Alcohol Withdrawal Nursing Care Plan: 2 Sample Plans and Interventions

Alcohol withdrawal happens when a person who drinks heavily suddenly stops or cuts back. Symptoms can begin within 6 to 24 hours and range from shakiness and anxiety to seizures and delirium tremens. Your priorities are preventing seizures and injury, managing symptoms with medications per protocol, and supporting fluid and nutrition needs.

A · AssessmentD · DiagnosisP · PlanningI · InterventionE · Evaluation

Each care plan below follows the nursing process (ADPIE).

CARE PLAN 1 · NURSING DIAGNOSIS

Risk for Injury

Risk factors

Central nervous system overactivity during withdrawal
Risk of seizures
Risk of delirium tremens with confusion and hallucinations

PLANNING · EXPECTED OUTCOMES

Short-term goals

Client remains free of seizures and injury during withdrawal
Withdrawal score decreases with treatment within 24 to 48 hours

Long-term goals

Client completes withdrawal safely and is referred to ongoing treatment

ASSESSMENT

CIWA-Ar score as ordered
Vital signs, watching for rising heart rate, BP, and temperature
Tremors, sweating, agitation, and hallucinations
Time of last drink

INTERVENTIONS AND RATIONALES

INTERVENTION	RATIONALE
Give benzodiazepines per the withdrawal protocol based on the CIWA-Ar score	Benzodiazepines calm the overactive nervous system and prevent seizures.
Start seizure precautions	Withdrawal seizures most often occur in the first 12 to 48 hours.
Keep the room quiet, well lit, and low in stimulation	Less stimulation reduces agitation and misperceptions.
Report rising vital signs, fever, or new hallucinations right away	These can signal delirium tremens, which is a medical emergency.

EVALUATION

Client has no seizures or injuries
CIWA-Ar scores are trending down
Vital signs return to the normal range

CARE PLAN 2 · NURSING DIAGNOSIS

Imbalanced Nutrition: Less Than Body Requirements

Related to

Long-term alcohol use replacing food
Poor absorption of nutrients
Nausea and vomiting during withdrawal

As evidenced by

Low body weight
Low thiamine, magnesium, or potassium
Poor appetite

PLANNING · EXPECTED OUTCOMES

Short-term goals

Client eats at least 50% of meals within 72 hours
Electrolytes move toward normal with replacement

Long-term goals

Client follows a balanced diet and stays alcohol free

ASSESSMENT

Daily weight and food intake
Electrolytes including magnesium and potassium
Signs of Wernicke encephalopathy such as confusion, unsteady gait, and abnormal eye movements

INTERVENTIONS AND RATIONALES

INTERVENTION	RATIONALE
Give thiamine as ordered, before glucose-containing fluids	Thiamine helps prevent Wernicke encephalopathy, which glucose can trigger in a deficient client.
Replace electrolytes and give multivitamins and folic acid as ordered	Heavy drinking depletes key vitamins and minerals.
Offer small, frequent meals and antiemetics as ordered	Small meals are easier to tolerate during nausea.
Refer to a dietitian	A tailored plan supports recovery.

EVALUATION

Client eats at least half of meals
Electrolyte levels are improving
No signs of Wernicke encephalopathy

Practice this in Priority Care

Pick which client to see first, including one going into alcohol withdrawal.

Play Priority Care

Quick answers

Why give thiamine before glucose in a client with alcohol use disorder?

Giving glucose first can use up the little thiamine left and trigger Wernicke encephalopathy.

When are delirium tremens most likely?

Usually around 48 to 72 hours after the last drink. Watch for confusion, hallucinations, fever, and unstable vital signs.

For learning only. Individualize every care plan to your client, and follow your program, current guidelines, provider orders, and facility policy.