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Case Analysis # 147Erin LaFleurUniversity of New HampshireIntroductionAccording to the American Addiction Center (2017), approximately 17 million Americans (7.2% of the population) have an alcohol use disorder (AUD). Alcoholism is an addiction that causes dependence on alcohol and uncontrollable drinking. People with alcoholism may be preoccupied with when their next drink will be to the point where their drinking puts a strain on family relationships and friendships. They may have trouble keeping a job, or participate in destructive behaviors like drinking and driving. Alcoholism causes someone to experience withdrawal symptoms when they do not drink, and causes an increased tolerance to alcohol so that more must be consumed to have the desired effect (“Alcoholism Addiction Treatment,” 2017). Some people may wish they could quit drinking, have tried many times and have failed. Alcohol abuse has serious health implications, from immediate to chronic issues, and if someone has an alcohol use disorder it is extremely important that they seek the support needed to treat their addiction. Pathophysiology of Alcohol’s Effects on the BodyAlcohol abuse affects almost every organ system in the body. According to the National Institute for Alcohol Abuse and Alcoholism’s “Beyond Hangovers” (2015), too much alcohol intake can cause fat deposits in the liver, or inflammation which can lead to alcoholic hepatitis. Alcoholism causes cirrhosis, or scarring of the liver, and increases the risk of liver cancer. Chronic alcohol use causes platelets to stick together more, which can lead to hypertension, an MI or stroke. In addition, it weakens the heart muscle which can cause heart failure. People who abuse alcohol are more likely to experience immune system defects. The depression of the central nervous system can lead to pneumonia and other lung infections due to decreased clearance (“Beyond Hangovers,” 2015). According to Henry et al. (2016), alcohol irritates the mucosal lining of the stomach and intestines, which causes ulcers, gastritis, and even bleeding. This damage prevents proper absorption of nutrients and can actually lead to malnutrition and a reduction in important vitamins like thiamine (vitamin B1). Thiamine deficiency can lead to Wernicke-Korsakoff syndrome, in which the brain can become acutely to permanently damaged. It manifests itself with encephalopathy, confusion and altered gait (So, 2016). Pancreatitis can develop from inflammation of the pancreas, which can cause nausea, vomiting, and death in the worst case. The main cause of chronic pancreatitis is alcohol use disorders (Henry et al., 2016). Henry et al. (2016) also state that drinking three or more alcoholic beverages per day decreases the bones’ absorption of calcium, which can lead to osteoporosis. Proper treatment of alcohol use disorders is necessary in preventing serious complications.Alcohol withdrawal can have serious complications as well, especially for people with an alcohol use disorder. Osmosis (2017) created a YouTube video that explains why alcohol makes people feel the way it does. Gamma-aminobutyric acid (GABA) is the main inhibitory neurotransmitter in the brain and ethanol readily binds to its receptors. The more someone chronically drinks alcohol, the more desensitized ethanol becomes to the GABA, so more inhibitor is required to maintain a regular inhibitory level (Osmosis, 2017).Because alcohol is a central nervous system depressant, it also inhibits the glutamate excitatory response. The body produces more of the glutamate receptors in an attempt to compensate, so when alcohol intake is ceased abruptly, it causes an over excitatory effect. Withdrawal symptoms can range from minor, such as tremors, headache, or GI issues, to much more severe (Osmosis, 2017). In some cases, people may have seizures, alcoholic hallucinosis, or delirium tremens. Alcohol hallucinosis usually occurs within 12 to 24 hours of the last drink and can include headache, dizziness, and auditory, visual or tactile hallucinations. It is more common than delirium tremens, which occurs within 48 to 72 hours and it is much more serious. Delirium tremens can cause tonic-clonic seizures, hyperthermia, confusion, hypertension, and hallucinations (Osmosis, 2017).Case Study???????A case study exhibited in Winningham’s Critical Thinking Cases in Nursing (2016) is an example of the complications of long term alcohol abuse as well as withdrawal. J.G was a 49-year-old man admitted to the hospital for an upper GI bleed. J.G. was admitted 4 days ago, diagnosed with alcohol intoxication, and was released to his brother after 8 hours in the hospital. He came back to the emergency department 12 hours after discharge with an active GI bleed and was admitted to the ICU. He was diagnosed with alcohol intoxication and upper GI bleed (Harding, Snyder, Preusser, & Winningham, 2016). His admission vitals were 84/56, 110, 26, and he was vomiting bright red blood. He was given IV fluids and transfused six units of packed red blood cells (PRBCs). Upon assessing J.G., his vital signs were 