Chapter 19

Irritability and anxiety, mild tremors, and headache; last drink was the previous evening at 1900; anxiety 10/10; visibly fidgeting; consumes at least one bottle to a bottle and a half of wine every night; taking her prescribed benzodiazepine and alprazolam throughout the day rather than just before bedtime; unable to participate in family activities; symptoms of insomnia, anxiety; BP, 145/92 mmHg; heart rate, 109 bpm; pain, 3/10

Rationale: The client has cues that could indicate alcohol and possibly, benzodiazepine, withdrawal, anxiety, irritability, tremors, and headache. Also, the client has exhibited a change in functioning and ability to participate in daily life. The client’s blood pressure and heart rate are considered high and are indicative of a possible withdrawal.

The client is oriented to person, place, time, and situation, which is a normal finding. Likewise, respirations, temperature, and oxygen are all within normal limits.

The nurse will initiate the CIWA scale and medicate the client according to the observations and the client’s answers to this clinical scale. The client’s vitals will be closely monitored throughout the shift to decrease the chance that her BP becomes seriously high, increasing her risk for withdrawal seizures. The plan of care will include making sure that medication is available in the evening to decrease the client’s anxiety and help her sleep.

Delirium tremens; 2. Increased BP and HR

Rationale: The client exhibits signs of anxiety and is at highest risk for withdrawal and DTs.

Altered physiological signs (vital signs, sweating, tremors) and affect and increased anxiety are signs that are currently being exhibited so this is the risk.

1. Administer lorazepam per CIWA protocol; 2. Monitor for seizures and loss of consciousness.

Rationale: Lorazepam is indicated to help with withdrawal symptoms and prevent seizures in ETOH withdrawal.

ETOH withdrawal can cause seizures and DTs, which can lead to loss of consciousness.

Nursing action includes comfort measures, hydration, and continued monitoring.

Rationale: The client reports feeling less anxious and is now lying on her bed ready to take a nap. Her BP and pain score are decreased. Nurse has administered lorazepam per CIWA protocol.

Client’s BP, pain score, and anxiety are decreased.

1. Continue to follow the CIWA protocol and repeat based on the scores received.

2. Encourage the client to drink plenty of water.

3. Monitor for seizures and loss of consciousness.

Rationale: Close monitoring is imperative when a person is withdrawing from ETOH. Medicate as indicated by the CIWA protocol. Encouraging the client to drink water helps the medications to work better and cleanse the alcohol from her system. ETOH withdrawal can cause seizures and DTs, which can lead to loss of consciousness.