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Case
The patient is illustrative. Mr. H., 52, is admitted for a planned knee replacement. On admission he says he drinks "socially." On the evening of day 1, about 30 hours after his last drink, he is sweating, his hands are shaking, his heart rate is 118 and his blood pressure is 162/96. He keeps asking whether there are "bugs on the sheets."
Screening on admission
The AUDIT-C uses the three alcohol consumption questions from the Alcohol Use Disorders Identification Test: how often the person drinks, how many drinks on a typical day, and how often they have six or more drinks on one occasion. In a study of patients at three Veterans Affairs clinics, the AUDIT-C detected heavy drinking at least as well as the full 10-item AUDIT and performed similarly for detecting heavy drinking or active alcohol abuse or dependence (Bush et al., 1998). Asking these questions directly and without judgment on admission, rather than accepting "socially," would have flagged Mr. H.'s risk before surgery.
When the nurse asks the AUDIT-C questions on day 1, Mr. H. says he drinks six to eight beers most days.
Recognizing withdrawal
Alcohol suppresses the central nervous system, and with daily heavy use the brain adapts. When drinking stops suddenly, the nervous system becomes overactive. Mr. H.'s sweating, tremor, tachycardia, hypertension, anxiety and tactile disturbances fit alcohol withdrawal. Withdrawal can progress to seizures and delirium tremens, so it is a medical priority, not only a behavioral one.
Monitoring with the CIWA-Ar
The revised Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) is a 10-item scale for measuring the severity of withdrawal that keeps the clinical usefulness, validity and reliability of the longer original scale (Sullivan et al., 1989). It rates:
- nausea and vomiting
- tremor
- paroxysmal sweats
- anxiety
- agitation
- tactile disturbances
- auditory disturbances
- visual disturbances
- headache or fullness in the head
- orientation and clouding of sensorium
The total guides symptom-triggered treatment: medication, usually a benzodiazepine, is given when the score reaches the level set by the hospital's protocol, and the scale is repeated at set intervals. Mr. H.'s first score is 18, and the nurse gives the ordered dose and increases monitoring.
Nursing care
| Priority | Interventions |
|---|---|
| Safety | Seizure precautions; a low bed; frequent observation; a calm, well-lit room to reduce misperceptions |
| Physiological | Vital signs and CIWA-Ar as ordered; fluids and nutrition; thiamine as ordered before glucose to prevent Wernicke encephalopathy |
| Medication | Symptom-triggered benzodiazepine per protocol; watch for oversedation and falls |
| Psychosocial | Talk with Mr. H. honestly about his drinking once he is calmer; offer a referral to addiction services |
Evaluation
Over 48 hours, Mr. H.'s CIWA-Ar scores fall below the treatment threshold, his vital signs return to normal and he is no longer seeing things that aren't there. He agrees to meet with the addiction consult team before discharge.
References
Bush, K., Kivlahan, D. R., McDonell, M. B., Fihn, S. D., & Bradley, K. A. (1998). The AUDIT alcohol consumption questions (AUDIT-C): An effective brief screening test for problem drinking. Archives of Internal Medicine, 158(16), 1789–1795. https://doi.org/10.1001/archinte.158.16.1789
Sullivan, J. T., Sykora, K., Schneiderman, J., Naranjo, C. A., & Sellers, E. M. (1989). Assessment of alcohol withdrawal: The revised Clinical Institute Withdrawal Assessment for Alcohol scale (CIWA-Ar). British Journal of Addiction, 84(11), 1353–1357. https://doi.org/10.1111/j.1360-0443.1989.tb00737.x
