Transcript Delirium Tremens PPT

Delirium Tremens
Jaymie McAllister
EBP 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

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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=291TBlwlP1c
 Grand Mal Seizure
 https://www.youtube.com/watch?v=Nds2U4CzvC4&f
eature=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
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Benzodiazepines: Ativan, Diazepam
Anticonvulsants: Tegretol
Thiamine: Vitamin B1
Magnesium sulfate
5% dextrose in 0.45%-0.9% NaCl
 Nursing Care




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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=disease
s&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-practicequestions-7.html