Ask An Expert: Susan (detox nurse)

Today’s expert is Susan, a Registered Nurse working in a medical detox facility in Victoria, BC Canada.

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Mrs D: Why would someone need a detox nurse?

Susan: That is such an interesting question, one that I have heard many times over the years. Registered nurses are trained to clinically assess a patient for any potential medical conditions such as pneumonia and other infections, ongoing high blood pressure, ongoing abdominal pain, dehydration, nutritional deficiencies and headache as these are all conditions that can create medical crises in ongoing withdrawal. For instance, severe dehydration has the potential to escalate body temperature and can be mistaken for an infection. Both need to be identified to the physician.

Mrs D: What are some of the things that occur for a patient when they are detoxing?

Susan: The patient will be extremely sensitive to both sound and light. For long term alcohol abuse, their nutrition will often have been severely neglected, so as well as dealing with severe nausea, they require good advice on how and what to eat in the early days of withdrawal. A short answer came from a man who had experienced withdrawal more than once – ‘It’s like having the worst case of the flu you have ever had. You think you’re going to die, but you’re not.” He was speaking of heroin withdrawal, however it is also consistent with alcohol withdrawal, just a lower degree of pain.

Mrs D: Broadly speaking what do you do when you are helping a patient detox?

Susan: The human body will detox itself and in doing so it creates certain signs and symptoms in the process such as tremors, nausea that may include vomiting, anxiety and agitation, high blood pressure and high heart rate, insomnia, and perspiring profusely. What I am doing in my nursing role is assessing these signs and symptoms, monitoring vital signs and level of withdrawal, providing physician ordered medication and working with the client through the high anxiety or mood swings of alcohol withdrawal. Medication can be given if the anxiety or agitation is becoming unmanageable by the patient. Sometimes no medication is needed! If a patient is able to accept redirection, we try removing them to a quiet room, teaching them relaxation or breathing exercises. There are times when I will just walk with a patient on the unit and talk quietly – guiding them away from any density of sound. Closing curtains, dimming lights, or using sunglasses may also decrease the need for medication.

Mrs D: For what period of time are you usually with a patient who is detoxing from alcohol? How long does it take until they are safely detoxed?

Susan: We provide continuous nursing care around the clock and throughout the week. The biggest concern is for seizures and is in the first three days after the last drink. Overall the length of time we assist a patient detox depends on the type of alcohol they’ve been drinking, the amounts, the length of time they’ve been drinking alcoholically and their age.

Mrs D: What usually occurs in the first 12 hours? 24 hours? 48 hours?

Susan: The greatest potential for seizure and delirium tremens is in those first 48 hours and it depends on the level of intoxication present when the patient comes for admission. We measure intoxication using a breathalyzer. Initial assessments include time of last drink, if there is any history of seizures or delirium tremens and medical history along with an assessment of vital signs (extremely high blood pressure is a frequent finding). In the first 12 hours assessments are done every 4 hours or more frequently based on nursing judgement. In the next 24 hours, the assessments may decrease; however if they do not seem to be decreasing, the physician is asked to reassess their medical needs. By 48 hours, the patient’s condition has usually improved dramatically allowing planning for post discharge. At this time we’ll educate the patient about Post Acute Withdrawal Syndrome (PAWS).

Mrs D: What sort of hallucinations, seizures and delirium tremens can patient’s experience?

Susan: Delirium tremens is a state of confusion, that can be accompanied by hallucination and seizures. Auditory hallucinations can be whispers, someone talking in the same room, or other false perceptions of sound. Visual hallucinations have been described as shadows or seeing deceased or not present family members. Seizures are pretty frightening for anyone that hasn’t experienced or witnessed them before. They can last for seconds or up to five minutes. It involves the full body, sudden unconsciousness, and all muscles contracting and relaxing rapidly. The longer it lasts the more dangerous it becomes, and the patient may require hospitalisation. The nursing goal is to prevent any of these symptoms from occurring.

Mrs D: How much of a detox nurses role is providing medical support and how much is emotional support?

Susan: I don’t know if I can quantify that balance. I try to provide medical and emotional supports based on the medical issues present and the level of anxiety and fear that a patient expresses. This is highly individual and is dependent on the coping skills of a patient, as well as the level of withdrawal. For those patients that are attempting sobriety for a first time, I believe I’m more alert for the emotional support that is required. That being said, for that same patient, because he or she is unknown medically to me, I am medically assessing in a more detailed manner.

Mrs D: In terms of emotional support, what sort of things do you say to a person who is finding it extremely hard going through a medical detox?

Susan: This is a tough question – it so depends of the person and the situation. For many, they only know of a ‘detox’ from stories and movies, and each person is so very different. Patients come in with a  variety of concerns such as child or parent care, financial issues, or extreme lack of support. One of the most frequent things I say is: ‘What is the worst thing that can happen?’ That often opens a problem solving conversation. I do ask what fear is the most immediate and then provide reassurance about how nurses and auxiliary staff will help them. Another question is: ‘Why did you want to get sober and come in here?’ as a reminder of what the original goal was, so that again they can be aware of their choices. I try never to chastise someone for any of their past – they are usually doing a pretty good job of that themselves.

Mrs D: Are their any advantages/disadvantages to you helping a person detox at home vs in a medical facility?

Susan: It’s always an advantages to be sleeping in your own bed – that is providing you have a bed and a home left to go to. When an individual has great family and/or community support, support from their physician and maybe a counselor, detox at home is probably the best route. Medically, a client may need more daily nursing attention especially if there are other medical disorders besides detoxification from alcohol.

Mrs D: Are family and friends allowed contact with an individual when they are going through detox?

Susan: The short answer is ‘yes’. I will qualify that by saying that should any family member be themselves intoxicated, whether alcoholically or socially they are not allowed at that time. If contact creates emotional upheavals that interfere with the individual getting through detox safely, it is recommended that they have no contact until they are stronger.

Mrs D: How can an individual assess whether they are safe to stop drinking on their own or whether they should detox with the assistance of a nurse? What symptoms should they look for?

Susan: I do not believe that any individual should stop drinking alcohol on their own due to the potential for seizures, delirium and in the worst case scenario, death. This is especially true if there are any other co-occurring medical issues – issues such as poorly controlled diabetes, or cardiac conditions. This can also include psychiatric disorders. The nursing care required is always under the direction of a physician – especially if medications or diagnostic evaluations are required. Symptoms include tremor, headache, nausea vomiting and/or diarrhea.

Mrs D: If someone stopped drinking on their own and experienced some of these symptoms, what steps can they take to help themselves?

Susan: Contact a physician for direction. Go to an emergency room.

Mrs D: What is the best part of your job?

Susan: Detox nursing challenges my abilities as a nurse with minimal use of pharmaceutical or technologies. It is the basic nursing care that I originally learned combined with the honour of sharing a lot of sadnesses, huge gratitude and a lot of laughter as people get well. A detox facility is often the closest many folks get to getting treatment or ever being in treatment. It is a nursing opportunity to care for and educate this individual in taking a really huge step forward when finances, family, friends – all the bridges – have dissolved. It is just a great career.