154/90, 110, 24. He appeared anxious and flushed, had a tremor in his hands, and stated he had a headache (Harding et al., 2016). In the past 5 hours he had not had any emesis, bright red blood in stool, or melena. At first, J.G. denied having an alcohol problem, but later admitted to “drinking a fifth of vodka daily for the past two months,” (Harding et al., 2016). He also drank after being discharged the first time. J.G. also admitted to having seizures in the past while withdrawing. He stated that he never means “to drink very much” and that he “just can’t help it,” (Harding et al., 2016). J.G. had had trouble keeping a job over the past several months. J.G. was exhibiting signs of alcohol withdrawal (Harding et al., 2016).???????His admission laboratory results were Hgb 10.9g/dL, Hct 23%, ALT 69 units/L, AST 111 units/L, GGT 75 units/L, ETOH 291 mg/dL (Harding et al., 2016).The normal range for hemoglobin for males is 14-18g/dL and the normal hematocrit is 42-52% (Henry et al., 2016a). Since J.G. had a much lower hemoglobin and hematocrit, this indicated that had been bleeding and lost blood. ALT (alanine aminotransferase) is an enzyme found in liver cells so when the liver is damaged, the enzyme is released into the blood, causing increased levels. Normal ALT levels are 4-36 units/L (Henry et al., 2016a). AST (aspartate aminotransferase) is another enzyme found in the liver, and muscles like the heart. It is less specific to the liver than ALT, but they are most often ordered in conjunction. Normal AST levels are 0-35 units/L (Henry et al., 2016a). J.G. had an increase in both of these enzymes, which indicates he had liver damage. As for GGT (gamma glutamyltransferase), this is the most sensitive test for liver disease. It is an enzyme primarily found in the liver, pancreas, and kidneys. It is elevated in heavy drinkers and is useful in diagnosing alcoholic liver diseases. Normal GGT level is 0-30U/L (Hinkle & Cheever, 2014). J.G. also had an elevated GGT which is indicative of a liver problem. The ETOH indicates that J.G. had alcohol in his system when he was admitted to the hospital. His chronic alcohol use is indicated in the ALT, AST, and GGT tests. While ETOH is specific to alcohol, it is not a marker for chronic use (“Ethanol,” 2014). Hemoglobin and hematocrit are not specific to chronic alcohol use. While his lab results clearly indicated a chronic liver disease like hepatitis or cirrhosis, J.G. experienced his symptoms as a result of chronic alcohol consumption. Most people who are chronic alcohol users experience withdrawal symptoms around 6 hours after cessation, but symptoms depend on the individual (Hinkle & Cheever, 2014). The physician would have been informed on J.G’s substance abuse history, his previous admission, and what his laboratory results indicated.Alcohol use disorders are diagnosed using the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V). There are 11 symptoms listed in the DSM-V, of which an individual must exhibit two in order to be diagnosed with an alcohol use disorder (Bergland, 2015). J.G. exhibited five of the 11 symptoms, so this means he had a moderate alcohol use disorder. He admitted to drinking more and longer than he wanted, he had tried cutting down before, but did not succeed. His problem with alcohol caused him job issues in the past several months, he has spent a long time recovering from alcohol’s effects in the past, and he exhibited signs of withdrawal upon not drinking, including past seizures (Harding et al., 2016).J.G continue to go into withdrawal delirium. If someone is withdrawing from alcohol, there are medications that are commonly prescribed for treatment. Benzodiazepines, such as chlordiazepoxide (Librium) are used to treat psychomotor symptoms of withdrawal. These are the drugs of choice (Henry et al., 2016b). There are other types of drugs that are found to be more effective when used in conjunction with benzodiazepines, however there is conflicting evidence regarding common use of these drugs. Carbamezapine (Tegretol), an antiseizure medication, can be helpful with minor symptoms of withdrawal, and can possibly help with decreasing cravings after withdrawal (Henry et al., 2016b). However, there is limited research done on whether this drug decreases the risk for seizures or delirium tremens. Clonidine (Catapres) can help reduce autonomic symptoms of alcohol withdrawal. There is also conflicting research on the use of beta blockers like atenolol (Tenormin) (Henry et al., 2016). Some believe that a beta blocker should only be used if the patient has a history of coronary artery disease. Others believe that when used in conjunction with benzodiazepines, beta blockers can actually reduce tremors and decrease alcohol cravings (Henry et al., 2016b). As previously stated, alcoholism can cause serious chronic health problems. J.G’s physician may have ordered him other lab tests in addition to assess for nutritional deficiencies or other medical problems related to alcoholism and GI bleeding. Lab values for serum proteins such as albumin would have been helpful in assessing nutrition (Henry et al., 