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TRANSCRIPT
Caring for the patient in Alcohol Withdrawal
Cortney K. Muns, BSN,RNAlverno College MSN Candidate
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Instructions for navigating the tutorial
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Click on the to go to the “sections” slide
You will be given opportunities throughout to test your knowledge
At the end of the tutorial, the learner will
be able to.. Identify keys components to the pathophysiology of alcohol
withdrawal and neurological involvement Identify the body’s responses to stress and how the HPA axis
relates to aging Identify the signs, symptoms, and behaviors of alcohol
withdrawal Apply learned concepts to a case study involving the care of
the patient in alcohol withdrawal Identify how genetics and metabolism are related in alcohol
abuse Identify inflammation and it’s role in comorbidities
associated with alcohol abuse
SectionsClick on individual sections to jump to that
section
Case Study (1) Neurological Pathophysiology(2) Hypothalamic-pituitary-adrenal Axis(HPA Axis), “f
ight or flight”, & Generalized Stress Response(3) Signs & Symptoms of alcohol withdrawal(4) Symptom Management(5) Nursing Interventions(6) Genetics & Metabolism (7) Alcoholic Liver Disease & Inflammation (8)
Case Study
31 year old male, admitted to your unit for alcohol detox, states he had his last drink over 24 hours ago, and exhibits the following signs and symptoms-
Complains of nausea but no vomiting Tremulousness States he has a tight “rubber band”
feeling around his head Profuse sweating Click here
to return to data
Case Study Continued
Feels intense anxiety Denies hallucinations Denies agitation Knows the current place and time
We will come back to this case study later in the tutorial
Click here to return to
data
Brain Communication
Neurons- nerve cells that communicate to each other using electrical and chemical signals (neurotransmitters)
Synapse- giving and receiving ends where neurotransmitters are transported from one neuron to the next
Presynaptic neurons release neurotransmitters to receptors on the postsynaptic neuron
Lovinger, 2008
Neurotransmitters: The Heavy Hitters
gamma-Aminobutyric acid (GABA)
Glutamate
GABA
Glutamate
Microsoft, 2007
GABA Main inhibitory
neurotransmitter in the human body
Found in all areas of the brain
Regulates neuronal excitability throughout the body
Binds to GABA receptors in the presynaptic and postsynaptic phases of transmission
Alcohol enhances GABA by increasing the inhibitory effects (sedative effect)
Current drugs in the benzodiazepine and barbiturate families can replace alcohol in the brain for successful and non life threatening alcohol withdrawal treatment
Lovinger, 2008
Neurotransmitter binding
NIAAA, 2009
Benzodiazepines bind here
glutamate
Exhibits excitatory effects on the brain
Like GABA, is found all over the brain
Binds to NMDA receptors in the brain
Acute alcohol exposure inhibits glutamate transmission, causing neuronal excitability (leading to seizures)
Chronic alcohol exposure increases the number of NMDA receptors
Increased numbers of NMDA receptors leads to withdrawal hyper excitability and alcohol induced neuronal damage when GABA cannot produce inhibitory effects
Involved in cognitive functions such as learning and memory
Drugs that act to reduce receptors involved with glutamate such as memantine and topiramate are either being studied or used for treatment
Lovinger, 2008
Neurotransmitter Basics: a quick review
GABA is an inhibitory neurotransmitter
GABA and alcohol bind to the same receptors
In alcohol withdrawal treatment, benzodiazepines bind to those same receptors, preventing neurological withdrawal symptoms
Glutamate in an excitatory neurotransmitter
Alcohol binds to certain receptors to produce sedating effects and long term use causes increased NMDA receptors
In the absence of alcohol, NMDA and glutamate create excitability since GABA is not present to inhibit this (seizures)
Hypothalamic-Pituitary-Adrenal (HPA) Axis
Neuroendocrine response to stress (Brain)(Hormones) Contributes to psychological and physiological
responses to alcohol Ultimately stimulates glucocorticoid secretion Three way relationship exists between alcohol
use, glucocorticoid secretion, and aging
Hutchison & Spencer, 1999
Hypothalamic-Pituitary-Adrenal (HPA) Axis
So now what?Cortisol released from the adrenal glands of the
kidneys prevent further release of CRH and ACTH. Is this a negative or positive feedback loop? Think
about it and save it for the end of the section.
