NursingSprint

➤ The client exhibits classic signs of alcohol withdrawal, including confusion, tremors, agitation, and irritability, typically seen within 6–48 hours after the last drink.

➤ The presence of disorientation, delusions (e.g., talking about a funeral for a deceased mother from 6 years ago), and autonomic instability (BP 170/95) suggests progression toward delirium tremens, a severe form of withdrawal.

✔️ Actions to Take

1. Administer lorazepam

➤ Lorazepam is a first-line treatment for alcohol withdrawal to prevent progression to seizures and reduce CNS hyperexcitability.

➤ Benzodiazepines like lorazepam also help manage psychomotor agitation, anxiety, and confusion by enhancing GABAergic transmission.

2. Pad the client’s side rails

➤ Seizures are a major risk in alcohol withdrawal, especially 24–72 hours after cessation, so padding side rails protects the client from injury.

➤ Side rail padding is a key fall- and trauma-prevention intervention when altered mental status or seizure activity is anticipated.

✔️ Parameters to Monitor

1. Seizure activity

➤ Alcohol withdrawal lowers seizure threshold due to sudden CNS hyperexcitability from the absence of alcohol’s GABA-enhancing effect.

➤ Continuous seizure monitoring is essential to catch early signs like muscle twitching, eye rolling, or tonic-clonic movements, and initiate rapid treatment.

2. Fluid and electrolyte status

➤ Vomiting, diaphoresis, and poor oral intake in alcohol withdrawal can lead to hypovolemia, hyponatremia, or hypokalemia, all of which increase risk of arrhythmias and seizures.

➤ Monitoring labs like sodium, potassium, magnesium, and phosphate is critical to prevent cardiac and neurological complications during detoxification.