Bad experience with CAGE protocol patient

[Stcroix, ASN, PhD, RN]

A while ago I got a new patient from ER who came in for pneumonia and his underlying afib. He was on CAGE protocol for people who drink ETOH regularly. I have had many such patients, but this one will always stick in my mind. At 8AM when I assessed him his score was zero and was completely A&O. I asked about his drinking and he told me he drank "a couple scotches each night". I probed further and didn't get the sense of a problem. I told him I would be assessing him every two hours for any signs of withdrawal and would treat him according to the symptoms he presented. Long story short, by 1PM he was in full blown detox, shaking uncontrollably, sweating, hallucinating, and spiking a low fever. I ended up swatting him even after 3 stiff doses of Ativan. The team decided he was stable enough to stay on my unit, but we were confused as to why he went so sour so quickly. A couple hours later a family member showed up and filled in some blanks. It turns out he had had his last drink 3 days before because he had felt so poorly with the pneumonia, and of course, drank many more than 2 drinks a day. I got him on the third and often nastiest day of detox. I learned a lesson to always ask "when was your last drink?" ( I assumed since he was just admitted the last drink was recently) and won't make that mistake again. A week has passed and I saw that patient, he is doing well and remembered me form that first day of admission. I'll not forget him soon. Care to make any more suggestions/ comments about this or your experiences?

[Rhody34]

Knowing when the patients last drink and how much he/she drinks is important to know. Those are always my first questions when I have a patient on CIWA protocol. Our hospital's policy is we can medicate per MD orders Q1H for CIWA scores greater than 5. I can score my patient at a 5 easy... 3 or 4 for anxiety, then a 1 any where basically.... bang, 5.... patient medicated. I don't mess around with patients who may be detoxing... I think it's important to have the ativan on board, because you just never know! Even if they appear to be doing fine!

[Esme12, ASN, BSN, RN]

When was your last drink is a big question to remember.....as nurses we learn every day.

[Anna Flaxis, BSN, RN]

First of all, thank you for spelling "withdrawal" correctly!

Second: Always, always, ask when their last drink was! Also, "a couple of scotches" is really nonspecific. He could mean a couple of standard sized shots of scotch, or a couple of 8oz. glasses of scotch.

Live and learn!

[Stcroix, ASN, PhD, RN]

I did do the 'multiply by two' formula in my expectations. However, that missing question about the last drink got me..