On admission to the hospital, patients with a medical or surgical condition may not be identified as having a substance abuse problem. Those who experience alcohol withdrawal should be transferred to a detox unit—but this may not be possible because of comorbid conditions. Unanticipated alcohol withdrawal in hospitalized patients can add to hospitalization risks and costs. So nurses need to be able to recognize alcohol withdrawal syndrome and start appropriate interventions within the first 24 hours. Otherwise, such complications as seizures and substance withdrawal delirium may arise. This article discusses care for adult nongeriatric patients in alcohol withdrawal. (Other patient groups have their own unique needs.)
The U.S. Department of Health and Human Services identified the need for routine addiction screening by nurses in 1994. Most hospitals have implemented this practice by including it in initial nursing assessments. A careful assessment can yield clues to alcohol use disorders—and it’s essential to check for these disorders in all patients.
But because not all patients are identified on admission as having the potential for alcohol withdrawal, you must stay alert for signs and symptoms. These may arise 4 to 12 hours after the patient’s last drink and may emerge while the patient’s still intoxicated. Many patients with long-term alcohol dependence don’t allow their blood alcohol level (BAL) to drop below a comfortable level, so withdrawal may begin when BAL is still in the intoxication range.
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The Diagnostic and Statistical Manual of Mental Disorders 4th Edition, Text Revision (DSM-IV-TR) provides the following diagnostic criteria for alcohol withdrawal: Two or more of the following occurring within several hours to a few days of stopping or reducing alcohol use that has been heavy and prolonged:
- autonomic hyperactivity (such as sweating or a pulse faster than 100 beats/minute)
- increased hand tremor
- nausea or vomiting
- transient visual, tactile, or auditory hallucinations or illusions
- psychomotor agitation
- grand mal seizures.
Using the CIWA-Ar scale
The standard for assessing and documenting alcohol withdrawal symptoms is the Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) scale. The CIWA-Ar encompasses 10 areas—nausea and vomiting, tremor, paroxysmal sweats, anxiety, agitation, tactile disturbancs, auditory disturbances, visual disturbances, headache or fullness in the head, and orientation and clouding of sensorium. Using this scale, assess the patient at least every 4 to 6 hours around the clock. If the score exceeds 20, reassess in 1 to 2 hours, depending on symptom severity. Know that in patients with significant hepatic disease, symptom onset may be delayed up to several days. (Click the PDF icon above to view.)
Using the CIWA-Ar
Scoring with the CIWA-Ar scale is done systematically. You can become proficient in scoring fairly quickly by following the scoring sheet closely.
To assess for tremor, have the patient extend the arms with fingers spread. But be aware that many patients hyperextend their arms, which can cause difficulty evaluating extent of the tremor. To minimize this, have the patient put his or her hands on your hands so you’ll be able to feel the tremor. Or hand the patient a paper cup full of water and instruct him or her to drink it; as the patient drinks, observe tremor extent.
A minor tremor (scored 1 or 2) is a fine, flutter-like tremor. With a moderate tremor (3 or 4), the patient can bring cup to mouth with one hand but shows a noticeable tremor. With a severe tremor (5 to 6), the patient needs both hands to bring cup to mouth. In a full-body tremor (7), the patient can’t stand unassisted and has tremors all over, including the tongue.
To assess for paroxysmal sweats, rub the patient’s palms, back of the neck, and forehead. If you detect moisture, score this 1or 2. In a moderate sweat (scored 3 to 4), you can detect sweat on the forehead and palms; the patient feels clammy and clothing is damp. With a severe sweat (scored 6 to 7), clothing and bedding are wet and the patient’s body is wet and clammy. In a drenching sweat (7), clothing and bedding are soaked. During severe withdrawal, clothing or bedding may need to be changed two or three times per shift. Be aware that the patient is cold when out of bed, so be sure to cover him or her with a blanket.
To assess for anxiety, ask the patient to rate his or her anxiety (“internal nervousness”) on a 1-to-10 scale, with 10 being absolute panic. Most patients can rate their anxiety fairly accurately, but your observation of their behavior is also needed.
Agitation is a subjective feeling of inability to be still, but it also can be observed by others. Watch for tossing and turning in bed, and ask the patient if he or she is unable to be still. As BAL drops from a high level toward zero, the patient may pace continually. To tolerate hospitalization, the patient needs adequate medication; failure to medicate for agitation is akin to failing to medicate a surgical patient for pain.
Tactile disturbances (especially itching) may start when BAL declines. Itching usually arises at the back of the neck or head; you may see the patient scratching. Numbness and tingling sensations typically arise later (at least 24 hours after the last drink) and affect fingers, toes, forearms, and calves. Sensations of things crawling on the skin are rare in patients with treated withdrawal.
