Alcohol withdrawal: what happens when, and how the nurse keeps the client safe
NCLEX-RN topic: Substance use and other dependencies
- Mild withdrawal usually starts 6 to 24 hours after the last drink.
- Hallucinations can start at 12 to 24 hours, seizures at 6 to 48 hours.
- Delirium tremens usually starts at about 2 to 4 days; it is an emergency.
- Score symptoms with the CIWA-Ar; give benzodiazepines and thiamine as prescribed.
- Use fall and seizure precautions and keep the room quiet.
Key facts
- Clients often underreport drinking, so withdrawal can appear unexpectedly in clients admitted for other problems.
- Mild withdrawal includes anxiety, tremor, sweating, insomnia, nausea, tachycardia and rising systolic blood pressure, starting 6 to 24 hours after the last drink.
- Withdrawal hallucinations, usually visual such as insects or animals, typically begin 12 to 24 hours after the last drink.
Show all 7 key factsShow fewer
- Withdrawal seizures can occur 6 to 48 hours after the last drink; delirium tremens usually begins about 2 to 4 days after it and is a medical emergency.
- The CIWA-Ar scores 10 items; a score under 10 usually does not require medication, but protocols vary by agency.
- Benzodiazepines such as lorazepam, diazepam and chlordiazepoxide treat withdrawal and help prevent seizures and delirium tremens.
- Thiamine is given to prevent Wernicke encephalopathy (confusion, ataxia, nystagmus); magnesium and other electrolytes are replaced as prescribed.
Quick check1 question · 2 more at the end
A client with a long history of heavy alcohol use is being treated for alcohol withdrawal. The nurse notes new confusion, an unsteady gait and jerky, involuntary eye movements. Which prescription does the nurse expect the provider to give?
Correct answer: C.
Confusion, ataxia and nystagmus in a client with alcohol use disorder point to Wernicke encephalopathy, an acute, life-threatening condition caused by thiamine (vitamin B1) deficiency. Thiamine replacement treats it; untreated, it can progress to Korsakoff syndrome, a chronic memory disorder. The other drugs are used for opioid overdose or opioid withdrawal.
A Naloxone reverses opioids; it does not treat thiamine deficiency.
B Clonidine relieves autonomic symptoms of opioid withdrawal, not Wernicke encephalopathy.
C Correct: thiamine treats and prevents Wernicke encephalopathy, which presents with confusion, ataxia and nystagmus.
D Buprenorphine treats opioid withdrawal and opioid use disorder, not thiamine deficiency.
Full lesson
Each part starts with its main idea. Open a part when you want the details.
The short answer: Mild alcohol withdrawal (tremor, sweating, anxiety, tachycardia) usually starts 6 to 24 hours after the last drink. Hallucinations can appear at 12 to 24 hours, seizures at 6 to 48 hours, and delirium tremens usually after about 2 to 4 days. The nurse scores symptoms with the CIWA-Ar, gives benzodiazepines and thiamine as prescribed, and uses fall and seizure precautions.
1 Why does alcohol withdrawal show up on every unit?Alcohol withdrawal often appears in clients admitted for something else entirely. 1 min
Alcohol withdrawal often appears in clients admitted for something else entirely. Alcohol use disorder may affect up to 32% of hospitalized clients, and clients often underreport how much they drink. About half of people with alcohol use disorder have withdrawal when they cut down or stop. Up to 20% develop serious problems such as hallucinations, seizures or delirium tremens.
So when a surgical or medical client becomes shaky, sweaty and restless a day after admission, think of withdrawal and notify the provider.
