REVIEW ARTICLE

Alcohol withdrawal syndrome: knowledge and nursing care at a clinical surgery unit at a general hospital

Marciana Fernandes Moll^I; Carla Aparecida Arena Ventura^II; Fabiana Cristina Pires^III; Nathália Nunes Boff^IV; Cristiane Borges Facuri da Silva^V; Patrícia Costa de Oliveira^VI

^IUniversidade de Uberaba, Uberaba, MG, Brazil / Universidade de São Paulo, Escola de Enfermagem de Ribeirão Preto, PAHO/WHO Collaborating Centre for Nursing Research Development, Ribeirão Preto, SP, Brazil
^IIUniversidade de São Paulo, Escola de Enfermagem de Ribeirão Preto, PAHO/WHO Collaborating Centre for Nursing Research Development, Ribeirão Preto, SP, Brazil
^IIIUniversidade de Uberaba, Mário Palmério Hospital Universitário, Uberaba, MG, Brazil
^IVUniversidade de Uberaba, Mário Palmério Hospital Universitário, Uberaba, MG, Brazil
^VUniversidade de Uberaba, Mário Palmério Hospital Universitário, Uberaba, MG, Brazil
^VIUNIMED, Uberaba, MG, Brazil

Corresponding Author

ABSTRACT

OBJECTIVE: to investigate the nursing team's knowledge about alcohol withdrawal syndrome and to describe the care provided by this team to people with alcohol withdrawal symptoms admitted to the surgical clinic.
METHOD: descriptive and qualitative study. Twenty-two nursing professionals who worked in the surgical clinic of a general hospital answered a semi-structured interview that was recorded and later transcribed. Content analysis and thematic analysis were used to analyze the data.
RESULTS: the following categories were identified: "Knowldge of the Nursing Team on the alcoholic withdrawal syndrome" and "Care provided by the nursing team to persons with alcoholic withdrawal syndrome". The nursing team recognizes the signs and symptoms of alcohol withdrawal syndrome, but does not differentiate them into organic and psychic. Priority is given to mechanical containment associated with pharmacotherapy in the provision of care.
CONCLUSION: it is recommended to sensitize and qualify the nursing teams for an assistance based on the real needs of people with alcohol withdrawal syndrome is a challenge to be overcome to offer greater safety in the surgical process.

Descriptors: Nursing; Hospitalization; Alcohol Abstinence; Knowledge; Safety.

Introduction

The use of alcoholic beverage is a reality experienced in daily life, especially, during parties and celebrations. However, this consumption has become an intersectoral problem, since approximately 3.8% of all global deaths and 4.6% of disabilities in adjusted life years are related to alcohol use. The cost associated with the consequences described above is around 1% of the gross production of medium- and high-income countries⁽¹⁾.

Among the various justifications for the excessive consumption of alcohol, it is worth mentioning that this substance is lawful. Alcohol dependence is directly related to biological and cultural factors, since the symbolic value of alcohol defines how the individual's relationship with that substance is, being a process both individual, and social that will indicate the situations of the consumption of the drink⁽²⁾.

In general, alcohol consumption in the Americas is high compared to the rest of the world, since the considerable increase in alcohol consumption in the Americas has been progressive since 2010 and, by 2015, represents a percentage of 13% among women and 29% among men⁽³⁾.

Specifically, in Brazil, alcohol intake is characterized as a public health problem. In this perspective, a study shows that, in 2013, the prevalence was 13.7%, especially among young adults (aged between 18 and 29 years), whose prevalence is 18.8%⁽⁴⁾.

The above data demonstrate the growth of the consumption of alcoholic beverages in the Brazilian scenario, triggering alcohol dependence, considered a serious and frequent problem in the country. Alcohol dependence is understood as a set of cognitive and physiological behavioral phenomena due to the continuous or periodic, exaggerated consumption, of a psychoactive substance that the dependent feels difficult to control⁽⁵⁾.

