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I’m working on a nursing discussion question and need an explanation to help me learn.

Respond to these 3 different discussion board with 2 or 3 paragraphs and 2 references for each of the 3 discussions. Do not combine the 3 answers, you need to post each answer with its 2 references. Use APA 7th book

Alcohol Withdrawal Syndrome

The case that I will share in this discussion is under substance use disorder. The patient I have is J.R, a 52 y/o Hispanic male admitted to the hospital for alcohol withdrawal. He was alert, oriented x3 with periods of confusion and forgetfulness. He is single with no children and lives with his father and brothers. He has a history of GERD, alcohol abuse for 35 years, claiming he drinks 5-7 (32oz) a day. He denies any health concerns or abuse; however, he has had a suicide attempt in 2001 in which he cut his wrist. He has anxiety for years and identifies himself as an alcoholic. He went to rehab 5-6 times and Alcohol Anonymous, but he gets disappointed and relapses. He is currently unemployed and has no insurance.

He was admitted to the unit with a chief complaint of chest pain and stated that he had an anxiety attack that caused him to have shortness of breath. He was referred to addiction medicine and social work. Since covid-19 is still affecting California currently, some consults call the patient in their room. During the addiction medicine consult, an RN called the patient, but the patient declined to answer any questions and stated that he was okay. The nurse placed information on alcohol and drug treatment programs in the patient discharge summary and signing off. He was given his morning medication, including chlordiazepoxide (Librium), and was given lorazepam (Ativan) an hour prior.

The social worker spoke to me before seeing the patient and gave her information on how the patient is regarding cognition. The social worker gave him counseling, possible coping techniques, and a rehab referral list. The dilemma that I felt is how can the RN who worked for addiction medicine dismissed the consult that easily. The patient might be impaired due to withdrawal and medication. The patient was very groggy while speaking to the nurse over the phone; what if the social worker didn’t come? Is it because the patient does not have insurance? I was very thankful that the social worker arrived. If not, then I would feel that there is no justice in my patient’s case.

The Alcohol Withdrawal Syndrome (AWS) is the typical Alcohol Dependence Syndrome presentation (Sachdeva et al., 2015). The symptoms happen when an alcohol-dependent individual tries to stop or reduce heavy or prolonged alcohol use. The most common manifestations are tremor, restlessness, insomnia, nightmares, paroxysmal sweats, tachycardia, fever, nausea, vomiting, seizures, hallucinations (auditory, visual, and tactile), increased agitation, and tremulousness (Sachdeva et al., 2015). These signs and symptoms are caused by the interruption of the constant exposure of the Central Nervous System (CNS) to alcohol itself (Sachdeva et al., 2015). Hoffman and Weinhouse (2021) stated that alcohol simultaneously enhances inhibitory tone (via modulation of gamma-aminobutyric acid [GABA] activity) and inhibits excitatory tone (via modulation of excitatory amino acid activity). In a patient with alcohol dependence, homeostasis is only preserved with ethanol—abrupt cessation results in the central nervous system overactivity (Hoffman & Weinhouse, 2021).

The neurotransmitters involved in alcohol withdrawal are GABA, Glutamate, and Dopamine. The GABA receptor complex has particular binding sites for ethanol. Chronic ethanol use induces insensitivity to GABA. Cessation of alcohol or a reduction from chronically elevated concentrations results in decreased inhibitory tone (Hoffman & Weinhouse, 2021). When glutamate binds to the N-methyl-D-aspartate (NMDA) receptor, calcium influx leads to neuronal excitation by binding to the NMDA complex’s glycine receptor. Ethanol inhibits glutamate-induced excitation. Cessation of alcohol or a reduction from chronically elevated concentrations results in unregulated excess excitation (Hoffman & Weinhouse, 2021). Increases in dopamine during withdrawal likely contribute to hyperarousal (Hoffman & Weinhouse, 2021). The CYP-450 enzyme affected is CYP-450 2E1 which oxidizes ethanol to acetaldehyde, and then to acetic acid, roles also played by alcohol and aldehyde dehydrogenases ( Peter Guengerich & Avadhani, 2018).

