- Acute Confusion related to biochemical alterations and sensory deprivation as evidenced by changes in the usual responses to stimuli and exaggerated emotional responses and alterations in behavior
- Anxiety related to situational crisis, discontinuation of alcohol and physiological withdrawal as evidenced by feelings of inadequacy, shame, and guilt and expresses anxiety about life event changes
- Risk for Injury related to altered psychomotor performance and reduced muscle, hand, and eye coordination as evidenced by change of behavior
| Assessment | Nursing Diagnosis | Planning/Outcomes | Intervention | Evaluation |
| Subjective Data: -Hallucinations -Paranoia Objective Data: Alcohol withdrawal Abstinence | Acute Confusion related to biochemical alterations and sensory deprivation as evidenced by changes in the usual responses to stimuli and exaggerated emotional responses and alterations in behavior | -Underlying cause treated when possible. -Patient will regain orientation to person, place, time, and situation with an appropriate level of consciousness. -Patient will initiate lifestyle changes to prevent reoccurrence of acute confusion/delirium. -Patient will verbalize contributing factors of fluctuations in cognition. | 1. Provide a consistent environment. Continual interruptions by different healthcare workers can worsen disorientation. Try to limit interactions and staff members. 2. Restrain the patient as needed. Restraints are a last resort for a patient experiencing confusion as physical restraints can worsen symptoms of agitation. Restraints may be required to keep the patient and staff safe. 3. Reduce stimulation. Loud sounds, the beeping of machines, music, lights, and TV can worsen confusion. Do not overwhelm the patient with too many sources of stimulation. 4. Encourage family support. Family members and familiar faces may help diffuse situations and aid in reorientation. | -Patient initiated lifestyle changes to prevent reoccurrence of acute confusion/delirium. -Patient verbalized that the contributing factors are responsible for the fluctuations in cognition. |
| Subjective Data: -Feeling nervous -Verbalizing a sense of impending danger -Difficulty controlling one’s worrying Objective Data: -Restlessness and tense appearance -Tachycardia -Tachypnoea -Hyperventilation -Diaphoresis -Trembling/tremors -Weakness or tiredness -Difficulty concentrating -Difficulty sleeping GI distress | Anxiety related to situational crisis, discontinuation of alcohol and physiological withdrawal as evidenced by feelings of inadequacy, shame, and guilt and expresses anxiety about life event changes | -Patient will be able to acknowledge and discuss fears and concerns. -Patient will be able to verbalize feelings of anxiety and present ideas of how to handle those feelings. -Patient will be able to develop and demonstrate problem-solving techniques. -Patient will be able to identify appropriate resources. -Patient’s vital signs will remain or return to stable baseline state. -Patient will be able to maintain regular sleep routine. | 1. Reorient as needed. A person who is suffering from alcohol withdrawal is often unable to identify and recognize what is happening which increases anxiety. Reorientation is necessary until symptoms resolve. 2. Develop a trusting relationship with the patient. A trusting relationship can be achieved through honest and nonjudgemental interactions with the patient to help decrease fear and distrust of the healthcare team. 3. Maintain a calm environment. A calm and quiet environment can reduce the patient’s stress and promote an effective atmosphere for healing. 4. Provide resources for addiction. Once the patient has been stabilized, they may have fear and anxiety about experiencing future relapses and withdrawal symptoms. If the patient requests help, provide referrals to Alcoholics Anonymous and other resources. 5. Administer medications as indicated. Benzodiazepines are the gold standard treatment for AWS. They also help the patient relax, feel more in control, and reduce agitation. | -Patient acknowledged and discussed fears and concerns. -Patient verbalized feelings of anxiety and present ideas of how to handle these feelings. -Patient developed and demonstrated problem-solving techniques. -Patient identified appropriate resources. -Patient is able to maintain regular sleep routine. |
| Subjective Data: -Feeling weak -Verbalizing a sense of impending danger from falls Objective Data: -Tremors -Weakness -Decreased Coordination | Risk for Injury related to altered psychomotor performance and reduced muscle, hand, and eye coordination as evidenced by change of behavior | -Patient will remain free from falls. -Patient will engage in safe behavior and take action to reduce chance of injury. -Patient will remain free from any form of self-harm. -Patient will remain free from any skin breakdown or impairment in skin integrity. | 1. Assist the patient in ambulation and self-care activities. The nurse or unlicensed assistive personnel should assist the patient with ambulation or ADLs in the event that a seizure or fall occurs. 2. Provide an environment of safety. The bed should always be in a low position, with side rails up, and call bell within reach. 3. Implement seizure precautions. Padding the side rails, placing a mat on the floor beside the bed, and keeping emergency equipment at the bedside should be implemented in the event of a seizure. 4. Consider a 1:1 sitter. Patients may not be able or willing to follow commands when experiencing alcohol withdrawal. A trained staff member may be required to remain within arm’s reach at all times to prevent falls or alert the nurse to an emergency. | -Patient feels that he is free from falls. -Patient engaged in safe behavior and take action to reduce chance of injury. -Patient feels he is free from any form of self-harm. -Patient feels he is free from any skin breakdown or impairment in skin integrity. |