Between 5% and 10% of deaths in Brazil are attributable to alcohol use, corroborating the finding that alcohol consumption is high. As a consequence, the health services have the constant presence of these consumers in search of care due to their own dependence or its complications⁽⁵⁾. It is also worth noting, that the risk of premature death is increased among people who abuse alcohol. A study that conducted a meta-analysis of 81 observational studies found a three-fold higher risk of death among people who have alcohol-related disorders⁽⁶⁾.

From this reality, in the health services, professionals can encounter people with alcohol abstinence syndrome (AAS), resulting from the interruption or reduction of alcohol consumption or when the individual has reached such a significant alcohol tolerance that the body unable to consume the doses that would be needed to avoid withdrawal⁽⁷⁾.

A set of acute psychic and physical signs and symptoms characterize the manifestations of said syndrome⁽⁸⁾. Among the psychic manifestations are: insomnia, psychomotor agitation, sensory perception disorders and seizures. This physical signs still include: tremors, sweating, blood pressure fluctuation, temperature greater than 38 ºC, malaise and headache^(7,9).

The onset of these signs and symptoms usually appears between 24 and 36 hours, ranging from six to 72 hours and lasting, on average, seven to ten days⁽⁹⁾, which may occur during hospitalizations in general hospitals. In Brazil, in recent years, it was possible to observe that only during hospitalization in health services, due to clinical, surgical and obstetric complications resulting from the additive behavior, professionals are informed that people are dependent on alcohol, which often, occurs when already begins with withdrawal manifestations⁽¹⁰⁾.

In the health services, the nursing team plays an important role of assistance and, when specifying the problem of alcohol abstinence, their actions are essential, especially in face of physical or psychological manifestations that require qualified and intensive care. It is necessary, therefore, that the nursing professionals value the scientific aspects to offer a care of excellence⁽¹¹⁾.

In this way, nursing needs to be attentive to the type of reception it will offer to people with alcohol withdrawal syndrome, since there is still a lot of prejudice and labeling of the society, besides the lack of preparation of a large part of the team. However, due to the great demand of the population with this problem, it is important that the nursing professional is alert to the identification of signs and symptoms, including in non-specialized health services, since it can facilitate care and interdisciplinary interventions to care of the needs due to alcohol withdrawal.

Objectives

To investigate the knowledge of the nursing team working in the surgical clinic of a general hospital on alcohol withdrawal syndrome and describe the care provided by the nursing team of the surgical clinic to people with alcohol withdrawal syndrome hospitalized in this sector.

Method

Descriptive study, of a qualitative approach, developed in a city with approximately 300 thousand inhabitants, located in the interior of Minas Gerais. The general hospital that constituted the research scenario had 225 beds, of which 25 are destined to the surgical clinic.

All the nursing professionals who worked in the surgical clinic were invited to participate in this research, totaling 25 professionals. Of these, 22 accepted to participate: 18 (80.32%) women, 16 (72.72%) married and six (27.27%) were single or divorced. There were 14 nursing technicians (63.63%) and eight Nurses (36.36%).

Data was collected, from August to October 2016, through a semi-structured interview. The issues involved the following aspects: knowledge about the signs and symptoms of alcohol withdrawal syndrome, assessment of these signs and symptoms by the nursing team and nursing care offered to people with this syndrome during hospitalization for surgical interventions.

Before the beginning of data collection, one of the researchers approached the nursing professional and invited him to participate in the study. After the acceptance, the interview was scheduled in a reserved place in the hospital itself and stipulated by the participant himself. These interviews lasted 45 minutes and were recorded, and later, transcribed.

The data was analyzed through Content Analysis, which constitutes a set of communication analysis techniques, aiming at the systematization of message content, making logical and justified deductions and considering emitter, context and effects⁽¹²⁾.

After this technique of analysis, the data were systematized and evaluated, also through the Thematic Analysis, in which contents were identified that converged to similar meanings and were grouped in thematic units ⁽¹³⁾. This method of analysis was based on the guidelines that establish the following phases: pre-analysis, material exploration and treatment of results through inference and interpretation⁽¹²⁾.

