A 68-year-old client is receiving care on a surgical unit 48 hours following a bowel resection. The nurse observes the client exhibiting profound diaphoresis, coarse bilateral tremors, a heart rate of 138 beats/minute, and severe agitation. The client points to the corner of the room, frantically stating that spiders are crawling up the walls. The client's spouse casually mentions, "I forgot to bring the anxiety pills they take every day at home... alprazolam, I think." Which of the following nursing actions are appropriate to include in the client's immediate plan of care? (Select all that apply.)
- Implement seizure precautions by padding the side rails and ensuring suction equipment is readily available.Answer
- Administer prescribed intravenous lorazepam based on a symptom-triggered assessment scale.Answer
- CRequest a prescription for an antipsychotic medication such as haloperidol to rapidly manage the acute hallucinations.
- DInstruct the unlicensed assistive personnel (UAP) to monitor and record the client's neurological status and orientation every 15 minutes.
- EExplain to the family that sudden confusion and hallucinations are expected age-related complications of prolonged general anesthesia.
- Maintain a low-stimulation environment by dimming the room lights, closing the door, and limiting unnecessary interruptions.Answer
Answer
The appropriate nursing actions are to implement seizure precautions, administer a prescribed benzodiazepine taper, and maintain a low-stimulation environment.
The client is exhibiting classic manifestations of severe sedative-hypnotic (benzodiazepine) withdrawal, which typically peaks 24 to 72 hours after the abrupt cessation of a short-acting agent like alprazolam. Symptoms include profound autonomic hyperactivity (tachycardia, diaphoresis), coarse tremors, severe agitation, and perceptual disturbances such as visual hallucinations. This constitutes a life-threatening medical emergency due to the high risk of withdrawal seizures. The most appropriate nursing actions address both immediate safety and the underlying physiological deficit. Implementing strict seizure precautions (padding side rails, ensuring suction is available) is essential for physical safety. Administering a prescribed substitution taper with a long-acting benzodiazepine (such as lorazepam) based on a symptom-triggered assessment scale is the pharmacological standard of care to safely manage neuro-excitability. Finally, maintaining a low-stimulation environment significantly reduces sensory triggers that could exacerbate agitation or lower the seizure threshold.
Step-by-Step Solution
Key Concept
Sedative-Hypnotic Withdrawal Management and Prioritization