Pharmacological and Non-pharmacological Strategies
The presented patient has a lot of different symptoms, both pre-operational and post-operational. Nurse should carefully analyze all these symptoms in order to determine the cause. Then medical treatment of this cause should be performed.
In this particular case, Gus suffers from alcohol withdrawal syndrome. All his symptoms: confuse, agitation, headache, nausea, depression, goat and enlarged prostate are connected with drinking beer.
Of course, these symptoms could be caused by some other illnesses. However, the combination of these symptoms and the patient’s own statement that he drinks six cans of beer a day lead to ascertainity that the reason of patient’s health condition is alcoholism
Medical treatment of alcohol withdrawal syndrome combines both non-pharmacological and pharmacological strategies. However, the patient has a severe alcohol withdrawal syndrome. Therefore, different strategies of treatment should be combined in order to obtain the most effective and efficient result in the shortest time.
The patient Gus has a combination of various symptoms
His condition should be accurately examined and analyzed in order to develop effective and efficient medical treatment plan and determine necessary procedures (both non-pharmacological and pharmacological) for improvement his current condition.
The first step that should be made is analyzing current patient’s health conditions and past symptoms, i.e. performing clinical reasoning. During this process, nurses collect information considering past and present symptoms for clear understanding of patient’s problems.
Special plan of further medical activities is established (Hoffman 2007). Nurse should critically evaluate all collected information about patient’s conditions for correct determination of causes of existing problems (Scheffer& Rubenfeld 2000). Both psychological and physical symptoms should be taken into account.
If any problems arise with determination or evaluation of patient’s symptoms, nurse should appeal to the medical staff of the health providing institution. The patient could have some inherent previously undetermined health problems. Performing of Additional medical examination could be necessary.
It should be noted that medical staff should take into account all symptoms. Only joint vision provides correct determination of patient’s problem.
Nurse should consider the patient’s situation
The patient fell down (sustained a large laceration to the right shin and right collies fracture), had a surgery on his leg. In the post-operational period, the patient is confused and agitated. During visual observation nurses detected that the patient is clammy and has pale skin. Gus has a headache, he is complaining of nausea. The patient is pale and clammy.
After clear determination of the current situation, the second phase – collecting cause and information should be performed. Nurse reviews current information. Gus is drinking much beer (about six cans a day). The patient has a depression, gout and an enlarged prostate. Also, previously Gus did not take any medication (the patient said that he never takes the pills the doctors give him).
Nurse should combine past and present symptoms in order to determine possible causes of current patient’s problems.
Current patient’s condition (headache, complaining of nausea, agitation and confuse) are the direct symptoms of the alcohol withdrawal syndrome (Liang et al 2006). Additionally, such symptoms as pale skin and increased diaphoresis (patient is clammy) also can be caused by alcoholism. Gus drinks a lot of beer, so his current condition can be a consequence of alcoholism.
Additionally, nurse should evaluate previous health problems. As for depression – it is one of the symptoms of alcohol withdrawal syndrome. Gout cannot be caused only by alcoholism. However, men who drink a lot of beer are under increased danger of having a gout (Alcohol increases the risk of gout).
Beer has high purine content
While being digested, beer (particularly purine) obtains a form of uric acid. Usually, this uric acid trough urine leaves the human body. However in some cases human kidneys cannot process all the uric acid from the beer (when people drink too much beer or have some problems with their kidneys). This leads to increasing of blood pressure. The unleaded uric acid can take a form of crystal deposits in the joints and lead to gout (Alcohol increases the risk of gout). Gus drunk a lot of beer. So, this can be considered as a possible cause of his gout.
Also, nurse should pay attention that Gus had had enlarged prostate before he was hospitalized. This health problem also has some connection with drinking much beer. Beer consumption leads to increasing of prolactin in the organism. This hormone is connected with dihydrotestosterone. Increased amount of dihydrotestosterone leads to considerable increasing of prostate cells. This can cause prostate enlargement (Fox 1995).
The next phase of clinical reasoning process is identification of the particular problem. Nurse should combine all assumptions based on the analysis of patient’s symptoms.
All symptoms, which took place before hospitalization and occurred in the post-operational period, can be caused by various problems, but the combination of all these symptoms leads to the assumption that the patient suffers particularly from alcohol withdrawal syndrome.
So, when a particular cause of patient’s sufferings is determined, nurse should establish goals of further medical treatment. Gus suffers from alcohol withdrawal syndrome.