The investigation was initiated after the approval of the Research Ethics Committee of the University of Uberaba (CAAE: 57476116.0.0000.5145), which was succeeded by the clarification of all the participants about the objectives of the research and the signing of the Term of Free Consent and Enlightened. In order to protect participants' anonymity, they were identified by the letters NT (Nursing Technicians) with sequential numbers, and N (Nurses) with sequential numbers according to the order of the interviews.

Results

Through the analysis of the data, two thematic categories were identified: "The nursing team's knowledge about alcohol withdrawal syndrome" and "The care given by the nursing team to people with alcohol withdrawal syndrome".

The knowledge of the nursing team about alcohol withdrawal syndrome

The participants in this investigation highlighted the following signs and symptoms: tremors, tachycardia, sweating, fatigue, vomiting, dyspnea, inappetence, agitation, mental confusion, delusions, hallucinations, delirium, aggression, disconnected speech, depression and anxiety.

[...] they presented signs and symptoms such as: tremor, anxiety, tachycardia, agitation; yes, I can identify the signs and symptoms of this syndrome as: tremor, anxiety, tachycardia, agitation and flight [...].(N1); [...] aggression, speech disjointed, tremors in the body; but I can identify the signs and symptoms of this syndrome as: irritability, anxiety [...]. (N3); [...] agitation, confusion, aggression, disconnected speech, lack of appetite [...]. (N8); [...] tremor, agitation; but I can identify the signs and symptoms of this syndrome as: anxiety, tremors [...]. (T1); [...] tremors, sweating, agitation, nervousness, excess hunger, dry mouth, agitation, tremors, some presents confusion others do not, sweating, tachycardia, headache, may present convulsions. (T2)

The nursing team clearly recognizes the signs and symptoms of alcohol withdrawal syndrome, but, when one asked about the distinction between those that were related to the organic aspects and of those who were psychic, it was evidenced that this distinction was not clear.

It seems to me that everything is organic, is it not? (T5); I think nothing is psychic, otherwise they would have to go to Sanatorium. (E3); I have no idea. (T6)

This reality signals the need to train this team so that the distinction between the signs and symptoms is clear, as well as the risks they offer to the hospitalized person to perform a surgical intervention, which will make it possible to prevent complications in the pre, trans or post- operative. It becomes importante, considering that there are gaps in the knowledge of the nursing team that participated in this study, it is important to expose the care interventions given to people who present the syndrome.

Care provided by the nursing team to people with alcohol withdrawal syndrome

When the care provided to the person in alcohol withdrawal syndrome was raised, it was evidenced that the association of pharmacotherapy and mechanical restraint predominates, which is expressed in the following reports.

[...] depending on the agitation, it is necessary to perform mechanical containment in the individual. Monitor the same and perform the medications as prescribed [...]. (N2); [...] mechanical restraint, administration of sedation, muscle relaxants, according to medical guidelines [...].(N4); [...] reassure the person, administer CPM medications [...].(N8); [...] containment, medication according to medical evaluation and prescription [...].(T3); [...] sedation and restraint if prescribed by the doctor [...].(T13)

Only one participant mentioned promoting comfort and establishing a relationship centered on trust.

[...] trying to make the individual feel more comfortable and gain confidence, so that he feels more calm in the postoperative period. (T12)

This report indicates a specific intervention in the postoperative period, but a nurse mentioned an action to be performed also in the preoperative period, which contributes to the prevention of falls and trauma.

During the pre and post-operative it is important to reassure the person, guide the person to not leave the person alone, prevent the person from wandering alone to avoid suffering falls and traumas [...]. (N8)

Among all participants, only N8 included the companion during the pre- and post-operative periods of people with alcohol withdrawal syndrome, which means that this professional values the need for continuous monitoring of alcohol withdrawal syndrome, as well as the safety of hospitalized person, which qualifies the care provided.

