Alcohol withdrawal is a fact of life in our patient population. You are likely screening for it on intake and hopefully using a standard evaluation tool like those described in a prior post. Once you see an incoming patient is at risk for withdrawal, what is your plan?
Location, Location, Location
Withdrawing patients need to be located where they will not get lost in the system. Some facilities have the capacity to keep potentially withdrawing patients in an Infirmary or Special Needs Unit where they are directly monitored. Other facilities only place symptomatic patients in the infirmary and keep potentially withdrawing patients in a specific housing unit. If they develop symptoms they are transferred to a higher level of observation or treatment. The key principle is to have a designated place for potentially withdrawing inmates where officers and other staff are aware of what signs and symptoms indicate alcohol withdrawal.
Get the Timing Down
If you know when your patient last had a drink or can estimate it based on entry into the facility, you can have some idea of when withdrawal symptoms will peak. Of course, timing is individualized based on many factors such as the patient’s liver health and long-term nature of the alcoholism. However, generally, withdrawal from alcohol progresses to completion over 5 days with the greatest degree of symptoms in the first 24-36 hours. Without intervention, though, withdrawal can lead to delirium tremens at about 3-5 days from the last drink. This condition is serious and can lead to hallucinations, electrolyte imbalances, unconsciousness, and death. Even ‘frequent-flyer’ alcoholics with a known history of uncomplicated withdrawals in your facility should be watched closely and treated for withdrawal. A phenomena called ‘alcohol withdrawal kindling’ can emerge where progressive withdrawal episodes increase in neurotoxic intensity. This means your ‘regular’ withdrawing patient may not progress as mildly this time around.
Maintain the Protocol
Alcohol withdrawal is both a common and risky medical condition for the inmate-patient population. Therefore, it is important to have a standard protocol for treatment. A standard protocol establishes consistent and appropriate practices for all staff members and provides a safeguard in those situations where practitioners may be unfamiliar with the standard of care. The Federal Bureau of Prisons Clinical Practice Guideline for Detoxification of Chemically Dependent Inmates is a good place to start in determining necessary elements of a plan of care. Here are some important management principles that should be a part of any correctional alcohol withdrawal protocol:
When to Seek Provider Orders: If a patient is deemed a medium or high risk of alcohol withdrawal at intake, most protocols stipulate a provider evaluation and prescriptive therapy. Low risk patients may be put on a monitoring protocol and advanced to provider oversight if symptoms emerge. Many of the protocol treatments described in this post require a provider order but can be part of a protocol list to speed treatment ordering and avoid omissions.
Patient Evaluation: Withdrawal protocols should spell out how often patient evaluations should take place, with increasing evaluation frequency if severity progresses. Low risk patients, for example, may require three-times-a-day evaluation while high risk patients may require every two hour evaluations for a specific time period.
Benzodiazepine Therapy: A cornerstone of alcohol withdrawal management is the use of benzodiazepines to reduce the excitability of the nervous system that has been shocked by the loss of alcohol. This tranquilizing effect can relieve withdrawal symptoms such as insomnia, muscle spasms, involuntary movement disorders, anxiety, and convulsions. While some correctional providers recommend long-acting options, such as Valium, as they have the ability to self-taper over time, the FBOP guidelines recommends Ativan, a shorter-acting option. The point is to have benzodiazepine therapy as part of the protocol with specific guidelines at to timing and dose. This may end up being based on the facility medical director’s preference and comfort level. Having a consistant program for benzodiazepine therapy spelled out in a protocol eliminates variability and helps both nurses and providers maintain the program.
Vitamin Therapy: Many who are alcohol dependent are poorly nourished and frequently thiamine deficient. Thiamine replacement therapy is recommended as a part of a withdrawal protocol along with a multivitamin.
Symptom Management: Common withdrawal symptoms should be addressed on the protocol with standard treatment options. Many symptoms of alcohol withdrawal are reduced through benzodiazepine administration but other common side effects such as headache, nausea, and vomiting may need additional comfort measures such as pain relievers or anti-emetics. Having these options addressed on a protocol and then prescribed by a provider at the time of protocol initiation is efficient.
Nutrition and Hydration:Don’t forget the need for quality food and water during withdrawal. This point, in itself, may indicate a need for a special housing assignment for withdrawing inmates. Most chronic alcoholics are undernourished and can become dehydrated during withdrawal. This can lead to eleyctrolyte abnormalities and hypoglycemia. Encouraging eating and drinking is important. Some settings even have electrolyte replacement drinks available for use by patients in withdrawal. Many protocols include checking fingerstick blood glucose daily on high risk patients.
Know When to Hold ‘Em – Know When to Ship Them
Many, if not most, of our patients withdrawing from alcohol can be treated safely behind the perimeter, but some can’t. Knowing when a patient needs to be moved to a higher level of care is crucial. Generally, seizures, hallucinations, or hemodynamic instability are all indications of a need for acute care monitoring and treatment. Be sure to have indications for emergency transport spelled out in your alcohol withdrawal protocol.
What is your plan for managing alcohol withdrawal in your setting? Share your tips in the comments section of this post.
Other Alcohol Withdrawal Resources
To read more about alcohol and drug withdrawal in the correctional setting see Chapter 5 in the Essentials of Correctional Nursing. The text can be ordered directly from the publisher and if you use Promo Code AF1402 the price is discounted by $15 off and shipping is free.
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