Delirium Tremens

Jaymie McAllisterEBP Presentation

November 5, 2012

Objective

To obtain information about this condition in order to provide competent nursing care.

Ability to form appropriate an nursing diagnosis for a patient who presents with delirium tremens

To understand how this condition progresses and how it is to be treated.

Delirium Tremens

A severe form of alcohol withdrawal that includes sudden and severe mental and/or nervous system changes.

This is a medical EMERGENCY.

Pathophysiology

Ethanol enhances GABA (relaxation) neurotransmitter Chronic ethanol exposure alters GABA receptor

sites

Ethanol also acts as a NMDA antagonist

Alcohol withdrawal leads to a decrease in GABA and an increase of NMDA Leads to a loss of bodily control over

norepinephrine, glutamate and dopamine. Changes in GABA and NMDA activity cause the

clinical manifestations of DTs.(Burns, 2011)

Prevalence/Prognosis

Fewer than 50% of alcohol-dependent people develop significant withdrawal symptoms that require treatment

Only 5% of alcohol withdrawal patients develop delirium tremens Most common in white males

Current mortality rate for patients with DTs: 5-15% Even with appropriate treatment

Some symptoms can persist for a year or more Mood swings, fatigue

(Burns, 2011)

Case Scenario

A 52 year old male patient is admitted to the emergency department after falling 28 feet from a tree. The patient was diagnosed with a bilateral hip fracture, fractured left femur, and a fractured left tibia. The patient does not recall what happened during the incident and states that he was intoxicated with alcohol and has been a heavy drinker for the last 12 years. Forty-eight hours after being admitted the patient began exhibiting an alerted state of mentation that included confusion, stupor and apparent visual hallucinations. The patient was diaphoretic, with elevated BP, HR and respirations, and was experiencing bodily tremors. He could not communicate well and could not follow commands. It has been determined that the patient is experiencing delirium tremens related to alcohol withdrawal.

Clinical Manifestations Symptoms most often occur within 48 to 72 hours after the last drink

Can last 1 week to 1 month

Mental status changes Confusion, disorientation Difficulty staying awake, stupor Agitation Hallucinations

Seeing/feeling things that are not there (skin crawling)

Body tremors (shaking)

Seizures Grand mal seizures

60% of DT patients; have between 1-6 seizures

Other symptoms of withdrawal Anxiety, depression, head ache, nausea, sweating, palpitations

(NIH, 2011)

Manifestations

Videos

Delirium Tremens http://www.youtube.com/watch?v=291TBlwlP1

c

Grand Mal Seizure https://www.youtube.com/watch?v=Nds2U4Czv

C4&feature=fvwrel

Risk Factors

Excessive alcohol abuse over a period of years Average >8 years

Being >40 years old

Past history of severe alcohol withdrawal symptoms

Strong alcohol cravings

Increased number of days since last drink (prior to hospitalization)

(Burns, 2011)

(Moses, 2012)

Diagnostics

BUN and Creatinine Can be elevated, normal or low

Liver Function Test All parameters can be elevated

Toxicology screening May indicate other drugs in the system

Electrolyte Panel Metabolic Acidosis

CT of head Likely negative (Epocrates,

2011.)

CIWA-Ar

Clinical Institute Withdrawal Assessment for Alcohol

Best tool for assessing the severity of withdrawal

10 items that can be assessed rapidly at the bedside

Pt. must be able to communicate and reply logically

(Burns, 2011)

CIWA-Ar

Treatment

Medical Care Prescribe medications for symptoms

Benzodiazepines: Ativan, Diazepam Anticonvulsants: Tegretol Thiamine: Vitamin B1 Magnesium sulfate 5% dextrose in 0.45%-0.9% NaCl

Nursing Care Administer medications Observe for changes in mental status, V/S, electrolyte

balances Provide supportive care Discharge teaching r/t alcohol abuse and outpatient care

groups Aspiration and seizure precautions

(Burns, 2011)(Kneisl & Trigoboff, 2013)

Complications of Treatment

Oversedation

Respiratory depression **

Aspiration pneumonitis

Cardiac arrhythmias **

(NIH, 2011)

Nursing Diagnosis

*Fall risk related to altered mental status*

Risk for self harm related to hallucinations

Risk for harm related to seizures

Risk for fluid volume deficit

Risk for electrolyte imbalance

Fall Risk Interventions

Complete fall risk assessment (Hendrich II Model)

Place “High Fall Risk” band on the arm and signs in the room

Use a disposable brief and foley catheter insertion to prevent patient from ambulating to the bathroom during periods of delirium

Assist patient if there is any need for them to be out of bed

Keep patient/nurse ratio small in order to constantly monitor the patient (1:1 ratio preferred)

Give benzodiazepines PRN in order to reduce effects of delirium

Request an order for soft restraints PRN when the patient is extremely restless

Fall Risk Expected Outcomes

Patient will remain free of falls during the shift

These interventions will passed onto the next shift nurse and added to the chart, if possible.

Soft restraints will be used as a last resort to prevent patient from harming themselves and/or others.

PET Scan

NCLEX Questions

A client is admitted to the ER with symptoms of delirium tremens. After admitting the client to a private room, the priority nursing intervention is to:

A. Obtain a history of his alcohol use

B. Provide seizure precautions

C. Keep the room cool and dark

D. Administer thiamine and zinc

Nursing Guide, 2012

Rationale

B. Provide seizure precautions

Rationale: The client with delirium tremens has an increased risk for seizure; therefore the nurse should provide seizure precautions.

Nursing Guide, 2012

References

Burns, M. (2011, June 29). Medscape reference. Retrieved from http://emedicine.medscape.com/article/166032-overview

Epocrates. (2012, February 09). Diagnostic Tests. Retrieved from https://online.epocrates.com/noFrame/showPage.do?method=diseases&MonographId=549&ActiveSectionId=34

Kneisl, C. R., & Trigoboff, E. (2013). Contemporary psychiatric-mental health nursing. (3rd ed.). Boston, MA: Pearson Education, Inc.

Moses, S. (2012, June 5). Alcohol withdrawal. Retrieved from http://www.fpnotebook.com/Psych/CD/AlchlWthdrwl.htm

NIH (2011). Delirium Tremens dts; alcohol withdrawal- delirium tremens. Retrieved from http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001771/

Nursing Guide. (2012, November 5). NCLEX PN Practice Questions 7. Retrieved from http://nursingguide.cc/index.php/nclex-pn-practice-questions-7.html