016a). Alcohol can irritate the mucosal lining of the stomach and intestines, which prevents the absorption of nutrients.That means it would have been important to look at vitamins and minerals as well, such as thiamine, B12, calcium, et cetera. In order to prevent encephalopathy, thiamine is particularly important because if the level is too low, it can cause brain damage (So, 2016).J.G.’s alcohol withdrawal delirium lasted for 36 hours before subsiding. He did not have any seizures, and he was transferred out of the ICU to the psychiatric unit. He stated that he was ready to go home and to never “touch another drink” but wanted help (Harding et al., 2016). In order to assist him with his sobriety, his physician may have ordered him alcohol deterrent agents, such as naltrexone (Revia), acamprosate (Campral), or disulfiram (antabuse) (Harding et al., 2016). Naltrexone reduces the intoxication effects of alcohol by competing with alcohol for opioid receptor sites. This makes alcohol less enjoyable and helps to prevent relapses. When someone is a chronic heavy drinker, alcohol affects their brain neurotransmitters, so when they stop drinking it can cause a hyperexcitatory state. Acamprosate is used to help regulate this brain activity and reduce cravings (Henry et al., 2016b). Disulfiram, when combined with alcohol, can actually make someone feel physically ill, known as acetaldehyde syndrome. It causes nausea, vomiting, and facial flushing, which can deter an alcoholic from drinking in order to avoid having these side effects (Henry et al., 2016b).In addition to medications, J.G. needed education and referral before discharge from the hospital in order to assist with compliance and sobriety. J.G. was educated on the importance of attending all appointments and taking medications as prescribed. He was also educated on alcoholism’s long term effects on his health, and coping strategies to help him avoid alcohol such as relaxation techniques and avoiding stress. J.G. was also referred to Alcoholics Anonymous (AA), which is a support system of people going through a similar struggle (Harding et al., 2016). In order to increase his likelihood of attendance at these meetings, J.G’s provider used motivational interviewing to allow J.G. to set personal goals and internally motivate himself through examining his readiness for change. “J.G. met with his sponsor while in the hospital and attended his first AA meeting the day after his discharge from the hospital,” (Harding et al., 2016).Evidence Based Support for Nursing InterventionsAlthough it was not discussed in the case study of J.G., nurses use the Clinical Institute Withdrawal Assessment for Alcohol as a clinical practice guideline in the treatment of acute alcohol withdrawal. It incorporates 10 items the patient is scored on based on their symptoms. The patient’s score determines what kind of interventions they will receive (Bayard, McIntyre, Hill, & Woodside, 2004). It is used to rate nausea and vomiting, tremor, paroxysmal sweating, anxiety, tactile disturbances, auditory disturbances, visual disturbances, headache, agitation, and orientation. Generally, patients receiving a score greater than 8 points may receive pharmacological treatment for symptom management and prevention of further complications (Bayard et al., 2004). However, each hospital has its own policy with interventions. What makes CIWA appealing to nurses and any healthcare providers in general is how quick and easy it is to use. It takes approximately five minutes to complete, which is helpful for nurses who tend to have multiple things going on at once (Bayard et al., 2004).The main pharmacological intervention for alcohol withdrawal is the use of benzodiazepines (Adis Medical Writers, 2014). They have been proven to reduce alcohol withdrawal symptoms within the first two days of withdrawal by preventing 84% of seizures. The three main benzodiazepines used for alcohol withdrawal syndrome are chlordiazepoxide, diazepam, and lorazepam. Benzodiazepines replace the inhibitory effect of the alcohol that has been abruptly stopped, which reduces the hyper excitatory symptoms withdrawal can cause, such as seizures (Adis Medical Writers, 2014).Generally, alcohol withdrawal is treated in two different regimens. It can be symptom triggered administration of drugs or scheduled fixed dosing. In a study done by the Out Patient Department (OPD) of Psychiatry and De-Addiction at Post Graduate Institute of Medical Education and Research, Dr. Ram Manohar Lohia Hospital (RMLH) patients undergoing alcohol withdrawal were rated using the CIWA scale (Sachdeva, Chandra, & Deshpande, 2014). They were then randomized into either symptom triggered or fixed dose treatment. Researchers found that symptom triggered therapy was more effective and cost efficient. It reduced the unnecessary use of benzodiazepines in patients and led to shorter duration of treatment. Because the symptom triggered method uses the CIWA scale every hour, it does not follow the fixed dose tapering method that requires longer duration (Sachdeva et al., 2014). In order to assist in J.G’s compliance with treatment, a