Domain 9. Coping-stress tolerance
Class 3. Neurobehavioral stress
Diagnostic Code: 00258
Nanda label: Acute substance withdrawal syndrome
Diagnostic focus: Acute substance withdrawal syndrome
Nursing Diagnosis Acute Substance Withdrawal Syndrome
Nursing diagnosis is an important part of delivering nursing care to patients that may be experiencing acute substance withdrawal syndrome (ASWS). Nursing diagnosis helps to identify any underlying conditions or concerns and can then guide the nurse in giving the best possible care. It is essential to ensure that nursing diagnosis is carried out in an accurate and timely manner to ensure a patient’s recovery.
NANDA Nursing Diagnosis Definition
Acute Substance Withdrawal Syndrome (ASWS) is a set of symptoms that result from the sudden discontinuation of substance use. Symptoms can range from mild to severe, including physical and psychological symptoms such as nausea, headaches, sweating, tremors, irritability, insomnia, hallucinations, paranoia and depression. During withdrawal, a patient may also experience more lasting psychological problems such as impairment of mental clarity, anxiety, and fatigue.
Defining Characteristics: Subjects and Objectives
Subjective characteristics of Acute Withdrawal Syndrome may include complaints of sleep disturbances, cravings for the substance, increased anxiety, agitation, decreased tolerance for activities, hopelessness, and difficulty concentrating. Other objective symptoms may include rapid pulse, high blood pressure, tremors, sweating, increase in appetite, and dilated pupils.
Related Factors
The related factors of a nursing diagnosis can largely depend on the type of substance that is being abused. Generally, related factors can include such things as the level of dependency on a substance, the period of time the individual has been using the substance, the amount of the substance that is being used as well as any other co-occurring medical issues or environmental factors.
At Risk Population
A number of populations are at risk of developing Acute Substance Withdrawal Syndrome, including individuals with a history of substance abuse, those in close proximity to others who are abusing substances, and those lacking social support systems. Additionally, individuals who have had long-term exposure to the substance due to their occupation, recreational activities, or prolonged hospital stays may also be at greater risk for ASWS.
Associated Conditions
ASWS is most often associated with alcohol and opioid withdrawal, however, it can be experienced with other psychoactive drugs or medication as well. Some associated conditions of ASWS include mood disorders, suicidal thoughts and behaviour, seizures, stroke, kidney failure, hypertension, and heart failure.
Suggestions of Use
When a patient is identified as exhibiting symptoms of Acute Substance Withdrawal Syndrome, the first step is to carry out a comprehensive physical and psychosocial assessment to help ascertain the type and extent of the withdrawal symptoms. Next, a risk assessment should be applied to determine the patient’s current level of risk. Medical detoxification should be initiated immediately in order to reduce any potential physical harm that could come from the severe and drastic withdrawal processes. Additionally, a thorough mental health evaluation should be conducted to assess the patient’s need for cognitive behavioural therapy as well as other forms of psychosocial intervention.
Suggested Alternative NANDA Nursing Diagnoses
Other alternative diagnoses for Acute Substance Withdrawal Syndrome include but are not limited to Delirium from Substance Abuse, Stress from Substance Abuse, and Post-Acute Withdrawal Symptoms. Additionally, the patient may be diagnosed with Imbalanced Nutrition: Less than Body Requirements or Activity Intolerance related to the patient’s lack of motivation or energy during withdrawal.
Usage Tips
Before making a nursing diagnosis for Acute Substance Withdrawal Syndrome, it is important to collect clear and specific data about the patient’s symptoms. Once data has been collected, the nurse can then develop an appropriate nursing plan tailored to the patient’s individual needs. As ASWS can often be a prolonged and complex process, it is vital that the patient is regularly monitored and that any complications are identified early and managed appropriately.
NOC Outcomes
The goal when working with Acute Substance Withdrawal Syndrome is to ultimately improve the patient’s quality of life. The Nurse Outcome Classification (NOC) determines the ultimate effect of the nurse’s interventions based on a set of patient outcomes. Outcomes for Acute Substance Withdrawal Syndrome may include: Improved Treatment Adherence, Improved Pain Tolerance, Improved Self-Care, Improved Knowledge of Substance Abuse, Improved Substance Usage Coping, enhanced Health Comfort, Improved Diagnostic Information, Improved Quality of Life, Improved Decision-Making Capacity, and Decreased Anxiety.
Evaluation Objectives and Criteria
Nurses should monitor and evaluate the patient’s progress throughout the treatment. This can be done by regularly assessing the patient’s adherence to treatment, their level of functioning, quality of life, and satisfaction of care. At the end of the treatment, nurses can evaluate the effectiveness of the interventions by looking at the differences between the patient’s initial status or data prior to the treatment and their current status or data post-treatment.
NIC Interventions
Nursing Interventions Classification (NIC) outlines the various types of nursing interventions available for the management of Acute Substance Withdrawal Syndrome. These may include but are not limited to: Health Promotion, Medication Management, Health Education, Psychoeducation, Cognitive Behavioral Therapy, Physiological Monitoring, Stress Reduction, Intervention Planning and Referral, Support System Enhancement, Social and Environmental Management, Safety and Comfort Measures, Nutritional Counseling, and Rehabilitation and Community Re-entry.
Nursing Activities
Nursing activities for Acute Substance Withdrawal Syndrome primarily involve providing comfort measures, education and support to the patient. The nurse should create an environment where the patient feels comfortable and safe, and is empowered to take control of own recovery. Aspects such as monitoring the patient’s physical and psychological functioning, ensuring they are following through with prescribed treatments, and providing education and referrals to additional services can play a crucial role in aiding a patient’s recovery from ASWS.
Conclusion
Acute Substance Withdrawal Syndrome can be a complex health concern and requires thorough assessment and tailored treatment strategies. Careful monitoring and evaluation are essential in order to ensure that the interventions adopted are successful and the patient is able to make a full recovery.
Five FAQs
- What is Nursing Diagnosis Acute Substance Withdrawal Syndrome?
Acute Substance Withdrawal Syndrome (ASWS) is a set of symptoms that result from the sudden discontinuation of substance use. Symptoms can range from mild to severe, including physical and psychological symptoms. - Who is at risk for Acute Substance Withdrawal Syndrome?
Individuals with a history of substance abuse, those in close proximity to others who are abusing substances, and those lacking social support systems are all at risk for developing Acute Substance Withdrawal Syndrome. - What are associated conditions of ASWS?
Associated conditions of ASWS include mood disorders, suicidal thoughts and behavior, seizures, stroke, kidney failure, hypertension, and heart failure. - What nursing interventions are available for ASWS?
Nursing interventions for Acute Substance Withdrawal Syndrome primarily involve providing comfort measures, education and support to the patient. The nurse should create an environment where the patient feels comfortable and safe and is empowered to take control of own recovery. - What is the ultimate goal of ASWS?
The goal when working with Acute Substance Withdrawal Syndrome is to ultimately improve the patient’s quality of life. The Nurse Outcome Classification (NOC) determines the ultimate effect of the nurse’s interventions based on a set of patient outcomes.
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