1. Delirium Tremens Jaymie McAllister EBP Presentation November 5, 2012

2. 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.

3. Delirium TremensDelirium Tremens  A severe form of alcohol withdrawal that includes sudden and severe mental and/or nervous system changes.  This is a medical EMERGENCY.

4. 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)

5. 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)

6. Case ScenarioCase 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.

7. Clinical ManifestationsClinical 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  60% of DT patients; have between 1-6 seizures  Other symptoms of withdrawal  Anxiety, depression, head ache, nausea, sweating, palpitation s (NIH, 2011)

8. Manifestations

9. Videos  Delirium Tremens  http://www.youtube.com/watch?v=291TBlwlP1c http://www.youtube.com/watch?v=291TBlwlP1c  Grand Mal Seizure  https://www.youtube.com/watch?v=Nds2U4CzvC4&f eature=fvwrel https://www.youtube.com/watch?v=Nds2U4CzvC4&f eature=fvwrel

10. Risk FactorsRisk 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)

11. 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.)

12. 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)

13. CIWA-Ar

14. Treatment  Medical Care  Prescribe medications for symptoms  Benzodiazepines: Ativan, Diazepam  Anticonvulsants: Tegretol  Thiamine: Vitamin B1  Magnesium sulfate  5% dextrose in 0.45%-0.9% NaCl  Nursing Care  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)

15. Complications of Treatment  Oversedation  Respiratory depression **  Aspiration pneumonitis  Cardiac arrhythmias ** (NIH, 2011)

16. Nursing DiagnosisNursing 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

17. Fall Risk InterventionsFall 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

18. 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.

19. PET ScanPET Scan

20. NCLEX QuestionsNCLEX 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

21. 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

22. References  Burns, M. (2011, June 29). Medscape reference. Retrieved from http://emedicine.medscape.com/article/166032-overview http://emedicine.medscape.com/article/166032-overview  Epocrate s. (2012, February 09). Diagnostic Tests. Retrieved from https://online.epocrates.com/noFrame/showPage.do?method=disease s&MonographId=549&ActiveSectionId=34 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 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/ 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-practice- questions-7.htmlhttp://nursingguide.cc/index.php/nclex-pn-practice- questions-7.html