Alcoholism Case Study – Flashcards
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Have you ever thought that you should cut down on your drinking? (The C in CAGE stands for cut down. This is the first question that should be asked. When sober an alcoholic may make a pledge to reduce consumption.
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CAGE acronym is used to screen for alcoholism. CAGE represents four questions that contain: What is the first question the nurse should ask?
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A. stands for annoyed. "have people annoyed you by criticizing your drinking?"
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The second letter of CAGE screen for alcoholism: 2nd question.
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G. Stands for guilty. "have you ever felt guilty about your drinking?"
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CAGE screen for alcoholism: 3rd question.
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E. stands for eye-opener. "have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover?" This is a serious indication of over consumption.
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CAGE screen for alcoholism: 4th question
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Further assess the client's drinking behaviors. CAGE is only a screening tool.
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If the client answers "yes" to two of the four CAGE questions. What should the nurse do next?
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When did you hast have something to drink? Withdrawal can begin as early as 4-6 hours after substance abuse.
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Which question is most likely to assist with prediction of the onset of withdrawal symptoms if the client is dependent on alcohol?
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He had thoughts of wanting to jump off of a bridge. Risk for self harm is a priority problem that requires hospitalization.
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What data would support the need for admission of an alcoholic to the hospital?
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Thoughts of wanting to jump off of the bridge. Safety of client and others is the priority in a crisis situation.
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What is the priority nursing problem for the initial crisis plan of the alcoholic admitted to hospital?
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Risk for injury, Altered nutrition, and Risk for withdrawal
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Nursing diagnosis that are priority and should be addressed within 72 hours of admission?
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Increased aspartate aminotransferase (AST). The amount of AST in the blood is directly related to the number of damaged cells.
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Which lab finding would indicate that Nick probably has liver disease?
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Physiologic stabilization. The goals of acute mgt of alcohol detox begin with stabilizing the patient physically and maintaining normal vital signs.
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What goal is most important for alcohol detoxification?
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Vital signs at least every 4 hours.
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Which assessment is most important for safe alcohol detoxification?
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Within 4-6 hours of the client's last drink.
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When should the nurse begin assessment for withdrawal?
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Tremors, nausea and vomiting. Other symptoms can include elevated vital signs, diaphoresis, insomnia, and decreased concentration.
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What should the nurse anticipate if Nick experiences symptoms of early withdrawal from alcohol?
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Increased dopamine (etoh intake represses GABA, which inhibits dopamine and keeps dopamine levels low. When etoh is eliminated, dopamine rebounds above the normal level, resulting in excitation and alterations in thought, perception, and orientation)
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What mechanism of action accounts for symptoms of alcohol withdrawal?
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Administer Ativan 2mg PO (short acting benzo is best, because it does not have active metabolites that can affect a diseased liver) AND Reassess vitals in 2 hours (vitals need to be assessed to monitor for changes)
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The nurse preforms withdrawal assessment and observed that Nick has moderate tremors and that he reports nausea. Which interventions after reading orders should the nurse implement. SATA
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Potentiate effects of GABA (which has a calming effect)
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What is the therapeutic action of benzo's?
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Reduce the risk of Wernicke's disease.
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What is the rationale for giving B1 and a multivitamin?
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Let me find one of the staff to help you. This is an activity that can be delegated to a UAP
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When nurse takes nick his meds he advises he wants to take a shower. The nurse notices that he has mild tremors and reports feeling "shaky" Since the nurse needs to give others medications, what is the best response?
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The nurse should ask the UAP assisting Nick in the shower to complete the report. They witnessed the fall.
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Nick is with the UAP and slips in the shower and is not injured. Who should the nurse ask to complete the incident report?
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Disulfram (Antabuse) inhibits absorption of alcohol
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Because nick wants to return to work, but feels pressured to drink there he request disulfiram (Antabuse) therapy. How should the nurse respond with how this med works?
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Obtain Nick's written consent to comply with medication instructions.
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What nursing intervention is most important before beginning this med therapy.
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Severe HA, N/V, chest pains, and Hypotension
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consequences of drinking alcohol while taking disulfram (Antabuse) include which of the following? SATA
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do you have support and people who can help you?
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Which question should the nurse ask Nick in order to determine whether or not he is able to return to a pre-crisis level of functioning?
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Resources available to the client after discharge.
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What is the most important consideration for discharge planning?
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Take the UAP aside and explain that initial client teaching must be preformed by the nurse.
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The UAP is providing Nick with teaching related to 12 step programs. What action should the nurse take?
