Alcohol Withdrawal Nursing Care Plan

Nursing Diagnosis 1: Injury Risk (seizures, DTs)

Injury Risk (seizures, DTs) related to Alcohol withdrawal syndrome (AWS): physiologic dependence with discontinuation or reduction in heavy chronic use; spectrum from mild tremor to delirium tremens (DT) as evidenced by History of withdrawal seizures or delirium tremens; Coarse hand tremor and gait ataxia; Agitation, restlessness, and impulsivity; Visual hallucinations with reaching or swatting behavior; Disorientation to time, place, or situation.

Interventions

• Score CIWA-Ar at intervals matched to clinical acuity and facility protocol (commonly q1 to 4 h); document the trend.
• Assess level of consciousness, orientation, and pupil size at intervals matched to clinical acuity and facility protocol.
• Observe for prodromal seizure signs: increasing tremor, hyperreflexia, myoclonic jerks.
• Monitor vital signs (HR, BP, RR, temp, SpO₂) at intervals matched to clinical acuity and facility protocol during peak withdrawal.
• When an adrenergic adjunct (beta-blocker, clonidine, dexmedetomidine) is ordered, document that CIWA-Ar autonomic items may be masked and the score may underestimate severity.
• Implement seizure precautions per facility protocol: padded side rails up, suction and oxygen at bedside, bed in low position.
• Administer benzodiazepines as ordered per CIWA-Ar protocol or provider direction; document the score and dose given.
• Administer ordered electrolyte replacement (magnesium, potassium, phosphorus); recheck per provider order and facility protocol.
• Coordinate continuous observation (1:1 sitter or equivalent per facility protocol) for CIWA-Ar ≥ 16, active hallucinations, or recent fall.
• Modify the environment per facility protocol: low lighting, reduced noise, frequent reorientation, clock and calendar in view.
• Orient the patient to person, place, time, and situation at every encounter.
• Explain every procedure and medication in calm, simple language before performing it.
• Educate the family on what to expect (timeline, hallucinations, mood lability) and on validating emotion without endorsing hallucinations.
• Notify the provider promptly for seizure activity, CIWA-Ar rising despite ordered dosing, or vital-sign instability.
• Coordinate ICU transfer per facility protocol for refractory autonomic instability, repeated seizures, or escalating benzodiazepine requirements.
• Document the pattern of alcohol use (CAGE, AUDIT) and prior withdrawal history at admission.

Outcome: Patient remains free of seizure-related injury throughout admission; CIWA-Ar is monitored and reported at intervals matched to clinical acuity and facility protocol; Vital signs are monitored and reported within ordered parameters.

Nursing Diagnosis 2: Altered Perception

Confusion related to Alcohol withdrawal syndrome (AWS): physiologic dependence with discontinuation or reduction in heavy chronic use; spectrum from mild tremor to delirium tremens (DT) as evidenced by Disorientation to time, place, or situation; Visual or tactile hallucinations; Fluctuating level of consciousness; Inability to focus or sustain attention; Psychomotor agitation alternating with lethargy.

Interventions

• Assess orientation (person, place, time, situation) and attention at intervals matched to clinical acuity and facility protocol.
• Use CIWA-Ar hallucination subscales (auditory, visual, tactile) at each scoring interval per facility protocol.
• Screen for alternative contributors to altered mental status: hypoglycemia, hyponatremia, hypoxia, infection, head injury.
• Monitor for the Wernicke triad: ataxia, ophthalmoplegia (nystagmus, lateral gaze palsy), and global confusion.
• Administer IV thiamine as ordered per provider direction and facility protocol, commonly before any IV dextrose; continue as ordered.
• Maintain a calm, quiet environment with consistent caregivers when feasible per facility protocol.
• Keep familiar objects (glasses, hearing aids, photos) at the bedside; support sensory aids being in place.
• Limit room changes and minimize new staff exposure when feasible.
• Avoid physical restraints when feasible per facility protocol; use verbal de-escalation and continuous observation first.
• Reorient at every interaction: state name, role, location, day, and reason for hospitalization.
• Speak slowly and in short sentences; one instruction at a time.
• Coach family to validate emotion without endorsing hallucinations (for example, ‘I don’t see them, and I can see this is frightening for you’).
• Notify the provider for rising CIWA-Ar despite ordered dosing, new focal neurologic findings, or persistent hallucinations.
• Coordinate psychiatry consultation per facility protocol when hallucinations persist beyond resolution of autonomic symptoms.
• Document Confusion Assessment Method (CAM) features daily per facility protocol to support team communication about delirium course.