2 What happens, and when?Withdrawal follows a rough clock that starts at the last drink. 1 min
Withdrawal follows a rough clock that starts at the last drink. Knowing the clock tells you what to watch for next.
| Time after last drink | What to expect |
|---|---|
| 6 to 24 hours | Mild withdrawal: anxiety, tremor, sweating, insomnia, nausea, vomiting, tachycardia, rising systolic BP; usually resolves in 1 to 2 days if untreated |
| 12 to 24 hours | Withdrawal hallucinations, usually visual (often insects or animals) |
| 6 to 48 hours | Withdrawal seizures, usually generalized |
| About 2 to 4 days (MedlinePlus: 48 to 96 hours; Open RN: 72 to 96 hours) | Delirium tremens (DTs): sudden severe confusion, agitation, fever, severe tachycardia, high blood pressure, drenching sweats |
DTs is a medical emergency, best managed in intensive care. With good treatment, deaths are much less common than in the past, but they still occur from heart problems, high fever, aspiration and fluid or electrolyte imbalance. DTs can also start later, up to 7 to 10 days after the last drink.
3 How does the nurse measure withdrawal?The CIWA-Ar (Clinical Institute Withdrawal Assessment for Alcohol, revised) turns symptoms into a number. 1 min
The CIWA-Ar (Clinical Institute Withdrawal Assessment for Alcohol, revised) turns symptoms into a number. It rates 10 items: nausea and vomiting, tremor, sweats, anxiety, agitation, touch, hearing and visual disturbances, headache, and orientation. Each is scored 0 to 7, except orientation, which is scored 0 to 4.
The score guides symptom-triggered treatment: the nurse gives medication when the score reaches the level set by the agency protocol. A score below 10 usually does not need medication. Rising temperature, pulse and blood pressure are also signs of withdrawal to report.
4 What the nurse doesAfter airway, breathing and circulation, safety is the top priority. 1 min
After airway, breathing and circulation, safety is the top priority.
- Assess: Vital signs and CIWA-Ar per protocol. Also check orientation and look for hallucinations, nausea and vomiting, and fluid status.
- Prevent injury: Use fall precautions, because clients with vomiting or diarrhea often try to get to the bathroom alone. Use seizure precautions: bed in the lowest position, padded side rails, and suction and oxygen at the bedside. Keep the room quiet with little stimulation, dim the lights at night and avoid caffeine to support rest.
- Give medications as prescribed: A benzodiazepine (lorazepam, diazepam or chlordiazepoxide) calms agitation and helps prevent seizures and DTs. Give thiamine, often IV with dextrose, and replace magnesium, potassium and fluids as prescribed. Heavy drinking depletes thiamine and magnesium, and normal blood magnesium is 1.7 to 2.2 mg/dL.
- Watch for Wernicke encephalopathy: New confusion, an unsteady gait (ataxia) and jerky eye movements (nystagmus) point to thiamine deficiency. Untreated, it can progress to Korsakoff syndrome, a lasting memory disorder.
- Teach: Once the client is stable, talk without judgment about treatment, support groups and recovery services.
Common mistakes
The traps students fall into most. Read these before you practice.
Watch out: Delirium tremens is a later complication (days 2 to 4), not the first sign; tremor and anxiety come first.
Watch out: Withdrawal hallucinations are usually visual, not mainly auditory.
Watch out: A quiet, low-stimulation room helps; a bright, busy, noisy room makes withdrawal worse.
Watch out: Wernicke encephalopathy is acute and treatable with thiamine; Korsakoff syndrome is the chronic, irreversible memory disorder it can lead to.
Watch out: After airway, breathing and circulation, safety (falls and seizures) comes next, ahead of teaching about drinking.
How to remember it
Tie each complication to its window after the last drink, and you will know what to prepare for next. The hook "Shakes, Sees, Seizes, then DTs" lists them roughly in order:
- Shakes: tremor (6 to 24 h)
- Sees: hallucinations (12 to 24 h)
- Seizes: seizures (6 to 48 h)
- DTs: delirium tremens (about 2 to 4 days)
Self-check:
- A client's last drink was 20 hours ago. Name two complications they are in the window for right now.
- List three parts of seizure precautions.
- Name the vitamin that prevents Wernicke encephalopathy, and the three signs of Wernicke encephalopathy.