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QUEENSLAND CORRECTIVE SERVICES ADMINISTRATIVE FORM – ALCOHOL WITHDRAWAL ASSESSMENT REPORTING RECORD Availability: Public Implement Date: 28 August 2006 Surname Given Names Date of Birth ID No. Time of Assessment History of: Date of Assessment Allergies (in red) Place of Assessment Seizures (Y/N date) Referral Source: Presenting Problem/Need .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. ALCOHOL AND DRUG USE SUMMARY FOR THE PRECEDING 24 HOURS/14 DAYS PRIMARY DRUG SECONDARY DRUG/S DRUG NAME TIME LAST USED AMOUNT USED IN PRECEDING 24 HOURS NUMBER OF DAYS USED IN PRECEDING 2 WEEKS AVERAGE DAILY AMOUNT USED IN PRECEDING 2 WEEKS DRUG HISTORY DRUG NAME LAST USED AMOUNT Alcohol Withdrawal Assessment Reporting Record FREQUENCY 840998912 DURATION Version 01 ROUTE PRESCRIBED Page 1 of 17 PHYSICAL ASSESSMENT RECORD Surname Given Name Date of Birth ID No. BASELINE OBSERVATIONS Temp Pulse BP BAL Skin Pupils AWS Urinalysis UT Results SUMMARY OF CURRENT HEALTH STATUS (Physical / Mental) .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. PREVIOUS WITHDRAWAL HISTORY (including seizures/delirium tremens & treatment) .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. NURSING DIAGNOSIS .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. INITIAL MANAGEMENT PLAN .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. Name (Print) Alcohol Withdrawal Assessment Reporting Record Signature 840998912 Version 01 Page 2 of 17 ALCOHOL CONVERTER AMOUNT OF ETHANOL IN COMMON BEVERAGES BEER 1 oz = 28.5 mls 3.5Ioz = 100.0 mls 5 oz = 142.5mls 7 oz = 199.5 mls 10 oz = 285.0 mls (1 Can/Stubby) 13 oz = 375.0 mls (1 Lge Bottle) 26 oz = 750.0 mls 1 Ctn (24) Stubbies = 1 Ctn (12 Lge Bots 10 oz Glass (Middies) 1 = 285.0 mls 5 = 1425.0 mls 10 = 2850.0 mls 15 = 4275.0 mls 20 = 5700.0 mls FORTIFIED WINES ( PORT, SHERRY etc.) = = = = = 1.06 gms 3.75 gms 5.30 gms 7.40 gms 10.60 gms = 13.80 gms = 27.60 gms 331.2 gms = 331.2 gms = = = = = 10.6 gms 53.0 gms 106.0 gms 159.0 gms 212.0 gms 15 oz Glass (Schooners) 1 5 10 15 20 = = = = = = = = = = = = = 1 oz = 3.5 oz = 26 oz = 35 oz = 70 oz = 140 oz = 4 oz Serve = = = = = = 15.9 gms 79.5 gms 159.0 gms 238.5 gms 318.0 gms ½ oz 1 oz 3.5 oz 5 oz 13 oz 26 oz 40 oz 375.0 mls 2250.0 mls 4500.0 mls 9000.0 mls = = = - 13.8 gms 82.8 gms 165.6 gms 331.2 gms LIQUEURS = = = = 27.6 gms 165.6 gms 331.2 gms 662.4 gms 750.0 mls 4500.0 mls 9000.0 mls 18000.0 mls = = = = = = = 3.80 gms 13.40 gms 98.80 gms 134.00 gms 268.00 gms 536.00 gms 7.60 gms TABLE WINES (MOSELLE, CLARET etc) 427.5 mls 2137.5 mls 4275.0 mls 6412.5 mls 8550.0 mls 26 oz Large Bottles 1 6 12 24 28.5 mls 100.0 mls 750.0 mls 1 litre 2 litre 4 litre 60 ml 28.5 mls 100.0 mls 750.0 mls 1 litre 2 litre 4 litre 120 ml = = = = = = = 2.25 gms 7.94 gms 58.50 gms 79.40 gms 158.80 gms 317.60 gms 9.00 gms SPIRITS (GIN, VODKA, RUM, WHISKY etc) 13 oz Can/Stubbie 1 6 12 24 1 oz = 3.5 oz = 26 oz = 35 oz = 70 oz = 140 oz = 2 oz Serve = Alcohol Withdrawal Assessment Reporting Record = = = = = = = 14.25 mls 28.50 mls 100.00 mls 142.50 mls 375.00 mls 750.00 mls 1140.00 mls = = = = = = = 3.60 gms 7.20 gms 25.40 gms 36.00 gms 93.60 gms 187.20 gms 288.00 gms = = = = = 28.50 mls 57.00 mls 100.00 mls 375.00 mls 750.00 mls = = = = = 12.40 gms 24.80 gms 43.50 gms 163.50 gms 327.00 gms METHYLATED SPIRITS (Approx. 