Benzodiazepines (BZD) are the mainstay treatment in alcohol withdrawal (Sachdeva et al., 2015). The most used benzodiazepines for alcohol detoxification are chlordiazepoxide, diazepam (long-acting) and lorazepam, oxazepam (short/intermediate-acting). Benzodiazepines are cross-tolerant with alcohol and modulate anxiolysis by stimulating GABA-A receptors. It may serve as a substitute for the agent that is being withdrawn (Sachdeva et al., 2015). BZDs have been found effective in 1) preventing agitation and alcohol withdrawal seizures, 2) preventing delirium tremens, and 3) as cross-tolerant agents with ethanol (Sachdeva et al., 2015).

The management of alcohol withdrawal is directed at alleviating symptoms and identifying and correcting metabolic derangements. Benzodiazepines are used to control psychomotor agitation and prevent progression to more severe withdrawal. Supportive care, including intravenous (IV) fluids, nutritional supplementation, and frequent clinical reassessment, including vital signs, is essential (Hoffman & Weinhouse, 2021).

References

Hoffman, R. S., & Weinhouse, G. L (2021). Management of moderate and severe alcohol withdrawal syndromes. UpToDate. https://www.uptodate.com/contents/management-of- moderate-and-severe-alcohol-withdrawal-syndromes

Peter Guengerich, F., & Avadhani, N. G. (2018). Roles of Cytochrome P450 in metabolism of ethanol and carcinogens. Advances in experimental medicine and biology, 1032, 15–35.https://doi.org/10.1007/978-3-319-98788-0_2

Sachdeva, A., Choudhary, M., & Chandra, M. (2015). Alcohol withdrawal syndrome: Benzodiazepines and beyond. Journal of clinical and diagnostic research: JCDR, 9(9), VE01–VE07. https://doi.org/10.7860/JCDR/2015/13407.6538

2.

Alcohol Withdrawal Syndrome

Alcohol consumption is widespread throughout developed countries, with over 8 million people in the U.S. dependent on alcohol (Drew et al. 2017). According to Drew et al. (2017) postulate that approximately 20% of men and 10% women will suffer an alcohol-use disorder, also half will experience withdrawal symptoms such as seizures and delirium tremens (DTs) will occur in 3-5%. According to Wong et al. (2015), stipulates that alcoholism can affect the brain and behavior in a variety of ways, and multiple factors can impact these effects. Ethanol is the primary alcohol ingested by chronic user.

DT occurs in 3-5% of patients who are hospitalized for alcohol withdrawal (Yanta et al. 2015). DT usually begins 3 days after the appearance of withdrawal symptoms and lasts for 1 to 8 days, though symptoms may appear as quickly as 8 hours from the last drink. The mortality of hospitalized patients with DT is currently estimated to be 1- 4%; however, prior to the era of benzodiazepine use and intensive care, mortality reached 35% (Schmidt et al. 2016). DT can be predicted by several factors. If seizures remain untreated, up to one third of patients progress to DT. Other common factors include history of prior DT and Clinical Institute Withdrawal Assessment of Alcohol Scale, revised (CIWA-Ar) score > 15 (Drew et al. 2017).

My case discussion for this assignment is under substance use disorder. Mr. PB is a 55

year old African American male who was brought to my hospital emergency department (ED) by EMS after he was found down in alley. This admission is one of his numerous admissions for alcohol withdrawal. In the ED he was so confused, intermittently seizing, requiring IV Ativan administration. His initial labs showed elevated cardiac enzymes, LFT, ETOH level 300mg/dl and abnormal electrolytes. Based on the above work up, intensive care consult was required, and MR. PB subsequently admitted to the intensive care unit (ICU) for further treatment. On arrival to the unit PB was still in his drenched street clothes he had on when EMS picked him up in a street alley. PB was so dirty shivering and full of urine. In a little discussion with the transporting ED nurse on patient’s hygiene. His response was “nursing is 24 hours ok” and walked away.