Stressful situation(alcohol intoxication)
Hypothalamus Pituitary Gland
Adrenal Glands Hint: Roll mouse over body parts to reveal what they release.
Hutchison & Spencer, 1999 & Microsoft 2007
Adrenal Gland
HPA Axis & Alcohol Use
Alcohol use stimulates the HPA Axis Length of stimulation depends on
amounts of alcohol consumed or blood alcohol level (BAC)
Hutchison & Spencer, 1999 & Microsoft 2007
HPA Axis Activation & Genetics
Blood alcohol levels (BAC) and HPA Axis activation have a strong genetic component
Strong evidence exists of a defective gene, not allowing the correct metabolism of alcohol
People with this gene have significant high cortisol levels
Hutchison & Spencer, 1999
HPA Axis and Aging
Aging people are more at risk for HPA Axis overstimulation
Why?
Recovery is slower The feedback loop
takes longer to get the message back
Getting rid of catecholamines takes longer
Cortisol levels eventually will cause neuronal death
Hutchison & Spencer, 1999
Fight or FlightNorepinephrine/Noradrenaline
Released
Alpha1
Alpha2
Beta1
Beta2
Diaphoretic
Increased Blood Pressure
Dilated Pupils
GI Tract off
LowersInsulin
Increased HR
IncreasedRespirations
Case Question #1A patient in acute alcohol withdrawal is
experiencing sweats (diaphoresis) and an increase in heart rate (tachycardia). What is causing this?
Click on the correct answer
Sympathetic Nervous System
HPA Axis Delirium
Nursing Sensitive Outcomes
Accurate nursing assessment of patients with alcohol dependence can help to eliminate or minimize negative patient outcomes
Recognizing/identifying signs/symptoms/behaviors of those at risk for alcohol withdrawal syndrome
McKinley, 2005
Alcohol Withdrawal Syndrome Tremors Sweating Nausea Vomiting
Agitation Anxiety Auditory
disturbances Clouding of
sensorium Visual/Tactile
disturbances
Autonomic Hyperactivity
NeuropsychiatricAlterations
McKinley, 2005
Alcohol Withdrawal Syndrome
Signs/symptoms can appear within 24 hours of last drink
Peak of s/s happen as early as 24 hours and stop around 48 hours
Delirium tremens typically occur between 48-72 hours after last drink
Delirium tremens is considered an emergency and can end in death
McKinley, 2005
Kindling
Excessive activation of NMDA increases the chance of seizures
Long term exposure to alcohol depresses GABA, making brain more vulnerable to seizures
For nurses, the implication would be to assess patient history of withdrawal/detox and treat more aggressively those who are most at risk
48% of inpatient alcoholics who suffered seizures had gone through several detoxifications in their pasts
In the same study, 12% of alcoholics who had seizures during detoxification had little to no history of detoxification
Becker, 1998
Alcohol Withdrawal Assessment Tools
Clinical Institute Withdrawal Assessment (CIWA)
Selective Severity Assessment (SSA)
CAGE questions Alcohol Withdrawal Syndrome Type
Indicator Alcohol Use Disorders Identification
Test
CIWA
CIWA is a 10 item rating scale that discriminates symptoms of gastric distress, perceptual distortions, cognitive impairment, anxiety, agitation, and headache
Ragasis,2004
Sig
ns/s
ym
pto
ms
Nause
a/V
om
iting
Parox
ysm
al S
weats
0 No Nausea/Vomiting 1-3 Mild nausea 4-6 Intermittent Nausea with Dry
Heaves 7-Constant Nausea, Dry Heaves,
Vomiting
0-No sweat visible 1-3 Barely Sweating 4-6 Beads of Sweat Obvious on
Forehead 7- Drenching Sweats
Click here to return to data
Sig
ns/s
ym
pto
ms
Trem
ors
Anxie
ty
0-No tremors 1-3 Not visible, but can be felt fingertip
to fingertip 4- Moderate with arms extended 7-severe, even without arms extended
“Do you feel nervous?” 0-No anxiety/at ease 1-3 Mildly anxious 4-6 Moderately anxious 7-Acute panic, anxiety
Click here to return to data
Sig
ns/s
ym
pto
ms
Agita
tion
Headach
e/Fu
llness
0-Normal activity 1-3 Somewhat more than usual 4-6 Moderately fidgety/restless 7-Paces back and forth, thrashing about
None 1-Very mild 2-Mild 3-Moderate 4-Moderately sever 5-Severe 6-Very severe 7-Extremely severe
Click here to return to data
Visual Hallucinations
Does the light appear to be too bright?