Similarly, auditory hallucinations generally don’t occur with adequately treated withdrawal. But some patients show irritation when subjected to noise, or find noises or voices harsh. Visual hallucinations also is rare in adequately treated withdrawal; however, some patients find bright fluorescent hospital lights highly irritating. Irritation from noise and light reflect central nervous system irritability and underscore the need for a quiet, dark environment.
Headaches are common, particularly as intoxication decreases (in what’s commonly called a hangover). As headache gets more severe, nausea may arise. Diazepam or lorazepam may be sufficient to relieve headache.
Assess orientation and sensorium with simple questions, such as, “Where are you? What day is it? What time of day is it?” To evaluate the patient’s ability to process, use the “serial sevens” by asking, “What is 7 + 7?” Then add another 7, and another, and so on. When assessing serial sevens, consider how much sedation the patient has received. Most adequately treated patients show orientation to person, place and day by the second day.
Medication protocols for alcohol withdrawal
Patients should be kept comfortable during detox. Physicians and nurse practitioners may use a symptom-management or fixed-schedule protocol when prescribing medications to treat alcohol withdrawal. The symptom management approach can be determined by CIWA-Ar scores. For example:
- For a CIWA score below 8, no medication is needed.
- A score of 8 to 14 warrants 5 to 10 mg diazepam or equivalent lorazepam (0.5 to 1 mg)
- A score of 15 to 19 calls for 10 to 15 mg diazepam or equivalent.
- A score of 20 to 25 warrants 20 mg diazepam or equivalent.
- A score of 25 to 30 calls for 25 to 30 mg diazepam or equivalent.
In the fixed-schedule approach, diazepam or lorazepam is given every 2 to 6 hours around the clock; usually, the prescriber allows doses to be withheld if oversedation occurs. With this protocol, the nurse must notify the prescriber if doses fail to control withdrawal symptoms. Don’t give diazepam to patients with hepatic disease because of its long duration of action. If your patient becomes oversedated with diazepam, consider requesting a change to lorazepam. During detox, antiemetics and antidiarrheals are added only when needed, not on a regular basis beause of the possibility of abuse.
When giving medications, keep in mind your patient’s tolerance level; otherwise, you’re likely to undermedicate and promote the risk of seizure or delirium. Withdrawal complications commonly result from poor nursing judgment and undermedication. Nurses who don’t regularly work with alcoho-dependent patients tend to undermedicate. Some patients are used to drinking a case of beer, two bottles of wine, or up to a half gallon of vodka daily; they require a great deal of medication to control symptoms.
Thiamine routinely is given to patients in alcohol withdrawal on admission. Depending on withdrawal severity, monitor vital signs every 1 to 4 hours; also repeat the CIWA-Ar assessment and administer medications as ordered and needed. Make sure to offer patients fluids at each assessment and keep water at the patient’s bedside at all times. Rarely, patients become dehydrated and need I.V. fluids; if medicated at required levels to control symptoms, vomiting and diarrhea usually don’t occur.
Discharge planning must include referral for treatment of alcohol use disorder. Many facilities have certified addiction specialists willing to perform assessments and referral services to assist in the process.
Early assessment and proper treatment of alcohol withdrawal can prevent complications and improve patient outcomes. Caring for patients in alcohol withdrawal certainly can be challenging—but ultimately rewarding. These patients deserve the best possible care and respect. Contrary to popular belief, none of them wish to be in the position in which they find themselves.
When she wrote this article, Geraldine Birch Hurst was a certified addictions nurse and psychiatric clinical nurse specialist at Providence Portland Medical Center in Portland, Oregon and an adjunct professor at Clark College in Vancouver, Washington. She is currently retired and works per diem.
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Your paper states a patient can pace to cope with agitation. To clarify, should a patient who is hallucinating, at risk for seizures and has tremors be allowed to pace? Would this not be a risk for falls and injuries?
How often should health care workers check on a detox patient through the night.
Would the presence of family members help with patients who are agitated and physically aggressive from alcohol withdrawal?
You are as bad as RGH…. No answers at all ?
This method is seriously flawed. I went through it 6 months ago even though I was not drinking at all. How can this test be performed when a patient is sedated and unable to participate. My family and I went through hell because of this. I have serious short term memory loss. Re-think this approach before it runs more lives !
Does the CIWA Assessment, have a way of telling the doctor or nurse, that the Alcohol Withdrawal diagnosis may be incorrect? Meaning: If a patient has a pretty consistent score of 5 and 6, and the only symptoms the patient has, and have had, are anxiety, agitation, and hallucinations, will the test, itself, throw up a red flag, or is that completely up to the doctor to recognize he misdiagnosed a patient?