Assessment: After stabilizing PB I called and spoke to ED Manager about patient’s condition on admission to ICU. She gave numerous flimsy excuses for the nurse’s action. This is one of so many instances of poor care by some of the ED nurses that was never addressed. This is a management issue that hinders appropriate care. If this issue had been addressed previously PB

would not have arrived at the unit wet and shivering. This is very frustrating because it can slow down care flow of the patient. PB was talking excessively, tossing all over his bed, exhibiting tactile hallucination which is expected from alcohol syndrome (AWS). He was also very anxious, diaphoretic, palpitation with hyperreflexia. CIWA-Ar) score > 18

Management: Patients was kept calm in a controlled environment to try to reduce the risks of progression from mild symptoms to hallucinations. PB was started on intravenous rehydration, abnormal electrolytes corrected and ruled out for another comorbidity. With mild to moderate symptoms, patients should receive supportive therapy. Due to the risk of a comorbid condition called Wernicke-Korsakoff syndrome, patients can also receive a “banana bag” or cocktail of folate, thiamine, dextrose containing fluids, and a multivitamin (Newman et al. 2020). PB was also started on Serax (Oxazepam) 15mg orally every six hours with instruction to hold for sedation. Serax is part of benzodiazepine class of drugs mostly used for DT management. It works by slowing down the CNS to elicit feelings of calm and relaxation. Received Zofran 4mg IV as needed for nausea and vomiting. After two days in ICU, PB’s symptoms improved and was transfer to telemetry unit with case management consult for rehabilitation.

Several neurotransmitter receptors such as gama-aminobutyric acid (GABA), glutamate, dopamine, acetylcholine, and serotonin are vulnerable to the effects of alcoholism. Chronic ethanol ingestion leads to down regulation changes of the GABA receptors. Additionally, in chronic alcoholics, N-methyl-D-aspartate (NMDA) receptors undergo conformational changes and up-regulation. Therefore, when there is discontinuation of alcohol intake, patients lose the GABA inhibitory effect, leading to central nervous system (CNS) hyper stimulation.

Conclusion: Due to the widespread prevalence of alcohol use, disorders involving alcohol withdrawal are common. Alcohol withdrawal syndrome may result in morbidity and mortality, thus requiring early recognition and management. Stages of withdrawal include withdrawal symptoms, hallucinations, seizures, and delirium tremens. Treatment of AWS focuses on providing medications with GABA receptor activity (Newman et al. 2020). Benzodiazepines with symptom triggered therapy have been the predominant medication class utilized for AWS.

References

Drew, L., Brit, L. & Alex, K. (2017). The emergency management of severe alcohol withdrawal. The American Journal of Emergency Medicine, 35(7):1005-1011.

Newman, R. K. Stobart -Gallagher, M. A. & Gomez, A. E. (2020). Alcohol withdrawal.

Stat pearls Internet

Schmidt, K. J,, Doshi, M. R., Holzhausen, J.M., Natavio, A., Cadiz, M., Winegardner, J. E. (2016).

Treatment of severe alcohol withdrawal. Annals of Pharmacotherapy, 50(5):389-401.

Wong A, Benedict, N. J., Lohr. B. R., Pizon, A. F., & Kane-Gill, S. L. (2015). Management of

benzodiazepine-resistant alcohol withdrawal across a healthcare system: Benzo-

diazepine dose-escalation with or without propofol. Drug Alcohol Depend, 154:296-9.

Yanta, J. H., Swartzentruber, G. S., Pizon, A. F. (2015). Alcohol withdrawal syndrome: Improving

outcomes through early identification and aggressive treatment strategies. Emergency

Medicine, 17(6):1-20.

Basic_and_Clinical_Pharmacology_Fourteen.pdf (15.785 MB)

3.

