DRG Category: 895
Mean LOS: 10.6 days
Description MEDICAL: Alcohol/Drug Abuse with Rehabilitation Therapy
Acute alcohol intoxication occurs when a person consumes large quantities of alcohol. In most states, legal intoxication is 80 mg/dL, or 0.08 g/dL. Acute alcohol intoxication leads to complex physiological interactions. Alcohol is a primary and continuous depressant of the central nervous system (CNS). The patient may seem stimulated initially because alcohol depresses inhibitory control mechanisms. Effects on the CNS include loss of memory, concentration, insight, and motor control. Advanced intoxication can produce general anesthesia, while chronic intoxication may lead to brain damage, memory loss, sleep disturbances, and psychoses. Respiratory effects also include apnea, decreased diaphragmatic excursion, diminished respiratory drive, impaired glottal reflexes, and vascular shunts in lung tissue. The risk of aspiration and pulmonary infection increases while respiratory depression and apnea occur.
The cardiovascular system becomes depressed, leading to depression of the vasomotor center in the brain and to hypotension. Conversely, in some individuals, intoxication causes the release of catecholamines from adrenal glands, which leads to hypertension. Intoxication depresses leukocyte movement into areas of inflammation, depresses platelet function, and leads to fibrinogen and clotting factor deficiency, thrombocytopenia, and decreased platelet function.
The effects on the gastrointestinal (GI) system include stimulation of gastric secretions, mucosal irritation, cessation of motor function of the gut, and delayed absorption. Pylorospasm and vomiting may occur.
Alcohol intoxication occurs when a person ingests alcohol at a rate faster than his or her body can metabolize it. Alcohol is metabolized at a rate of approximately 15 g/hr. One standard drink (12 ounces of beer or 1 ounce of whiskey) provides about 14 g of alcohol. When a person drinks faster than the body metabolizes alcohol, she or he becomes intoxicated when blood alcohol levels reach 100 mg/dL, although the physiological effects occur at levels as low as 40 mg/dL.
Susceptibility to alcohol abuse appears to run in families and is the subject of vigorous ongoing investigations to locate genes that contribute. It is probable that the effects of multiple genes and environment are involved in alcoholism. Twin studies have shown a stronger concordance between identical rather than nonidentical twins (55% or greater concordance for monozygotic twins and 28% for same-sex dizygotic twins). Genetic differences in alcohol metabolism may result in higher levels of a metabolite that produces pleasure for those with a predisposition toward alcohol abuse. Associations between alcoholism and certain alleles of alcohol dehydrogenase (ADH2, ADH3, and ADH7) have been documented. Polymorphisms in SNCA, GABA-A, NPY, TAS2R16, CHRM2, DRD2, ALDH2, ANKK1, SLC6A4, and COMT genes have also been associated with alcohol abuse.
GENDER, ETHNIC/RACIAL, AND LIFE SPAN CONSIDERATIONS
Acute alcohol intoxication can affect people of any age, gender, race, or socioeconomic background. Alcohol use should be considered when a patient is seen for trauma, acute abdominal pain, cardiac dysrhythmias, cardiomyopathy, encephalopathy, coma, seizures, pancreatitis, sepsis, anxiety, delirium, depression, or suicide attempt.
TEENAGERS AND YOUNG ADULTS. The use of alcohol is seen as a part of growing up for many individuals. Binge drinking is common and dangerous. The combination of alcohol and potentially risky activities, such as driving or sex, is a source of high morbidity and mortality for teens.
PREGNANT WOMEN. Alcohol is a potent teratogen. Binge drinking and moderate to heavy drinking have been associated with many fetal abnormalities. There is no currently known safe drinking level during pregnancy.
ELDERLY. Loss of friends and family, loss of income, decreased mobility, and chronic illness or pain may increase isolation and loneliness and lead to an increased use of alcohol by the elderly.
GLOBAL HEALTH CONSIDERATIONS
Alcohol consumption has increased greatly in developing countries and is a health concern because, first, it is occurring in countries without a tradition of alcohol use, and second, these countries have few strategies for prevention or treatment. Alcohol causes approximately 20% to 30% of the following diseases and conditions: esophageal and liver cancer, cirrhosis of the liver, epilepsy, homicide, and motor vehicle collisions. Alcohol causes 1.8 million deaths each year and a significantly shortened life span in millions of others worldwide. Motor vehicle collisions and other unintentional injuries account for almost one-third of the alcohol-related deaths.
HISTORY. Ask the patient how much alcohol he or she consumed and over what period of time. Elicit a history of past patterns of alcohol consumption. You may need to consult other sources, such as family or friends, to obtain accurate information when the patient is acutely intoxicated on admission.
PHYSICAL EXAM. The intoxicated individual needs to have a careful neurological, respiratory, and cardiovascular evaluation. In life-threatening situations, conduct a brief survey to identify serious problems and begin stabilization. Begin with assessment of the airway, breathing, and circulation (ABCs).
