Discharge protocol for alcohol withdrawal?

[SP1CEGRL]

Hello everyone!! Struggling nursing student here, hoping someone can provide me with some input.

I am working on a case study where I have to create a detailed discharge plan for my patient who was admitted with ETOH/Benzo withdrawal. He was admitted on 4/10 and they already had him cleared for discharge on 4/12. They had said something about him being on the CIWA protocol which I have been looking up and it's getting me very confused. He had an order for Librium 50mg which was Q6H PRN. The CIWA protocol seems to follow an around-the-clock schedule with tapering and I'm confused as why someone might only have a PRN order instead.

Also, if he was cleared for discharge on the second day already, would he be given a prescription for Librium to take home? And if he was receiving it PRN in the hospital, is that how they would go about sending him home with it or would they taper him off of it?

I greatly appreciate any help anyone can provide me with! Thank you for taking your time to read.

[Meriwhen, ASN, BSN, MSN, RN]

CIWA is not exactly a protocol. CIWA is the Clinical Institute Withdrawal Assessment scale for alcohol withdrawal. What CIWA does is that it scores the patient's withdrawal based on the patients signs/symptoms. That score gives the nurse an idea of the withdrawal acuity. The actual alcohol withdrawal protocol used to treat the patient can vary widely, depending on facility policy, the patient's health history, and the patient's history of ETOH abuse.

Look at why Librium is used. Librium or another long-acting benzo is used during ETOH withdrawal primarily to stave off delirium tremens (DT) and seizures. The patient is at greatest risk for developing DT during the first 72 hours after the BAC hits .000. Librium doesn't "detox" the patient. Nor is the goal of Librium use to make the patient as comfortable as possible, or to make the experience of detox as painless as possible. Librium is there to prevent a medical emergency.

For the record, DT is not the tremors that a freshly-detoxing patient may experience, though many will often term those shakes as being DT. In reality, the symptoms of DT are delirium, hallucinations, fever, altered LOC, tachycardia and seizures. It can result in coma or even death. DTs are serious.

A person with a shorter or less severe history of ETOH abuse may only require PRN Librium. A person who has been a hard-core drinker for 20-30 years may be put on a Librium taper since their likelihood of withdrawal complications and DTs are much higher. A person with a seizure history may be kept on round-the-clock Librium even if their ETOH history isn't that extensive, because their seizure threshold is already lower.

In the case of your patient, his ETOH history may not be that extensive and/or his withdrawal S&S not that severe as to need continual Librium.

As far as when he leaves: if Librium PRN was the only benzo he received while he was there, even if he did get it every 6 hours, there's no need to taper him. He only used it for two days, and that is not enough to develop a physical dependency on it. A mental dependency, yes: addicts are often quick to substitute one drug for another, and they may become attached to how the Librium dulls everything just like the ETOH did. Physical dependency in two days is highly unlikely.

Yes, he may feel somewhat uncomfortable once the Librium stops and he has to deal with his emotions and physical discomforts again, but he'll be fine.

Now, there are patients who do get sent home with Librium. If that's the case, usually it's done with instructions to taper the dose down (e.g., on day 1 it's taken QID, on day 2 it's TID, etc.).

Hope this helps.

[SP1CEGRL]

Thank you so much! I really appreciate it and it helped me a lot