In general, among the care provided to people with alcohol withdrawal syndrome, the use of medication associated with mechanical restraint is predominant, which may be necessary to provide the safety of the person in crisis and those close to him. However, Nursing care should not be restricted to interventions in moments of crisis, but be performed from the identification of the first signs and symptoms, to ensure more humanized and less coercive care.

Discussion

It is noted, considering that hospitalization in the general hospital leads to interruption of alcohol use, it is highly probable that a person dependent on this substance will develop into alcohol withdrawal syndrome within the hospital itself⁽¹⁴⁾.

The most common symptoms of alcohol withdrawal syndrome are tremors, gastrointestinal discomfort, anxiety, irritability, increased blood pressure, tachycardia, and autonomic hyperactivity. Other less common but, more serious symptoms are seizures, hallucinations, and delirium⁽¹⁴⁾.

The symptoms of this syndrome are autonomic instability characterized by tachycardia, hypertension, hyperthermia and sweating, as well as others such as tremors, fatigue, vomiting, dyspnea and lack of appetite⁽⁷⁾. Still, it is important to note that persistent autonomic dysfunction may result in secondary brain injury, and may be fatal ⁽¹⁵⁾.

The psychic symptoms result from anatomical and physiological changes in the brain that trigger neurobiological changes in the anatomical structure of the neurons, which interrupts the euphoric effect of alcohol and, therefore, the person no longer feels the pleasure of before, but is still impelled to seek the substance, once your body has adapted to its presence and will feel the lack in case of abstinence⁽¹⁷⁾.

Participants, in general, identify the signs and symptoms of alcohol withdrawal syndrome, emphasizing psychic symptoms, however, do not value the symptoms considered more serious. In addition, the participants do not distinguish organic signs and symptoms from psychics, which demonstrates a lack of knowledge. In this sense, a recent study clarifies that such symptoms may not be recognized in the daily clinical practice of nurses, especially if they do not have the specific knowledge⁽⁹⁾.

Nursing professionals continue to receive little or no information and training on issues related to alcohol withdrawal, which may be among the factors that lead the nurse to not distinguish between the signs and symptoms of possible alcohol-related health problems⁽⁷⁾.

The knowledge gap shows the fragility in the training of the participants, which can affect the quality of Nursing care to people with alcohol withdrawal syndrome, since this distinction on signs and symptoms influences care delivery⁽¹¹⁾.

The nurse is the professional who has more proximity to people hospitalized, from admission, to discharge, and this allows him to analyze carefully changes and evolution, whether organic or psychic⁽¹⁷⁾.

However, when it comes to people with alcohol withdrawal syndrome, the lack of knowledge about the particularities of this impairment compromises the provision of necessary care, which may occur due to deficiencies in training or by self-indulgence⁽¹⁷⁾. Thus, it is necessary that the nursing team be able to recognize physical and psychic signs and symptoms of alcohol withdrawal syndrome.

With regard to the nursing care offered to people with alcohol withdrawal symptoms, it is noted that there is a gradual change in understanding regarding the delivery of care in Psychiatry, since drug treatment is no longer seen as a method unique and exclusive, but, rather, a therapeutic resource allied to others, such as the formation of bond with hospitalized people⁽¹⁸⁾. However, this reality is not present in the daily care of most of the participants of this investigation, that prioritize the association of pharmacotherapy with the mechanical containment to provide care to the person in alcohol withdrawal syndrome.

It is added that the use of mechanical containment should be preceded by an overall assessment of the situation in which the person is, in order to verify the actual need for such a procedure, which may or may not be accompanied by chemical containment⁽¹⁹⁾.

In general, it is inferred that the participants of this investigation do not make this global assessment and do not consider the particular characteristics of each subject they are caring for, which is pointed out as fundamental in a study that approached the nurse's perception in caring for the person with disorder mental⁽²⁰⁾.

