, applesauce, and toast) diet can be initiated once this initial phase has passed.
5. Administer antiemetics.
Severe nausea or vomiting may require the administration of antiemetics to prevent fluid loss.
6. Encourage natural remedies.
Ginger can help manage nausea and vomiting, while peppermint can help relax the digestive tract. Other nausea remedies include lemon, cinnamon, and cumin extract.
Risk for Injury
Patients suffering from alcohol withdrawal are at greater risk for injury due to their symptoms. The development of seizures also presents a safety risk.
Nursing Diagnosis: Risk for Injury
Related to:
- Altered psychomotor performance
- Seizures or involuntary clonic/tonic muscle activity
- Impaired balance
- Reduced muscle, hand, and eye coordination
- Hallucinations
- Disorientation
As evidenced by:
A risk diagnosis is not evidenced by any signs and symptoms, as the problem has not occurred yet and the nursing interventions will be directed at the prevention of symptoms.
Expected outcomes:
- Patient will remain injury-free.
Assessment:
1. Assess and monitor seizure activity while promoting patient safety.
Grand mal seizures are common in patients suffering from withdrawal symptoms and may be related to hypoglycemia, decreased magnesium levels, and elevated blood alcohol levels.
2. Assess and monitor gait and coordination.
Assess if the patient is safe to ambulate or perform tasks. The patient may require strict bedrest or assistance until symptoms resolve.
Interventions:
1. Assist the patient in ambulation and self-care activities.
The nurse or unlicensed assistive personnel should assist the patient with ambulation or ADLs in the event that a seizure or fall occurs.
2. Provide an environment of safety.
The bed should always be in a low position, with side rails up, and call bell within reach.
3. Implement seizure precautions.
Padding the side rails, placing a mat on the floor beside the bed, and keeping emergency equipment at the bedside should be implemented in the event of a seizure.
4. Consider a 1:1 sitter.
Patients may not be able or willing to follow commands when experiencing alcohol withdrawal. A trained staff member may be required to remain within arm’s reach at all times to prevent falls or alert the nurse to an emergency.
References
- Alcohol Withdrawal. Carol Galbicsek. Last edited February 24, 2022. https://www.alcoholrehabguide.org/alcohol/withdrawal/
- Alcohol withdrawal. Medline Plus. Review Date 1/17/2021. https://medlineplus.gov/ency/article/000764.htm
- Alcohol Withdrawal Symptoms, Timeline & Detox Treatment. Authored by Amelia Sharp. Reviewed by Ryan Kelley, NREMT. Last Updated: June 30, 2022. https://americanaddictioncenters.org/withdrawal-timelines-treatments/alcohol
- Alcohol use disorder – Diagnosis and treatment – Mayo Clinic. (2022, May 18). Top-ranked Hospital in the Nation – Mayo Clinic. Retrieved April 2024, from https://www.mayoclinic.org/diseases-conditions/alcohol-use-disorder/diagnosis-treatment/drc-20369250
- Alcohol withdrawal. (2024, January 25). Cleveland Clinic. Retrieved April 2024, from https://my.clevelandclinic.org/health/diseases/alcohol-withdrawal
- Lewis’s Medical-Surgical Nursing. 11th Edition, Mariann M. Harding, RN, PhD, FAADN, CNE. 2020. Elsevier, Inc.
- Newman RK, Stobart Gallagher MA, Gomez AE. Alcohol Withdrawal. [Updated 2021 Nov 13]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK441882/
- Newman, R. K., Stobart Gallagher, M. A., & Gomez, A. E. (2023, July 21). Alcohol withdrawal – StatPearls – NCBI bookshelf. National Center for Biotechnology Information. Retrieved April 2024, from https://www.ncbi.nlm.nih.gov/books/NBK441882/
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