Is the color different?Does it hurt your eyes?Are you seeing anything
that is disturbing to you?
Are you seeing things you know aren’t there?
0-None 4-Mild sensitivity
to light to occasionally seeing things you can’t
7-Constant visual hallucinations
Auditory Hallucinations
Are you aware of sounds around you?
Are they harsh?Do they frighten you?Are you hearing
anything disturbing?Are you hearing things
you know aren’t there?
0-None 2-Very mild harshness
of ability to frighten 3-Moderate 4-Moderately severe
hallucinations 5-Severe hallucinations 6-Extremely severe
hallucinations 7-Continuous
hallucinations
Tactile Hallucinations
Do you feel any itching, or pins and needles?
Any numbness or burning?
Do you feel bugs crawling on or under your skin?
0-None 1-Very mild itching 2-Mild itching 3- Moderate itching 4-Moderate
hallucinations 5-Severe hallucinations 6-Extremely severe
hallucinations 7-Continuous
hallucinations
Clouding of Sensorium/Orientation
“ What day is it? Where are you? Who am I?”
0-oriented 1-Cannot do serial
additions or uncertain of dates
2-Disoriented to date but not by more than 2 days
3-Disoriented for date by more than 2 days
4-Disoriented to time/place
Case Study
Prepare to use your critical thinking skills and assess your patient in alcohol withdrawal!
What is going on? Patient is sweating profusely Exhibits moderate tremors w
hen asked to extend arms Appears to be restless and jit
tery during assessment
Patient complains of intense headache, a “rubber band” is tight around his head
Patient complains of intense anxiety
Patient denies audio/visual/tactile hallucinations
Patient is alert and oriented to self, place and time
Patient complains of moderate nausea, no vomiting
Objective Data Subjective Data
Click here to review the case study!
Click here to return to case study
Scores
Profuse sweating 4-7
Moderate tremors 4 Moderate agitation
4-6
Moderate headache 4-6
Intense anxiety 4-6 No hallucinations 0 Oriented 0 Mild nausea 1-3
Score range is 21-32Now what?
Objective Data
Subjective Data
Click on individual signs/symptoms to take you to the scores
Treatment for alcohol withdrawal
Benzodiazepines are given, to meet receptors in the brain alcohol is no longer binding to, to prevent hyperexcitibility and seizures
Intravenous fluids Anti inflammatory medications for the headache Thiamine (patients often malnourished) Multivitamin (patients often malnourished) Folic Acid (patients often malnourished) Therapeutic relations with patient (support)
Always remember to continue to use the nursing process for outcomes and continued care!
Alcohol Abuse, Genetics, & Metabolism
The processing of alcohol involves….
1. Gastrointestinal tract absorption2. Alcohol distribution in the body3. Liver metabolismGenetics and Environmental factors
influence these processes
NIAAA, 2007
Environmental influences GI Surgeries
Concentration of alcohol in beverage
Rate of consumption Presence of food in the stomach
Genetic Influences
Liver Enzymes
(Needed for alcohol breakdown)
Cytosolic alcohol
dehydrogenase(ADH)
Mitochondrial aldehyde
dehydrogenase(ALDH2)
NIAAA, 2007
Genetics and Metabolism
The amount of alcohol metabolized in the body relies on:
Liver Size & Body Mass
Genetics have influences on ADH & ALDH and affect how people metabolize alcohol
This can help to explain why certain groups of people have variances in levels of alcohol abuse
NIAAA, 2007
Alcohol Abuse and Associated Health Conditions
Alcoholic Liver Disease (ALD) Alcoholic Cardiomyopathy Alcohol Related Dementia Peripheral Neuropathy Gastritis Pancreatitis
Alcoholic Liver Disease
(ALD)
Fatty Liver Alcoholic Hepatitis Cirrhosis
Long term alcohol abuse is leading cause of liver disease in the U.S.
Alcohol, Research, & Health, 2000
Is inflammation important?
