CHAPTER 11 Substance Abuse

161

Patient in Alcohol Withdrawal

NURSING DIAGNOSIS Acute confusion related to alcohol abuse and delirium as evidenced by increased agitation, hallucinations, fluctuations in
level of consciousness and psychomotor activity, disorientation, or misperceptions.

PATIENT GOALS 1. Demonstrates decrease in alcohol withdrawal severity.

2. Experiences no injury or complications of acute alcohol withdrawal.
3. Experiences no hallucinations.
4. Experiences no seizures.

Outcomes (NOC)

Interventions (NIC) and Rationales

Substance Withdrawal Severity

Substance Use Treatment: Alcohol Withdrawal

Monitor vital signs during withdrawal to identify extreme autonomic nervous

system response.
Administer antiseizure drugs or sedatives to prevent alcohol withdrawal
delirium and relieve other symptoms during withdrawal.
Administer vitamin therapy to prevent Wernickes syndrome.
Address hallucinations in a therapeutic manner to provide reality orientation.
Determine CIWA-Ar score every 4 hours until it is less than 8 for 24 hours
to assess need for medications.
Provide emotional support to patient/family to decrease anxiety.

Substance cravings ___

Agitation ___
Hyperreflexia ___
Tremors ___
Change in vital signs ___
Disorientation ___
Altered level of consciousness ___
Difficulty interpreting environmental stimuli ___
Misinterpretation of cues ___
Sleeplessness ___
Hallucinations ___
Seizures ___

Measurement Scale
1
2
3
4
5

=
=
=
=
=

Severe
Substantial
Moderate
Mild
None

Asks for validation of reality ___

Reports decrease in hallucinations or delusions ___
Perceives environment accurately ___
Exhibits logical thought flow patterns ___
Exhibits reality-based thinking ___
Exhibits appropriate thought content ___

Measurement Scale
1
2
3
4
5

=
=
=
=
=

Keep suction, Ambu-bag, and oral or nasopharyngeal airway at bedside to

establish respiratory function after seizure activity.
Use padded side rails and keep side rails up to prevent injury during seizure
activity.

Delirium Management

Distorted Thought Self-Control

Seizure Precautions

Never demonstrated
Rarely demonstrated
Sometimes demonstrated
Often demonstrated
Consistently demonstrated

Monitor neurologic status on an ongoing basis to determine appropriate

interventions.
Verbally acknowledge the patients fears and feelings to decrease anxiety.
Provide patient with information about what is happening and what can be
expected to occur in the future to assist in reality orientation.
Maintain a well-lit environment that reduces sharp contrasts and shadows to
reduce external stimuli.
Remove stimuli, when possible, that create misperception in a particular
patient (e.g., pictures on the wall or television) to reduce misinterpretation of
environment.
Inform patient of person, place, and time to promote orientation.
Use environmental cues (e.g., signs, pictures, clocks, calendars, and color
coding of environment) to stimulate memory, reorient, and promote
appropriate behavior.

NURSING DIAGNOSIS Ineffective self-health management related to inadequate coping mechanisms and resources as evidenced by abuse of
alcohol

PATIENT GOALS 1. Acknowledges a substance abuse problem

2. Commits to alcohol cessation
3. Identifies positive coping mechanisms and resources to use during alcohol abstinence

Outcomes (NOC)

Interventions (NIC) and Rationales

Alcohol Abuse Cessation Behavior

Substance Use Treatment

Encourage patient to take control over own behavior to change undesired

behaviors.
Discuss with patient the impact of substance use on medical condition or
general health to promote acknowledgment of consequences of use.
Identify constructive goals with patient to provide alternatives to the use of
substances to reduce stress.
Assist patient to learn alternative methods of coping with stress or
emotional distress to reduce substance use.
Identify support groups in the community for long-term substance abuse
treatment to promote continued abstinence.

Expresses willingness to stop alcohol use ___

Develops effective strategies to eliminate alcohol use ___
Commits to alcohol elimination strategies ___
Uses strategies to cope with withdrawal symptoms ___
Uses effective coping mechanisms ___
Adjusts lifestyle to promote alcohol elimination ___
Obtains assistance from health professional ___
Uses available support groups ___
Eliminates alcohol use ___

Measurement Scale
1
2
3
4
5

=
=
=
=
=

Never demonstrated
Rarely demonstrated
Sometimes demonstrated
Often demonstrated
Consistently demonstrated

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Addictive Behaviors

NURSING CARE PLAN 11-1