Substance Abuse and Abuse Q 27
What are the appropriate interventions for caring for the client in alcohol withdrawal. Select all that apply.
A. Monitor vital signs.
B. Provide stimulation in the environment.
C. Maintain NPO status.
D. Provide reality orientation as appropriate.
E. Address hallucinations therapeutically.
Correct Answer: A, D, & E.
When the client is experiencing the withdrawal of alcohol, the priority of care is to prevent the client from harming himself or others. The nurse would monitor vital signs closely and report abnormal findings. The nurse would reorient the client to reality frequently and would address hallucinations therapeutically.
Option A: Determine the cause of anxiety, involving the patient in the process. Explain that alcohol withdrawal increases anxiety and uneasiness. Reassess level of anxiety on an ongoing basis. The person in an acute phase of withdrawal may be unable to identify and accept what is happening. Anxiety may be physiologically or environmentally caused. Continued alcohol toxicity will be manifested by increased anxiety and agitation as effects of the medication wear off.
Option B: The nurse would provide a low stimulating environment to maintain the client in as calm a state as possible. Maintain a calm environment, minimizing noise to reduce stress. Provide a calm environment, minimizing noise and shadows to reduce the incidence of delusions and hallucinations. Speak in a calm, quiet voice. Regulate lighting as indicated. Turn off the radio and TV during sleep. Reduces external stimuli during hyperactive stage. The patient may become more delirious when surroundings cannot be seen, but some respond better to a quiet, darkened room.
Option C: Adequate nutritional and fluid intake needs to be maintained. Administer fluids and electrolytes, as indicated. Severe alcohol withdrawal causes the patient to be susceptible to fluid losses (associated with fever, diaphoresis, and vomiting) and electrolyte imbalances, especially potassium, magnesium, and glucose.
Option D: Reorient frequently. The patient may experience periods of confusion, resulting in increased anxiety. Develop a trusting relationship through frequent contact being honest and nonjudgmental. Project an accepting attitude about alcoholism. Provides the patient with a sense of humanness, helping to decrease paranoia and distrust. The patient will be able to detect biased or condescending attitudes of caregivers.
Option E: Orient the patient to reality. He may also experience hallucinations and may try to harm himself and others. Reorient frequently to person, place, time, and surrounding environment as indicated. May reduce confusion, prevent and limit misinterpretation of external stimuli. Avoid bedside discussion about the patient or topics unrelated to the patient that do not include the patient. The patient may hear and misinterpret conversation, which can aggravate hallucinations.