It is noteworthy that only one of the participants mentioned promoting comfort and establishing a trust-centered relationship to provide care for people with withdrawal symptoms, which is related to care based on the therapeutic relationship. This strategy is mentioned as essential for effective mental health nursing care and requires the promotion of attention, dialogue and demonstration of interest in the thoughts, feelings and behaviors of the people⁽¹⁸⁾. In this sense, the use of therapeutic communication should be valued throughout the hospitalization period, in order to establish a bond with the person and, thus, facilitate management in times of crisis⁽²¹⁾.

The surgical specificity of these individuals was addressed by one of the nurses, who included the companion during the pre- and post-operative periods of people with alcohol withdrawal, so that there is a partnership for the continuous monitoring of alcohol withdrawal syndrome and the safety of the person hospitalized.

However, the necessary care during the transoperative period was not pointed out by the participants. Such care is essential and needs to be valued and, in this sense, a recent study⁽²²⁾ evidenced that the development of pressure ulcer (PU) is one of the most frequent complications during the surgical procedure and among the intrinsic risk factors for its occurrence, clinical conditions such as: vasculopathies, hypertensive peaks, malnutrition and dehydration destabilize capillary perfusion and predispose to this complication. Thus, the need to provide care in the perioperative period is reinforced for people with alcohol withdrawal syndrome who tend to present the autonomic instability that generates these intrinsic factors. Thus, they represent priority care: use of protective resources (eg padded devices) to maintain the integrity of the skin during the surgical procedure; ensure effective blood perfusion by attaching extremities of upper or lower limbs; align the head to the spine and hip and assess the specific needs for maintaining the integrity of the skin, according to the position indicated for access to the surgical area⁽²²⁾.

In this perspective, the general hospital, as a new care setting in Psychiatry in Brazil allows the participation of the family/companion during the hospitalization time, and this new subject in daily care favors the evolution of the hospitalized person and enables the humanization of care^(23-24).

When considering that the alcohol withdrawal syndrome is a frequent reality in all health services, sometimes leading people to treatment, sometimes as an episode triggered during hospitalization, it is essential that the nurse incorporates a therapeutic and non-oppressive role, is based on the biomedical model that aims only the disease and not the subject in its social context, and considering the different dimensions that constitute the human being. Thus, at present, the professional must organize his actions based on the integrality of health care, based on a more flexible and creative approach, looking at a complex and unique care⁽²⁵⁾.

Conclusion

In general, it was evidenced that the nursing team recognizes the signs and symptoms of alcohol withdrawal syndrome, but does not distinguish them in organic or psychic, which makes it impossible to evaluate the risks to which these people are exposed and, therefore, interfere with care delivery, which focus on the mechanical containment associated with pharmacotherapy.

However, it is highlighted that one of the limitations of this study is that it occurred in only one health service, which restricts the possibilities of generalization. Regarding the choice of the surgical unit hospitalization unit, this can be seen from two perspectives: firstly, in the general hospital where the research was carried out, there are six Psychiatric beds that are located in the medical clinic and all the nursing staff working in this sector was able to provide nursing care in Psychiatry and the same training did not extend to other units of hospitalization, such as the surgical clinic; on the other hand, the alcohol withdrawal syndrome may interfere with the surgical intervention itself, in the pre, trans and postoperative periods, and it was not possible in this study to identify care focused on the mitigation of this aggravation, which would certainly broaden the discussion in this sense.

Even in view of the limitations mentioned above, it is believed that this study presented important results for the planning of educational interventions for nursing professionals working in the health services, especially in non-specialized services in Psychiatry. The findings found reinforce the need for all actions related to the care of hospitalized persons, especially those who will undergo surgical interventions, to be focused on meeting all the organic and psychic needs, especially with a focus on reducing the risks that the alcohol withdrawal syndrome can lead to the surgical process.

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Corresponding Author:
Marciana Fernandes Moll
E-mail: mrcna13@yahoo.com.br

Received: Sep 9^th 2018
Accepted: Dec 7^th 2018