Alcohol Use Disorder

The case I will share concerns patient CC. The patient was black, and she is 46 years old. She was brought into the hospital with a severe case of alcohol disorder. She had been abusing alcohol for a long time, and she had refused to go to rehab. Her brother and mother brought her in. In addition to having an alcohol use problem, she was also HIV positive and hypertension. This is the second time she was seeking treatment for alcohol abuse. Her family knew the importance of seeking treatment for alcohol abuse, but the patient had refused to go back despite having the problem for close to eight years now. She smokes and drinks uncontrollably. This time she passed out on the streets, and a neighbor who was walking by happened to see her. She was then rushed to the hospital. Her loved ones thought this was a good chance to seek treatment again because she does not go to Alcoholic Anonymous anymore(AA). She has a history of hypertension and takes Metropol 500mg twice a day. The patient has no known allergy.

The ethical dilemma issue in the case happened after she was hospitalized. She started having a relationship with a fellow patient admitted for the same point. It was not clear whether they were having sex, but given that I had the files for both patients, I knew that the other patient was not HIV positive. I was caught between a rock and a hard place on whether to disclose the information of one of the patients to the other as a way of protecting him. It was also not clear if what they had was a romantic relationship. Therefore, it was not easy to know whether it was appropriate to discuss the situation with both of them. I considered counseling them about safe sex; however, it would seem inappropriate if what they were having was just a platonic relationship. I was also restricted by the requirement to keep the patient information private (HHS.gov, 2015). The other patient, who was male, improved and was released earlier before it was apparent whether they had a relationship. He would come to the hospital to see her, which meant that it was impossible to tell him anything since he was no longer a patient.

In the case of CC, there was a need to put her under both pharmacological and non-pharmacological care. Naltrexone was prescribed which brand name is Vivitrol 50mg by mouth twice a day. Titration of 50mg during and 100mg weekend together with cognitive-behavioral therapy. It was clear from her history that the death of her father led her to alcoholism. They were very close, and she unable to get over his death. Depression leads to alcohol abuse. Alcohol abuse had interfered with her studies, and she did not finish college. Alcoholism disrupts one’s life greatly (Mayo Clinic, 2018). She ran away from home when her loved ones said that they would take her to rehab. They were worried, and that is why they agreed not to take her for treatment again, provided she did not run away from home again. Her condition had gotten worse, and she would go for days without her family knowing where she was. Her relationship with patient DD kept her in hospital, and she showed commitment to the treatment.

The teaching considerations for patient CC must include informing her of the side effects of the medicine. The side effects include headaches, diarrhea, constipation, dizziness, among others. However, the side effects would disappear in a few days or two weeks at most (Familydoctor.org editorial staff, 2020). There was also a need to inform her caregivers what to expect once the patient was discharged. They were also told that her urge to drink would not go away because of chronic alcohol. However, the medication could help her overcome the desires. She will need a social worker and help with nutrition. There is also a need to help her turn her life around and engage in other productive activities. It was important for the patient to understand that a large intake of naltrexone could cause liver damage (Earley et al., 2017).

References

Earley, P. H., Zummo, J., Memisoglu, A., Silverman, B. L., & Gastfriend, D. R. (2017). Open-label study of injectable extended-release Naltrexone (XR-NTX) in healthcare professionals with opioid dependence. Journal of Addiction Medicine, 11(3), 224-230. https://doi.org/10.1097/adm.0000000000000302

Familydoctor.org editorial staff. (2020, September 1). Naltrexone for alcoholism. familydoctor.org. https://familydoctor.org/naltrexone-for-alcoholism/

HHS.gov. (2015, April 16). Privacy. https://www.hhs.gov/hipaa/for-professionals/privacy/index.html

Mayo Clinic. (2018, July 11). Alcohol use disorder – Diagnosis and treatment – Mayo Clinic. Mayo Clinic – Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/alcohol-use-disorder/diagnosis-treatment/drc-20369250

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