Outcome: Patient is monitored for orientation, attention, and hallucinations at intervals matched to clinical acuity and facility protocol; Hallucinations and confusion are reassessed during and after ordered benzodiazepine therapy; Sleep-wake patterns are monitored and supported with environmental modification per facility protocol.

Nursing Diagnosis 3: Impaired Verbal Communication

Fall Risk related to Alcohol withdrawal syndrome (AWS): physiologic dependence with discontinuation or reduction in heavy chronic use; spectrum from mild tremor to delirium tremens (DT) as evidenced by Coarse tremor, gait ataxia, and impaired coordination; Orthostasis from autonomic instability and volume depletion; Agitation, restlessness, and impulsivity; Visual or tactile hallucinations leading to misperception of the environment; Sedation from ordered benzodiazepine or phenobarbital therapy.

Interventions

• Complete a fall-risk assessment at admission, each shift, and after any change in condition per facility protocol.
• Assess orthostatic vital signs per provider order when clinical state allows.
• Monitor sedation level (RASS or facility scale) before and after ordered benzodiazepine or phenobarbital doses.
• Reassess gait and balance when the patient is preparing to ambulate.
• Maintain the bed in low position, brakes locked, top side rails up, with call light within reach per facility protocol.
• Use bed and chair alarms per facility protocol while severity criteria are met.
• Coordinate continuous observation (1:1 sitter or equivalent per facility protocol) when fall risk is high.
• Place non-slip footwear on the patient before any out-of-bed activity.
• Position the call light, urinal, water, glasses, and hearing aids within reach.
• Coordinate with physical therapy or rehab per facility protocol when ataxia or deconditioning is prominent.
• Educate the patient on calling for help before standing or ambulating during the withdrawal course.
• Educate the family on the rationale for bed alarms, sitters, and reorientation, and on not assisting the patient out of bed without staff.
• Teach the patient about orthostatic precautions: sit on the edge of bed for a minute, then stand with staff support.
• Notify the provider for any fall or near-fall, new orthostasis, or worsening ataxia.
• Coordinate post-fall huddle per facility protocol when a fall occurs.

Outcome: Patient remains free of falls during admission; Fall-risk assessment is documented at admission and after each change in condition per facility protocol; Bed and chair alarms are in place per facility protocol while severity criteria are met.

Nursing Diagnosis 4: Impaired Urinary System Function

Anxiety related to Alcohol withdrawal syndrome (AWS): physiologic dependence with discontinuation or reduction in heavy chronic use; spectrum from mild tremor to delirium tremens (DT) as evidenced by Tremor, diaphoresis, and tachycardia perceived by the patient; Hallucinations (visual, tactile, auditory) the patient finds frightening; Fear of seizures or worsening symptoms; Unfamiliar hospital environment and frequent interventions; Sleep disturbance from autonomic hyperactivity and monitor alarms.

Interventions

• Assess anxiety level using a 0 to 10 scale at the start of every shift and PRN.
• Identify the patient’s stated triggers (hallucinations, monitor alarms, fear of seizure, fear of relapse, fear of judgment).
• Observe for physical signs of anxiety: tachycardia out of proportion to clinical state, restlessness, hand-wringing, hypervigilance.
• Assess sleep quality and contributors (alarms, lighting, frequent interventions, tremor, anxiety) daily.
• Provide a calm, reassuring presence; speak clearly and at a measured pace.
• Explain procedures and findings in plain, patient-friendly terms before performing them.
• Cluster cares to allow uninterrupted rest periods when clinical state allows.
• Limit non-essential nighttime stimuli (overhead lights, loud conversations, unnecessary alarms) per facility protocol.
• Facilitate family contact within facility policy.
• Coordinate with chaplaincy, social work, or interpreter services per patient preference and facility policy.
• Teach diaphragmatic breathing and grounding techniques the patient can use independently when clinical state allows.
• Educate the patient and family on the withdrawal timeline, what hallucinations and tremor look like, and the role of benzodiazepine therapy.
• Teach the family what each monitor alarm means and what is and is not clinically concerning.
• Coordinate with chaplaincy, social work, or psychiatry per facility protocol if anxiety persists or worsens despite non-pharmacologic measures.
• Notify the provider for severe or persistent anxiety unresponsive to non-pharmacologic measures.

