3. Analysis/nursing diagnosis:
   • Risk for injury (self-directed violence): tendency for self-destructive acts related to intake of mindaltering substances and chronic low self-esteem.
   • Altered nutrition, less than body requirements, related to a lack of interest in food, interference with absorption/metabolism of nutrients and amino acids.
   • Ineffective individual coping: denial/defensive coping related to tendency to be domineering and critical, with difficulties in interpersonal relationships.
   • Conflict with social order related to extreme dependence coupled with resentment of authority.
   • Spiritual distress or general dissatisfaction with life related to feelings of powerlessness, low frustration tolerance, and demand for immediate need satisfaction.
   • Dysfunctional behaviors/sexual dysfunction related to tendency for excess in work, sex, recreation, marked narcissistic behavior.
   • Social isolation related to use of coping mechanisms that are primarily escapist.
   • Knowledge deficit (learning need) regarding condition, prognosis, treatment, self-care, discharge needs.


4. Nursing care plan/implementation:
   • Detoxification phase - maintain physiological stability.
     1. Administer adequate sedation to control anxiety, insomnia, agitation, tremors.
     2. Administer anticonvulsants to prevent withdrawal seizures (Valium, Librium, phenobarbital, magnesium sulfate).
     3. Control nausea and vomiting to avoid massive GI bleeding or rupture of esophageal varices (antiemetics, antacids).
     4. Assess for hypertension, tachycardia, increased temperature, Kussmaul’s respirations.
     5. Assess fluid and electrolyte balance for dehydration (may need IV fluids) or overhydration (may need a diuretic).
     6. Reestablish proper nutrition: high protein (as long as no severe liver damage), carbohydrate, thiamine, vitamins B complex and C.
     7. Promote patient safety - provide quiet, calm, safe environment: bed rest with rails, and head of bed elevated; well-lit room to reduce illusions; constant supervision and reassurance about fears and hallucinations, assess depression for suicide potential.
   • Recovery-rehabilitation phase: encourage participation in group activities; avoid sympathy when client tends to rationalize behavior and seeks special privileges - use acceptance and a nonjudgmental, consistent, firm, but kind approach; avoid scorn, contempt, and moralizing or punitive and rejecting behaviors; do not reinforce feelings of worthlessness, self-contempt, hopelessness, or low self-esteem.
   • Problem behaviors:
     1. Manipulative - be firm and consistent; avoid “bid for sympathy.”
     2. Demanding - set limits.
     3. Acting out - set limits, enforce rules and regulations, strengthen impulse control and ability to delay gratification.
     4. Dependency - place responsibility on client; avoid giving advice.
     5. Superficiality - help client make realistic selfappraisals and expectations in lieu of grandiose promises and trite verbalizations; encourage formation of lasting interpersonal relationships.
   • Common reactions among staff:
     1. Disappointment - instead, set realistic goals, take one step at a time.
     2. Moral judgment - instead, support each other.
     3. Hostility - instead, offer support to each other when feeling frustrated from lack of results.
   • Refer client from hospital to community resources for follow-up treatment with social, economic, and psychological problems, as well as to self-help groups, to reduce “revolving door” situation in which client comes in, is treated, goes out, and comes in again the next night.
     1. Alcoholics Anonymous (AA) - a self-help group of addicted drinkers who confront, instruct, and support fellow drinkers in their efforts to stay sober 1 day at a time through fellowship and acceptance.
     2. Alanon - support group for families of alcoholics. Alateen - support group for teenagers when parent is alcoholic.
     3. Aversion therapy - client is subjected to revulsion-producing or pain-inducing stimuli at the same time he or she takes a drink, to establish alcohol rejection behavior. Most common is disulfiram (Antabuse), a drug that produces intense headache, severe flushing, extreme nausea, vomiting, palpitations, hypotension, dyspnea, and blurred vision when alcohol is consumed while person is taking this drug.
     4. Group psychotherapy - the goals of group psychotherapy are for the client to give up alcohol as a tension reliever, identify cause of stress, build different means for coping with stress, and accept drinking as a serious symptom.
   • Health teaching: teach improved coping patterns to tolerate increased stress; teach substitute tension-reducing strategies; prepare in advance for difficult, painful events; teach how to reduce irritating or frustrating environmental stress.


5. Evaluation/outcome criteria: complications prevented, resolved; everyday living patterns are restructured for a satisfactory life without alcohol; demonstrates feelings of increased self-worth, confidence, and reliance.


6. See sample Critical Pathway: Alcohol Withdrawal Program