Assessments for Alcohol Use and Withdrawal (Nursing)

by Brenda Marshall, EdD, MSN, RN

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    00:01 So, before I was saying CAGE and AUDIT-C.

    00:04 So, these are very short questions that you can ask the patient and it will assess their alcohol use.

    00:15 So, the AUDIT-C is what is used in the medical center that I work in and it is looking at the - it came from clinical trials just to see how a person falls in alcohol use disorder.

    00:33 So, here are some of the questions we would ask.

    00:36 How often do you have a drink containing alcohol? You don't wanna be able to be very slangy and say, "[Inaudible 00:43] need a drink?" Because for many people, that has no meaning.

    00:47 So, how often do you have a drink containing alcohol? And the answers that they can give you or you can have it written down and it can be a survey that you add to them.

    00:59 It could be never, monthly, less than two times or four times a month, two or three times a week or four or more times a week.

    01:12 And only four and more times a week would raise a flag because two to three times a week is what people are considered social drinkers.

    01:22 They may go out to dinner once, twice a week or maybe even three times a week and have a glass of wine or a beer.

    01:31 Then, you're going to say, "Well, how many standard drinks containing alcohol do you have on a typical day? Most people don't know what a standard drink is.

    01:41 So, you say, "Oh, so, you drink beer.

    01:45 So, how many red cups would you say you have? A red cup as we know is almost a can and a half of beer. It's a large cup.

    01:54 But if they're drinking, if they say, "Well, I have - I have, you know, a martini." "Well, how many martinis would you say you have in a typical day?" And the answers are one or two, three or four, five to six, seven to nine or 10 or more.

    02:14 Then, you ask them, "How often do you have six or more drinks on one occasion?" Now, why do we ask six or more drinks? Because for women, binge drinking is considered four to five.

    02:27 For men, binge drinking is considered five to six and because of our body mass and the way that we metabolize alcohol differently.

    02:37 So, if we ask six or more, then, we've covered everyone and the answer would be daily or almost daily, weekly, monthly, less than monthly and never.

    02:49 So, think about why and when a person is going out to a wedding for example.

    02:58 That person might have six or more drinks on one occasion.

    03:02 The wedding may last from noon until 9:00 at night.

    03:06 There may be champagne. There may be the champagne toast, there may be wine.

    03:10 And so, when we're thinking about someone having that two or three times a year, we're thinking, their birthday, we're thinking weddings, we're thinking New Year's Eve.

    03:22 These are times where we're not looking at a person as having alcohol use disorder because of that usage.

    03:31 Now, if we have somebody who does the AUDIT-C or the CAGE which is, you know, asking, "If you're having a drink in the morning, do you drink every day? Are you having a hard time remembering what happened after you drink?" If we find that there is somebody who now, we are thinking may have alcohol use disorder, we move into a second assessment and that second assessment is called a CIWA and that stands for Clinical Institute Withdrawal Assessment for Alcohol and this assessment is done through the medical center, through your hospitals.

    04:20 It will be part of your electronic medical records and should be able to come up on its own and it looks at 10 different symptoms.

    04:56 Now, the CIWA is specific to see the likelihood of this patient going through withdrawal and the reason for that is because the nurse needs to be able to assess this patient who we know now has alcohol use disorder and is likely to have some withdrawal.

    05:17 Remember, 50% of people who have alcohol use disorder have some level of withdrawal and we're going to intervene early enough so that 3 to 5% of that population that would go on to having seizures and requiring ICU bed will not go into that late stage of withdrawal.

    About the Lecture

    The lecture Assessments for Alcohol Use and Withdrawal (Nursing) by Brenda Marshall, EdD, MSN, RN is from the course Alcohol Use Disorder (Nursing).

    Included Quiz Questions

    1. 4–5
    2. 5–6
    3. 6–7
    4. 3–4
    1. CIWA
    2. CAGE
    3. COWS
    4. AUDIT-C
    1. AUDIT-C
    2. CIWA
    3. COWS
    4. CAGE

    Author of lecture Assessments for Alcohol Use and Withdrawal (Nursing)

     Brenda Marshall, EdD, MSN, RN

    Brenda Marshall, EdD, MSN, RN

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