Therefore, treatment should eliminate symptoms by using both non-pharmacological and pharmacological strategies. Medical treatment should decrease patient’s discomfort and prevent happening of more severe symptoms (Myrich 1998). Also, nurse should take into account the post-operational condition of the patient.
Nurse should perform additional examination in order to confirm alcohol withdrawal syndrome and determine any other medical disorders. Additional physical examination includes procedures which allow determining inadequate heart function, irregular heartbeat, pancreatic disease, liver disease, nervous system impairment, and infectious diseases (Myrich 1998).
After determination of particular goals nurse should take actions for eliminating of Gus’ alcohol withdrawal syndrome.
First of all the nurse should determine the severity of alcohol withdrawal syndrome on the basis of the existing symptoms. Gus is confused and agitated. His has a severe alcohol withdrawal syndrome.
Only non-pharmacological treatment will not lead to overall recovery of the patient. Such treatment should be used in combination with pharmacological treatment in order to improve positive outcomes from using medication (Myrich 1998).
Non-pharmacological treatment requires a great amount of nursing care
Patient’s environment should be quite, safe, non-stimulating and non-threatening with reduced lighting. Nurse should speak slowly and explain every step of treatment in order to eliminate the patient’s anxiety. Any arguments and confrontations should be eliminated. Any interpersonal interaction should be also limited (Shand et al 2003). Nurse should ascertain that the patient clearly understands his condition and his location.
According to Ballenger, ‘the most distributing and perhaps controversial issue regarding non-pharmacological treatment of alcohol withdrawal is the concern that failure to medicate may lead to alcohol-induced toxicity to nerve cells (i.e., neurotoxicity), which may increase the patient’s susceptibility to seizures following repeated withdrawals (i.e., kindling)’ (Ballenger & Post 1978, pp.1-14).
As it was stated above, in this particular case non-pharmacological alcohol withdrawal should be combined with pharmacological alcohol withdrawal.
Some of the patients who suffer from alcohol withdrawal syndrome have vitamin deficiencies. There are several reasons of such deficiencies: alcohol-induced changes in patient’s digestion that lead to impair absorption of nutrients into the bloodstream; and poor dietary. Nurses should give folic acid and thiamine in order to eliminate vitamin deficiencies (Myrich 1998).
Folic acid leads to maturation of blood cells. Patients should take folic acids for several weeks. Thiamine is very important for energy metabolism. Lack of thiamine leads to the development of Wernicke syndrome. This syndrome is reflected in anomalous gait, confusion and paralysis of some eye muscles. Nurse should give Gus 100 milligrams of thiamine every day during all the time of withdrawal (Myrich 1998).
Among the most popular medications used for treatment of alcohol withdrawal are benzodiazepines (BZ’s). Use of this medication leads to patient’s detoxification. Also, benzodiazepines are less likely to lead to abuse (Mayo-Smith 1997).
Treatment by BZ’s should be performed according to the special schedule. One of the existing methodologies of BZ’s treatment can be used. For example, nurse can give to Gus 10 mg of diazepam (Valium) once an hour for one or two days (depending on the extent of improvement of patient’s condition). Such treatment will lead to patient’s sedation or reduction of symptoms (Myrich 1998).
In the beginning of treatment of alcohol withdrawal syndrome diazepam should be given every hour or every two hours till decreasing and elimination of symptoms.
Usually, during diazepam treatment no any medication is necessary, because diazepam has a very long half-life period. Using of diazepam provides more accurate control on patient’s treatment. Also, absorption rate of this medication is better than absorption rate of other BZ’s.
However, before beginning of treatment by diazepam nurse should check whether the patient has a liver disease. This medication is not given to patients with liver disease because of it’s long time effect on organism (Hurst, 2013).
One more methodology of treatment by chlordiazepoxide was proposed by Parker in British Medical Journal (Parker et al 2008).
During the first day, the patient should receive 20 mg of chlordiazepoxide four times a day; during the second day the patient should receive – 15 mg of chlordiazepoxide four times daily; during the third day the patient should receive – 10 mg of chlordiazepoxide four times daily; during the fourth day the patient should receive - five mg chlordiazepoxide four times daily; and during the last day the patient should receive – five mg of chlordiazepoxide twice daily. The treatment can be increased if symptoms of alcohol withdrawal are not totally deducted. However, the period of chlordiazepoxide treatment should not exceed two weeks.
