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CHAPTER 11 Substance Abuse 161

Addictive Behaviors
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
Substance cravings ___ Monitor vital signs during withdrawal to identify extreme autonomic nervous
Agitation ___ system response.
Hyperreflexia ___ Administer antiseizure drugs or sedatives to prevent alcohol withdrawal
Tremors ___ delirium and relieve other symptoms during withdrawal.
Change in vital signs ___ Administer vitamin therapy to prevent Wernickes syndrome.
Disorientation ___ Address hallucinations in a therapeutic manner to provide reality orientation.
Altered level of consciousness ___ Determine CIWA-Ar score every 4 hours until it is less than 8 for 24 hours
Difficulty interpreting environmental stimuli ___ to assess need for medications.
Misinterpretation of cues ___ Provide emotional support to patient/family to decrease anxiety.
Sleeplessness ___
Hallucinations ___ Seizure Precautions
Seizures ___ Keep suction, Ambu-bag, and oral or nasopharyngeal airway at bedside to
establish respiratory function after seizure activity.
Measurement Scale Use padded side rails and keep side rails up to prevent injury during seizure
1 = Severe activity.
2 = Substantial
3 = Moderate
4 = Mild
Delirium Management
5 = None Monitor neurologic status on an ongoing basis to determine appropriate
Distorted Thought Self-Control Verbally acknowledge the patients fears and feelings to decrease anxiety.
Asks for validation of reality ___ Provide patient with information about what is happening and what can be
Reports decrease in hallucinations or delusions ___ expected to occur in the future to assist in reality orientation.
Perceives environment accurately ___ Maintain a well-lit environment that reduces sharp contrasts and shadows to
Exhibits logical thought flow patterns ___ reduce external stimuli.
Exhibits reality-based thinking ___ Remove stimuli, when possible, that create misperception in a particular
Exhibits appropriate thought content ___ patient (e.g., pictures on the wall or television) to reduce misinterpretation of
Measurement Scale Inform patient of person, place, and time to promote orientation.
1 = Never demonstrated Use environmental cues (e.g., signs, pictures, clocks, calendars, and color
2 = Rarely demonstrated coding of environment) to stimulate memory, reorient, and promote
3 = Sometimes demonstrated appropriate behavior.
4 = Often demonstrated
5 = Consistently demonstrated

NURSING DIAGNOSIS Ineffective self-health management related to inadequate coping mechanisms and resources as evidenced by abuse of
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
Expresses willingness to stop alcohol use ___ Encourage patient to take control over own behavior to change undesired
Develops effective strategies to eliminate alcohol use ___ behaviors.
Commits to alcohol elimination strategies ___ Discuss with patient the impact of substance use on medical condition or
Uses strategies to cope with withdrawal symptoms ___ general health to promote acknowledgment of consequences of use.
Uses effective coping mechanisms ___ Identify constructive goals with patient to provide alternatives to the use of
Adjusts lifestyle to promote alcohol elimination ___ substances to reduce stress.
Obtains assistance from health professional ___ Assist patient to learn alternative methods of coping with stress or
Uses available support groups ___ emotional distress to reduce substance use.
Eliminates alcohol use ___ Identify support groups in the community for long-term substance abuse
treatment to promote continued abstinence.
Measurement Scale
1 = Never demonstrated
2 = Rarely demonstrated
3 = Sometimes demonstrated
4 = Often demonstrated
5 = Consistently demonstrated

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