Alcohol Withdrawal
A 48-year-old client admitted for an elective procedure reports drinking six to eight beers daily. Forty-eight hours after the last drink the nurse notes new agitation.
Recognize cues
Vital signs: BP 172/98, HR 124, RR 24, temperature 38.0 C. The client has coarse hand tremors, is drenched in sweat, is oriented only to person, and reports seeing insects on the wall. Withdrawal assessment score is 24.
Which finding requires the most immediate follow-up?
Take action
The provider orders a symptom-triggered benzodiazepine protocol, IV thiamine before glucose-containing fluids, IV fluids, and frequent withdrawal scoring.
Which two actions should the nurse take first?
Evaluate outcomes
Twelve hours later the withdrawal score is 6, the client is oriented to person, place and time, denies hallucinations, and has had no seizures. BP 134/80, HR 88, tremor is minimal.
Which finding best indicates the treatment is working?
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