RESPIRATORY. Assess the patency of the patient's airway. Check the patient's respiratory rate and rhythm, and listen to the breath sounds. Monitor the patient carefully for apnea throughout the period of intoxication. Determine the adequacy of the patient's breathing.
CARDIOVASCULAR. Check the strength and regularity of the patient's peripheral pulses. Take the patient's blood pressure to ascertain if there are any orthostatic changes. Check the patient's heart rate, rhythm, and heart sounds. Inspect for jugular distension, and assess the patient's skin color, temperature, and capillary refill.
NEUROLOGICAL. Assess the patient's level of consciousness. The brief mental status examination includes general appearance and behavior, levels of consciousness and orientation, emotional status, attention level, language and speech, and memory. Conduct an examination of the cranial nerves. Assess the patient's deep tendon and stretch reflexes. Perform a sensory examination by assessing the patient's response to painful stimuli, and check for autonomic evidence of sympathetic stimulation. Check the adequacy of the gag reflex.
PSYCHOSOCIAL. Individuals admitted to the hospital during episodes of acute alcohol intoxication need both a thorough investigation of the physiological responses and a careful assessment of their lifestyle, attitudes, and stressors. Binge drinkers and dependent drinkers have complex psychosocial needs. Identify the patient's support systems (family and friends), and assess the effect of those systems on the patient's health maintenance.
|Test||Normal Result||Abnormality with Condition||Explanation|
|Blood alcohol concentration||Negative (< 10 mg/dL or 0.01 g/dL)||Positive (> 10 mg/dL or 0.01 g/dL)||Legal intoxication in most states is 80100 mg/dL|
|Carbohydrate deficient transferrin (CDT)||026 units/L for women; 020 units/L for men||> 20 units/L||Demonstrates excessive alcohol consumption for 14 weeks|
|Liver function gammaglutamyl transferase (GGT)||425 units (females); 740 units (males)||Elevated above normal||Evidence of liver disease or alcoholism|
|Aspartate aminotransferase (AST)||820 units/L||Elevated above normal||Evidence of liver disease or alcoholism|
|Alanine aminotransferase (ALT)||810 units/L||Elevated above normal||Evidence of liver disease or alcoholism|
Blood glucose levels: Elevated or low blood glucose levels without a family history of diabetes mellitus indicate chronic alcohol use.
PRIMARY NURSING DIAGNOSIS
DIAGNOSIS. Altered thought processes related to CNS depression
OUTCOMES. Cognitive orientation; Cognitive ability; Electrolyte and acid-base balance; Fluid balance; Neurological status; Safety behavior
INTERVENTIONS. Airway management; Aspiration precautions; Behavior management; Delusion management; Environmental management; Surveillance
MEDICAL. Electrolyte replacement, especially magnesium and potassium, may be necessary. Dehydration is a common problem, and adequate fluid replacement is important. Intravenous fluids may be necessary. During periods of acute intoxication, use care in administering medications that potentiate the effects of alcohol, such as sedatives and analgesics. Calculate when the alcohol will be fully metabolized and out of the patient's system by dividing the blood alcohol level on admission by 20 mg/dL. The result is the number of hours the patient needs to metabolize the alcohol fully.
Anticipate withdrawal syndrome with any intoxicated patient. Formal withdrawal assessment instruments are available to help guide the use of benzodiazepines. If the patient is a dependent drinker, an alcohol referral to social service, psychiatric consultation service, or a clinical nurse specialist is important.
|Medication or Drug Class||Dosage||Description||Rationale|
|Thiamine||100 mg IV||Vitamin supplement||Counters effects of nutritional deficiencies|
|Benzodiazepines||Varies by drug||Anti-anxiety||Manage alcohol withdrawal|
Create a safe environment to reduce the risk of injury. Reorient the patient frequently to people and the environment as the level of intoxication changes. Create a calm, nonjudgmental atmosphere to reduce anxiety and agitation.
Alcoholic withdrawal can occur as early as 48 hours after the blood alcohol level has returned to normal or, more unusually, as long as 2 weeks later. Monitor for early signs such as agitation, restlessness, and confusion. Keep the room dark and decrease environmental stimulation. Avoid using the intercom. Remain with the patient as much as possible. Encourage the patient to take fluids to diminish the effects of dehydration. Avoid using restraints unless the patient is at risk for injuring herself or himself or others.
As the patient recovers, perform a complete nutritional assessment with a dietary consultation if appropriate.
Physical findings: Initial neurological, respiratory, and cardiovascular function and ongoing monitoring of these systems
Alcohol history, assessment, and interventions (note that history may need to be kept confidential)
Response to referral to substance abuse screening and diagnosis if appropriate
Symptoms of withdrawal and response to treatment
Response to nutrition counseling
DISCHARGE HOME HEALTHCARE
PREVENTION. Focus teaching on the problems associated with intoxication and strategies to avoid further intoxication. Encourage the patient to adapt proper nutrition.
REFERRALS. Refer the patient to appropriate substance abuse support groups such as Alcoholics Anonymous (AA).
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