What do you think? Click on a box to find out?
No Yes
So, what happens with inflammation in ALD?
Repeated
Alcohol Abuse
Cytokines
Released
Endotoxins
Produced
Promote Scar
Formation
Stimulate More
Cytokines
Activate Immune System
Roll mouse over underlined words for more information.
Chronic inflammation from chronic alcohol exposure can cause
hepatocyte apoptosis
Neuman, 2001
What if inflammation continues?
Increased numbers of cytokines continue to be activated
Increased scarring occurs Cell injury increases Increase in cell death Compromised organ function Organ failure
Treating ALD….depends on what is going on.
Alcoholic Liver Disease
(ALD)
Fatty Liver Alcoholic Hepatitis Cirrhosis
Depending on what is happening to the liver, interventions lie in decreasing the
inflammation, resting the organ, preventing hepatic encephalopathy, preventing ascites, and abstaining from the stressor (alcohol)
Nursing Considerations
One role of the nurse is to provide safe patient care that contributes to ideal patient outcomes. In caring for the patient in alcohol withdrawal these include:
Keeping safety in mind (seizure pads) Eliminate extraneous stimuli (keep it quiet) Prevent falls (bed/chair alarms, rounding) Watching for s/s of bleeding (since the liver might be
compromised) Critical thinking for s/s of other disease processes that might
mimic AWS, as to avoid mistreating (medicating for AWS when patient might have a low blood sugar)
Monitor all values related to liver function (coagulation, enzymes, etc.)
What can you do as a nurse?
Promote healing through nursing/medical interventions
Be familiar with the pathophysiology of what is going on with the patient
Look at the “whole” picture Advocate for the patient
References
Animated images not otherwise specified, Microsoft Clip Art, (2009), obtained at http://office.microsoft.com/en-us/clipart/default.aspx
Axen, D., Koranda, A., & McKay, A., (2004). Using a Symptom-Triggered Approach to Manage Patients in Acute Alcohol Withdrawal. Medsurg Nursing, February 2004, (13)1.
Author unknown., Medical Consequences of Alcohol Abuse. (2000). Alcohol Research & Health., Vol. 24, No. 1.
Becker, H.C., Kindling in Alcohol Withdrawal. (1998). Alcohol Health & Research World. Vol. 22, No. 1.
Hutchison, K.E. & Spencer, R.L., Alcohol, Aging, and the Stress Response. (1999). Alcohol Research & Health. Vol. 23, No. 4.
Lovinger, D.M., Communication Networks in the Brain: Neurons, Receptors, Neurotransmitters, and Alcohol.(2008). Alcohol Research & Health. Vol. 31 No. 3. Retrieved on the world wide web on March 31st, 2009 at http://pubs.niaaa.nih.gov/publications/arh313/196-214.htm.
References
McKinley, M.G., (2005). Alcohol Withdrawal Syndrome: Overlooked and Mismanaged? Critical Care Nurse. Vol. 25, No. 3.
National Institute on Alcohol Abuse and Alcoholism., (2007). Alcohol Metabolism: An Update. Retrieved on the world wide web on April 16th, 2009 at http://pub.niaaa.nih.gov/publications/AA72/AA72.htm
National Institute on Alcohol Abuse and Alcoholism, 2009, Permission obtained for use of pictures/graphics.
Neuman, M. G., (2001). Cytokines-Central Factors in Alcohol Liver Disease. Retrieved on the world wide web on May 2nd, 2010 at http://pubs.niaaa.nih.gov/publications.arh27-4/307-316.htm.
Ragaisis K.M., (2004). Alcohol Screening in the Acute Care Hospital. Journal of Addictions Nursing, 15: 171-175.
Saitz, R., (1998). Introduction to Alcohol Withdrawal. Alcohol Health & Research World. Vol. 22, No. 1.
Correct!
As you have seen in previous slides, the sympathetic nervous (SNS) system, part of the GSR, is responsible for many signs and symptoms of alcohol withdrawal
Click here to return to the tutorial
Think Again!
Without inflammation , injuries would not be localized and the immune system would not be able to do its job, preventing healing and further infections.
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Correct!
When the body has an “injury”, inflammation occurs, attempts to localize the injury, and calls the immune system to work as a team to heal the injury and prevent further spread or damage.
Click here to return to inflammation slide