Outcome: Patient verbalizes decreased anxiety with consistent presence and explanation; Patient demonstrates at least one coping strategy (diaphragmatic breathing, grounding, music) when clinical state allows; Patient sleeps in 4-hour blocks when clinical state and environment allow.

Nursing Diagnosis 5: Impaired Nutritional Status

Body Nutrition Deficit related to Alcohol withdrawal syndrome (AWS): physiologic dependence with discontinuation or reduction in heavy chronic use; spectrum from mild tremor to delirium tremens (DT) as evidenced by Chronic alcohol use replacing dietary intake; Macrocytic anemia (↑ MCV) on CBC; Hypomagnesemia, hypokalemia, hypophosphatemia; Hypoalbuminemia and muscle wasting; Reported weight loss > 5% in past 3 months.

Interventions

• Assess baseline weight, BMI, and recent weight change at admission.
• Monitor daily electrolytes (magnesium, potassium, phosphorus), glucose, and renal function per provider order.
• Perform an oral exam for cheilosis, glossitis, and dental disease at admission.
• Screen for peripheral neuropathy, ataxia, and ophthalmoplegia at admission.
• Administer IV thiamine as ordered per provider direction and facility protocol, followed by oral thiamine when ordered.
• Administer folic acid 1 mg PO daily and a daily multivitamin as ordered.
• Administer ordered electrolyte replacement (magnesium, potassium, phosphorus); recheck after each replacement dose per provider order.
• Advance diet as ordered, commonly starting with a regular diet unless contraindicated per provider order.
• Notify the provider when phosphorus, potassium, or magnesium drop > 20% from baseline during nutrition advancement, per facility refeeding protocol.
• Educate the patient on the role of nutrition in recovery (energy, mood, sleep, neuropathy improvement).
• Teach foods rich in B-complex vitamins, magnesium, and protein for outpatient intake.
• Provide written discharge instructions on continuing thiamine, folate, and MVI as prescribed.
• Coordinate registered dietitian consultation at admission per facility protocol.
• Notify the provider for falling phosphorus, potassium, or magnesium on serial labs.

Outcome: Patient tolerates oral intake within ordered parameters by discharge; Electrolytes (magnesium, potassium, phosphorus) are monitored and reported toward ordered parameters; Refeeding-syndrome indicators (cardiac, respiratory, neurologic) are monitored and reported per facility protocol.

Nursing Diagnosis 6: Impaired Health Maintenance

Health Maintenance Alteration related to Alcohol withdrawal syndrome (AWS): physiologic dependence with discontinuation or reduction in heavy chronic use; spectrum from mild tremor to delirium tremens (DT) as evidenced by Reported daily heavy alcohol use > 6 months; Tolerance (escalating amounts to achieve effect); Repeated unsuccessful quit attempts; Continued use despite known medical or social harm; Use of alcohol as primary coping mechanism for stress, sleep, or affect.

