hey guys in this care plan we will explore alcohol withdrawal syndrome in delirium tremens so in this alcohol withdrawal syndrome care plan we will cover the desired outcome the subjective and objective data along with the nursing interventions and rationales so our medical diagnosis is alcohol withdrawal syndrome so alcohol withdrawal syndrome is a set of symptoms that occurs when a person suddenly slows down or stops drinking completely alcohol withdrawal includes delirium tremens autonomic hyperactivity nausea vomiting hallucinations psychomotor agitation anxiety and generalized tonic-clonic seizures after consuming alcohol regularly over a long period of time the body becomes physically dependent on that substance so cessation or significant reduction in alcohol results in that alcohol withdrawal syndrome in delirium tremens which caused a significant distress or impairment in their lives so the patient will maintain or regain an appropriate level of consciousness have stable vital signs the absence of hallucinations the patient will remain free of injury and regain control of daily activities in functioning this is all what we want when they leave the hospital now let's take a look at our care plan for alcohol withdrawal syndrome starting with the subject of data so your patient is not gonna be feeling very well at all they're going to be having headaches they're gonna feel anxious they might feel really confused they might have some nausea heart palpitations all of this occurs because the body is so used to having that alcohol regularly depressing their CNS system and so with the sudden withdrawal the body is reacting very severely sometimes when the alcohol leaves the system that confusion doesn't get any better this is super concerning because they're lacking many vitamins that we usually get and they need that for their brain right so that excessive alcohol intake was kind of preventing those nutrients from getting to the brain like it needed to so we'll talk about interventions that will help with this later now let's talk about the objective data so the lack of CNS depression can cause the patient to become really rest list agitated and they might have tremors which you usually can see and if you can't you can ask them to hold their hands out or even just kind of gently touch their hands and you'll feel the shakiness in their hands often the person detoxing is gonna experience uncontrollable sweating so you might have to change their sheets often you might see some cardiac dysrhythmias on the EKG or telemetry as the body reacts to that lack of alcohol their vital signs are probably going to show some tachycardia in hypertension which is usually treated with medications that actually treat the withdrawal which we'll talk about later so seizures are serious serious side effect of withdrawal that some might have because of the effects on the brain now let's talk about the nursing interventions for alcohol withdrawal syndrome so you need to perform a complete assessment on this patient include the vital signs play really close attention to the patient's respiratory system you want to make sure they're still breathing you want to pay attention to their neurologic system like that confusion or agitation and you want to pay attention to their cardiac status like that high blood pressure and that high heart rate right so these can all be severely affected with this withdrawal include any withdrawal questions that your organization uses per protocol we'll talk about the sea wall later so this is going to help you to obtain baseline and determine the stage and severity reassessing often usually every three hours will help you determine the effectiveness of the interventions there's different stages so stage one would include the hyperactivity stage two includes hallucinations and seizure activity Stage three includes DTS confusion fever and anxiety so you might think of this as mild moderate and severe maintain a patent airway an initiate oxygen as needed if their pulse ox levels drop depending on what the doctor's orders say or the protocols be sure to ask questions per your facility protocol regarding the suicidal ideation why well sometimes when these patients are coming off alcohol they feel confused they feel anxious they just feel really not themselves so they might start to have some suicidal ideations and experience some self-destructing ideas so provide isolation as needed or restraint if necessary per facility protocol to keep that patient and others safe so it's really really important to monitor the patient's heart for cardiac dysrhythmias and irregularities first initiate a 12-lead EKG to obtain a baseline then put the patient on telemetry per doctor order or protocol so that you can watch their heart on a regular basis remember how I mentioned prolong confusion in some patients after the alcohol wears off so this is called Wernicke Korsakoff syndrome and it's because of the lack of simon so this has to be treated immediately or prevented by providing an IV banana bag which is called a banana bag because it's yellow it's actually full of vitamins that the brain needs this is so that that confusion does not remain permanent this can be really scary for family members because the patient's not usually confused so they're like what is going on so of course also consider IV hydration because this patient is probably dehydrated and you don't want to promote any cardiac dysrhythmias you should in this initiate seizure precautions per protocol this is so that you can prevent anything from dangerous from occurring like falling out of bed or choking on their own saliva so keep that suction at the bedside if you need to you can even provide a camera in the room if they're known to have seizures a lot that way you know when to get in there and help so you want to provide a really calm and safe environment for these patients reorient them as you need to if they're confused this is going to help decrease their anxiety and increase the safety of them they already feel like really sick and not themselves so you want to help them to not feel so overstimulated so administer medications as appropriate and as ordered by the doctor so my organization uses the co op protocol which I think many do so this is to determine the dose of either the lorazepam or the diazepam depending on which they choose based on the scores that we get after going through the questions so let me give you some examples of questions that we might ask the patient will ask do you feel anxious and if so how would you write your anxiety from zero to ten are you seeing or hearing or feeling anything unusual do you feel restless other parts of the SI WA are really just kind of objective you can see them for example how badly are they sweating or shaking are their vital signs off the charts they have high blood pressure you know high heart rate so medications that we would use are going to help to reduce the hyperactivity we're gonna prevent seizures hopefully can promote their sleep they also help to decrease the blood pressure and heart rate so our last intervention is to provide education and resources for that patient and family if they're there so this is so important you guys you need to help this patient for moving forward what's gonna happen when they leave the hospital it's scary and it's hard for them it's so so hard for them to stop drinking for good they need that support and guidance thanks for watching another nursing comm lesson click the link below in the description to watch thousands more lessons over on nursing comm also be sure to hit the subscribe and the little bell to make sure you're reminded when new lessons come out and if you want to just keep watching more lessons go ahead and click this video over here to continue learning like we always say here at nursing calm happy nursing [Music]