This section will apply the nursing process to caring for a hospitalized client diagnosed with a substance use disorder who is receiving withdrawal treatment.

Assessment

The following client history should be obtained from a client diagnosed with a substance use disorder^[1]:

• History of substance use: Include names of the substances used, the time of last use, the duration of use, the quantity and frequency of use, and the method of use (e.g., oral, intravenous, inhaled, intranasal). A detailed substance use history helps determine the expected time frame for emergence of withdrawal symptoms and the potential for severe withdrawal syndromes.
• Detailed history of previous withdrawal treatments: For clients who have previously undergone withdrawal management, a history of these treatments should be obtained.
• Treatment history: The history of any previous treatment programs should be obtained. History should include previous treatments (such as inpatient or outpatient programs, 12-step programs such as Alcoholics Anonymous, or medications such as naltrexone or acamprosate), as well as what treatments have been helpful or not helpful.
• Mental health history: Concurrent mental health illness can impact the client’s withdrawal symptoms. Clients should receive integrated post-withdrawal treatments for multiple diagnoses of mental health and substance use disorders.
• Social history: Identification of social supports (such as a supportive family member who can encourage abstinence and potentially dispense withdrawal medication), as well as barriers (such as poor transportation), can also help determine the most appropriate post-withdrawal treatment plan (e.g., residential, outpatient, and recovery programs).
• Medical history and recent physical symptoms: Medical problems can contribute to the client’s symptoms and/or worsen withdrawal symptoms.

The client should receive a comprehensive physical examination to evaluate signs related to current withdrawal symptoms, as well as symptoms of concurrent medical and mental health diagnoses. If the client has been diagnosed with alcohol use disorder, signs of complications such as liver or pancreatic disease should be assessed.^[2]

Screening Scales

Screening scales may be administered such as CIWA-aR (for alcohol withdrawal symptoms) and COWS (for opioid withdrawal symptoms). Read more information about these scales in the “Withdrawal Management/Detoxification” section of this chapter.

Diagnostic and Lab Work

Laboratory testing for clients admitted for withdrawal treatment may include these items^[3]:

• Complete blood count
• Serum electrolytes, including potassium, magnesium, and phosphate
• Glucose
• Creatinine
• Liver function tests
• Amylase and lipase
• Blood alcohol level
• Urine drug testing for benzodiazepines, cocaine, and opioids. (The opioid test may include testing for heroin, codeine, morphine, buprenorphine, oxycodone, methadone, and fentanyl.)
• Urine human chorionic gonadotropin (HCG) test for premenopausal women to check for pregnancy
• Electrocardiogram (ECG) for clients over 50 years of age or if there is a history of cardiac problems

Diagnoses

A nursing diagnosis related to the abrupt cessation of a psychoactive substance is a syndrome diagnosed as Acute Substance Withdrawal Syndrome. As a syndrome diagnosis, defining characteristics are the related nursing diagnoses, including Acute Confusion, Anxiety, Disturbed Sleep Pattern, Nausea, Risk for Electrolyte Imbalance, and Risk for Injury.^[4]

Outcome Identification

An example of a broad goal related to withdrawal treatment is the following:

• The client will stabilize and remain free from injury.^[5]

These are some sample SMART outcomes^[6]:

• The client’s vital signs will remain within normal ranges during treatment.
• The client’s electrolyte levels will remain within normal ranges during treatment.
• The client will participate in planning a post-withdrawal treatment program before discharge.

Planning Interventions

In addition to implementing the withdrawal treatment plan prescribed by the provider, the nurse collaboratively develops a post-withdrawal treatment plan with interprofessional health care team members. The plan should be client-centered and include their goals and readiness for change. Motivational interviewing is a helpful therapeutic technique when planning individualized treatment goals and programs.^[7]

Implementation

Nursing interventions provide a supportive environment while the client undergoes withdrawal treatment. Vital signs are monitored closely because increases in temperature, pulse, and blood pressure are signs of withdrawal. After ensuring that an individual’s physiological needs of airway, breathing, and circulation are met, safety measures receive top priority. Safety measures during withdrawal treatment may include interventions such as fall precautions, seizure precautions, or implementing restraints as needed to maintain the safety of the individual or those around them. ^[8]

Seizures can occur in clients experiencing alcohol withdrawal. Seizure precautions include keeping the bed in the lowest position with side rails padded. Suction and oxygen equipment must be available at all times at the patient’s bedside.

Medications are administered as prescribed to keep the client safe and comfortable, so they do not suffer.^[9]

Clients with substance use disorders may exhibit a poor nutritional status due to long-term use of substances taking precedence over food and fluid intake. Nurses provide hydration and gradually reintroduce healthy foods while also promoting rest. Clients with alcohol use disorder are specifically at risk for thiamine (B1) and magnesium deficiencies that can lead to cardiac arrest. Thiamine and other electrolyte replacement is typically included during withdrawal treatment.^[10]

Developing a therapeutic nurse-client relationship can encourage the client to explore harmful feelings of anxiety, hopelessness, and spiritual distress. Encouraging self-care and hygiene helps improve clients’ self-esteem. Nurses educate clients about healthy coping skills and evidence-based treatment and recovery services available in the community.^[11] 

Evaluation

Evaluation occurs on several levels by assessing the individualized SMART outcomes related to the effectiveness of the withdrawal treatment plan, symptom management, and the client’s readiness and progress towards changes in their behavior.^[12]