After patient’s total detoxification, treatment by BZ’s should be stopped because prolonged treatment by this medication can lead to oversedation, confusion and ataxia.
Gallant (1989) in his researches proposes the use of short-acting BZ’s for effective treatment of alcohol withdrawal syndrome and in the same time reducing of negative consequences of this treatment. This medication includes lorazepam and oxazepam (in Myrich 1998).
Also, some non-sedating anti seizure medications (carbamazepine and valproic acid) could be given to Gus. These medications decrease symptoms of alcohol withdrawal. No abuse appears during the use of such medication (Myrich 1998).
According to some researcher’s opinion treatment by clomethiazole can provide better medical results and has more effect on patient’s condition. This medication is usually used for treatment severe stages of alcohol withdrawal syndrome.
However, use of clomethiazole has considerable negative consequences
The patient could be dependent form this medication. Also, clomethiazole is very toxic medication and can lead to hepatic impairment (Acute alcohol withdrawal and delirium tremens).
Additionally, nurse should use alcohol withdrawal scale – CIWA-AR. This scale provides measurement of alcohol withdrawal and determination of the amount of necessary medication and necessity of future BZ’s treatment.
After completion of treatment, the nurse has to determine and evaluate the effectiveness of treatment: time of treatment; amount of used medication; extent of improvement of patient’s condition (decreasing of pre-operational and post-operational symptoms).
Clinical reasoning is a set of dynamic procedures. Often nurses have to combine various phases of clinical reasoning process in order to perform correct evaluation of patient’s condition and determine the most effective treatment.
Nurse’s actions towards treatment of the particular patient were described in this essay. The medical staff should analyze all symptoms (both pre-operational and post-operational), determine the cause of patient’s condition and establish a strategy of further treatment.
Gus suffered from severe alcohol withdrawal syndrome. Treatment of this stage of the syndrome is performed by the combination of both non-pharmacological and pharmacological strategies. Various strategies and their consequences were described above. During treatment, patient’s condition should be continuously examined. After completion of treatment (i.e. patient’s total detoxification), nurse should examine the process of treatment in order to improve it in the future.
- Acute alcohol withdrawal and delirium tremens, n.d., viewed 15 November 2013, <http://www.patient.co.uk/doctor/Acute-Alcohol-Withdrawal-and-Delirium-Tremens.htm >
- Alcohol increases the risk of gout August 2004, viewed 14 November 2013, < http://www.health.harvard.edu/fhg/updates/update0804a.shtml >
- Ballenger, JC & Post, RM 1978, 'Kindling as a model of alcohol withdrawal syndromes', British Journal of Psychiatry, vol.133, pp.1-14.
- Hoffman, K 2007, A comparison of decision making by ‘expert’ and ‘novice’ nurses in the clinical setting, monitoring patient haemodynamic status post abdominal aortic aneurysm surgery, University of Technology, Sydney.
- Fox, A August1995, 'Alternative approaches to treating an enlarged prostate', Let's Live magazine.
- Hurst, G, Alcohol and surgery: don't miss the risk, 2013, viewed 15 November 2013, < http://www.nursingcenter.com/lnc/journalarticle?Article_ID=802532 >
- Liang, J, Zhang, N & Cagetti, E 2006, 'Chronic intermittent ethanol-induced switch of ethanol actions from extrasynaptic to synaptic hippocampal GABAA receptors', Journal of Neuroscience, vol.26, no.6, pp. 1749-1758.
- Mayo-Smith, MF 1997, Pharmacological management of alcohol withdrawal. A meta-analysis and evidence-based practice guideline, vol. 278, no.2, American Society of Addiction Medicine Working Group on Pharmacological Management of Alcohol Withdrawal, JAMA.
- Myrich, H 1998, 'Treatment of alcohol withdrawal', Alcohol Withdrawal & Research World, vol.22, no.1.
- Parker, AJ, Marshall, EJ & Ball, DM, 2008, 'Diagnosis and management of alcohol use disorders', British Medical Journal, vol.336, no.7642, pp.496-501.
- Scheffer, B &Rubenfeld, M 2000, 'A consensus statement on critical thinking in nursing', Journal of Nursing Education, n0. 39, pp. 352-359.
- Shand, F, Gates, J, Fawcett, J & Mattick, R 2003, Treatment of alcohol problems, National Drug and Alcohol Research Centre (NDARC).