proper nursing intervention is motivational interviewing. Motivational interviewing is a way to guide a patient to strengthen motivation for change. The goal is to reduce ambivalence toward change in a way that is less coercive than other types of interviewing. Collaboration with the patient allows them to develop their own goals based on personal values and desires. In a study done by the Society of Trauma Nurses (2016), researchers analyzed patients at risk for alcohol from February 2012 to June 2014 using the alcohol use disorders identification test-consumption (AUDIT-C). Approximately 3,000 patient charts of at risk alcohol users were retrospectively reviewed and separated based on whether they received motivational interviewing or traditional methods for continued follow up care (Wagner, Garbers, Lang, Borgert, & Fisher, 2016). Their willingness to participate in follow up care was also analyzed based on the intervention they received. Those that received motivational interviewing had a higher rate of patient follow up than those that received traditional counseling services (Wagner et al., 2016).???????Based on research, there are different ways of treating alcohol withdrawal. The CIWA scale is common for assessing the severity of alcohol withdrawal and is useful for determining how to treat a patient based on symptoms. In addition, treating a patient based on symptoms is more effective than fixed dose regimens. For medications, the use of benzodiazepines is widely accepted as being the forerunner in symptom management and prevention of seizures (Henry et al., 2016b). What needs further research is the use of other drugs as adjuncts to the use of benzodiazepines. In addition, there are differences regarding when to give drugs to assist with sobriety, the alcohol deterrents like naltrexone, disulfiram, or acamprosate. Sometimes they are prescribed during withdrawal while others are for post withdrawal. As for a patient with an alcohol use disorder following discharge, participating in follow up care is important for maintaining sobriety. Motivational interviewing helps a patient with internal motivation and setting personal goals to reduce ambivalence toward change. It has been proven to be more effective than traditional therapy when treating people with an AUD (Wagner et al., 2016). Areas for further research should include the effectiveness of Alcoholics Anonymous (AA). J.G. was referred to AA, however there is conflicting research regarding the efficacy of such an intervention. ConclusionAlcohol use disorders are more common than most of the country may expect. The effects of alcohol on the body can cause serious chronic health issues in many systems of the body. In addition, the effects of withdrawal can be serious as well. Whether it be mild to serious to delirium tremens, alcohol withdrawal may require the need for medical attention. Nurses play an important role in assessing signs and symptoms of withdrawal, as well is in educating patients about alcohol use disorders and how to maintain sobriety if they have an alcohol use disorder.ReferencesAdis Medical Writers. (2014). Benzodiazepines are the mainstay of treatment for acute alcoholwithdrawal syndrome. Ebsco Host. Retrieved from Addiction Treatment: The Signs, Causes, & Recovery Information. (2017).Retrieved from . Bayard, M., McIntyre, J., Hill, K., & Woodside, J. (March 15, 2004). Alcohol WithdrawalSyndrome. American Family Physician. Retrieved from, C. (2015). What Are the Eleven Symptoms of "Alcohol Use Disorder"? PsychologyToday. Retrieved from Hangovers: understanding alcohol’s impact on your health (2015). Retrieved from. Lab Tests Online. (September 30, 2014). Retrieved from, M., Snyder, J. S., Preusser, B. A., & Winningham, M. L. (2016).?Winningham's criticalthinking cases in nursing: medical-surgical, pediatric, maternity, and psychiatric. St. Louis, MO: Elsevier.Henry, N.J.E., McMichael, M., Johnson, J., DiStasi, A., Ball, B.S., Holman, H.C., …Lemon, T.(2016). RN Adult Medical Surgical Nursing, Review Module Edition 10.0. Assessment Technologies Institute, LLC. Henry, N.J.E., McMichael, M., Johnson, J., DiStasi, A., Wilford, K.L., Lemon, T. (2016). RNMental Health Nursing, Review Module Edition 10.0. Assessment Technologies Institute, LLC. Hinkle, J.L. & Cheever, K.H. (2014). Brunner and Suddarth’s Textbook of Medical SurgicalNursing: Thirteenth Edition. Philadelphia, PA: Wolters Kluwer Health. Lippincott Williams & Wilkins.Osmosis. (March 6, 2017). Alcoholism- causes, symptoms, diagnosis, treatment, pathology.Retrieved from , A., Chandra, M., & Deshpande, S. N. (2014). A Comparative Study of FixedTapering Dose Regimen versus Symptom-triggered Regimen of Lorazepam for Alcohol Detoxification.?Alcohol & Alcoholism,?49(3), 287-291.So, Yuen T. (2016). Wernicke encephalopathy. Up to Date. Retrieved from, A. J., Garbers, R., Lang, A., Borgert, A. J., & Fisher, M. (May 2016). IncreasingFollow-up Outcomes of At-Risk Alcohol Patients Using MotivationalInterviewing.?Journal of Trauma Nursing, volume 23(issue 3). Retrieved from ................
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