Interventions

• Complete AUDIT and CAGE screening at admission; document pattern of use, quantity, frequency, and last drink.
• Assess prior treatment history: detox episodes, prior MAT, rehab attendance, longest period of sobriety.
• Assess readiness to change using the stages-of-change model (precontemplation through maintenance).
• Screen for co-occurring conditions: depression, anxiety, PTSD, trauma history.
• Assess social supports, housing stability, employment, and legal issues at admission.
• Use motivational interviewing techniques: open questions, affirmations, reflections, summaries (OARS).
• Maintain a non-judgmental, therapeutic stance throughout admission.
• Provide written and verbal information on medication-assisted treatment (MAT) options: naltrexone, acamprosate, disulfiram.
• Coordinate inpatient visit or phone call with a peer recovery specialist or recovery-program contact per facility protocol.
• Teach the patient that alcohol use disorder is a chronic, relapsing medical condition.
• Help the patient identify personal triggers (people, places, emotions, times of day) and develop coping plans.
• Educate on warning signs of relapse and how to access crisis resources (988, local crisis line, ED).
• Coordinate referral to a MAT prescriber prior to discharge per facility protocol; in-house MAT initiation when ordered and clinically appropriate.
• Arrange follow-up with primary care, addiction medicine, or behavioral health within 7 days of discharge per facility protocol.
• Provide AA, SMART Recovery, or other recovery-program contact information and meeting locations.
• Engage social work for housing, employment, and legal support as needed.

Outcome: Patient verbalizes understanding of alcohol use disorder as a chronic medical condition; Patient identifies at least 2 personal triggers for use when clinical state allows; Patient identifies at least 2 alternative coping strategies when clinical state allows.

Chronic alcohol use enhances GABA-A inhibitory tone and suppresses NMDA glutamatergic excitatory tone. The CNS adapts by downregulating GABA receptors and upregulating NMDA receptors. When alcohol is abruptly removed, inhibition collapses while glutamatergic drive remains amplified, producing an unopposed excitatory state with autonomic hyperactivity and a lowered seizure threshold.

Timeline: 6 to 24 h → Stage 1 (tremor, anxiety, nausea, mild HTN/tachycardia); 12 to 48 h → Stage 2 alcoholic hallucinations (typically visual, sensorium intact); 24 to 48 h → Stage 3 withdrawal seizures (generalized tonic-clonic, commonly 1 to 2 episodes; status uncommon); 48 to 96 h → Stage 4 delirium tremens (DT) with confusion, agitation, hallucinations, fever, and severe autonomic instability (reported mortality 1 to 5% treated, up to 25% untreated). DT commonly peaks at 48 to 96 h, and a late-onset tail to 7 to 10 days has been reported, especially with partial benzodiazepine coverage or co-occurring illness; step-down monitoring should be reassessed with the provider team rather than de-escalated early. Risk factors for severe withdrawal include prior DT, prior withdrawal seizures, comorbid medical illness, age > 65, and baseline electrolyte abnormalities.

Severity is graded with the CIWA-Ar (Clinical Institute Withdrawal Assessment for Alcohol, revised), a 10-item scale (score 0 to 67) scored at intervals matched to clinical acuity and facility protocol (commonly q1 to 4 h). Symptom-triggered dosing guided by CIWA-Ar is commonly preferred over fixed-schedule benzodiazepines in monitored settings per the ASAM 2020 Clinical Practice Guideline; selection between symptom-triggered, fixed-schedule, and front-loaded regimens is a provider-team decision per facility protocol.

Care is supportive and coordinated by the medical team: scheduled or symptom-triggered benzodiazepines per provider order and facility protocol, IV thiamine before any IV dextrose to support Wernicke prevention, electrolyte repletion (magnesium, potassium, phosphorus), volume resuscitation as ordered, and stepwise escalation to phenobarbital or dexmedetomidine adjuncts and ICU-level monitoring when severity escalates.

• CIWA-Ar: ≤ 8 mild · 9 to 15 mod · ≥ 16 severe
• First-line: Benzodiazepines per provider order (lorazepam commonly preferred in liver disease)
• DT mortality: 1 to 5% treated · up to 25% untreated
• Seizures: 24 to 48 h · GTC · commonly 1 to 2
• Thiamine timing: 100 mg IV commonly given before any IV dextrose per facility protocol

• Makic, M. B. F., & Martinez-Kratz, M. R. (Eds.). (2023). Ackley and Ladwig’s Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care (13th ed.). Elsevier.
• The ASAM Clinical Practice Guideline on Alcohol Withdrawal Management. (2020). Journal of Addiction Medicine, 14(3S Suppl 1), 1–72.
• Mayo-Smith, M. F., Beecher, L. H., Fischer, T. L., et al. (2004). Management of alcohol withdrawal delirium: An evidence-based practice guideline. Archives of Internal Medicine, 164(13), 1405–1412.