Alcohol withdrawal syndrome (AWS) occurs when a person suddenly stops or reduces drinking after heavy alcohol consumption.
Alcohol is a CNS depressant. With heavy and chronic alcohol use, the body and brain will start to become dependent. When the depressant is stopped, the brain becomes overexcited which results in side effects of withdrawal. These symptoms range from mild to severe and include a combination of emotional, physical, and psychological symptoms.
The onset of AWS will depend on the frequency, pattern, quantity, and duration of alcohol use, with early signs developing within a few hours after the last alcoholic drink. Symptoms peak after 24 to 48 hours and either resolve or worsen to alcohol withdrawal delirium, also known as delirium tremens or “DTs”.
Delirium tremens occurs in those with a history of heavy alcohol abuse. Symptoms usually begin several days after the last drink. This serious condition can result in seizures and death if not treated.
The Nursing Process
The management of AWS starts with the identification of high-risk individuals. Treatment and other interventions will vary depending on the severity of the 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.
Helping a patient manage and overcome addiction requires patience, a non-judgmental attitude, and therapeutic communication.
Nursing Care Plans Related to Alcohol Withdrawal
Anxiety Care Plan
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
- 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
- The patient will express a reduction of fear and anxiety to a manageable level
- The patient will demonstrate problem-solving skills and make use of available resources
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.
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.
Acute Confusion Care Plan
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
- 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
- Exaggerated emotional responses and alterations in behavior
- Auditory or visual hallucinations
- Fear or anxiety
- Inability to follow commands
- The patient will not experience auditory or visual hallucinations
- The patient will be alert and oriented x 4 at discharge
Acute Confusion 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.
Acute Confusion 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.
Risk for Injury Care Plan
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
- Altered psychomotor performance
- Seizures or involuntary clonic/tonic muscle activity
- Impaired balance
- Reduced muscle, hand, and eye coordination
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.
- The patient will remain injury-free
Risk for Injury 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.
Risk for Injury 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 and Sources
- 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
- 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/