98% Ethyl Alcohol) ½ oz = 14.25 mls 1 oz = 28.50 mls 3.5 oz = 100.00 mls ½ Litre = 500.00 mls 21 oz = 600.00 mls 35 oz = 1 Litre = = = = = = 11.20 gms 22.40 gms 78.20 gms 391.00 gms 470.00 gms 782.00 gms 1 oz 2 oz 3.5 oz 13 oz 26 oz 840998912 Version 01 Page 3 of 17 NEUROLOGICAL OBSERVATIONS Name:............................................................... ID No................................................................ Date of Birth.............................................. Facility:...................................................... DATE TIME EYES OPEN C O M A BEST VERBAL RESPONSE S C A L E BEST MOTOR RESPONSE Spontaneous 4 To speech 3 To pain 2 None 1 Orientated 5 Confused 4 Inapp. Word 3 Incomp sounds 2 None 1 Obeys 5 Localise pain 4 Flexion to pain 3 Extension to pain 2 None 1 EYES CLOSED BY SWELLING E.N.T OR TRACHE INSITU USUALLY RECORD THE BEST ARM RESPONSE Time Blood Pressure Temperature Pulse Respirations P U P I L S RIGHT SIZE + = reacts REACTION - = no reaction LEFT SIZE C = Eye closed REACTION 1=• 2=• 3= • 4= • 5= • 6= • 7= • • 8= PUPIL SCALE (mm) Normal power A R M S Record right (R) and left (L) separately if there is no difference between the two sides. Mild weakness Severe weakness Spastic flexion Extension No response Normal power L Mild weakness Alcohol Withdrawal Assessment Reporting Record 840998912 Version 01 Page 4 of 17 E G S Severe weakness Extension No response MEDICATION CHART Correctional Facility:................................................................................................ PATIENT IDENTIFICATION SURNAME:..................................................................... GIVEN NAMES:.............................................................. D.O.B:............................................................................. MEDICATION REVIEW DUE.......................................... MEDICATION REVIEWED.............................................. Please Print Prescriptions must be printed in ink No erasures or white out permitted ADVERSE ALCOHOL WITHDRAWAL DRUG MONTH / YEAR NATURE OF REACTION DRUG REACTIONS Date P.R.N. MEDICATIONS (PRESCRIBED) Time Given By Date Time Given By Date Time Given by Date Time Given By SEE REGULAR PRESCRIPTIONS OVER PAGE DRUG DIAZEPAM Dose and Frequency Route Max. 60mg/day 5 - 10mg Q2hr prn Oral Doctor's Signature Start Date DRUG METOCLOPRAMIDE Dose and Frequency Route 10mg tds prn Oral/IM Doctor's Signature Start Date ONCE ONLY DRUGS DATE TIME DRUG Alcohol Withdrawal Assessment Reporting Record DOSE ROUTE 840998912 DOCTOR Version 01 GIVEN BY TIME GIVEN Page 5 of 17 SURNAME: GIVEN NAME: ALCOHOL WITHDRAWAL REGULAR PRESCRIPTIONS R = REFUSEDA = ABSENT I = ISSUED D.O.B: S=STARVING N=NO STOCK DAY, MONTH, YEAR TIME Drug THIAMINE Route Ora / / I M Dose 100mg Drs Signature Start Date Drug MULTIVITAMIN Route Oral Dose 1 Tab tds Drs Signature Start Date Drug Route Dose Drs Signature Start Date Drug Route Dose Drs Signature Start Date Drug Route Dose Drs Signature Start Date Drug Route Dose Drs Signature Start Date Drug Alcohol Withdrawal Assessment Reporting Record 840998912 Version 01 Page 6 of 17 Route Dose Drs Signature Start Date Drug Route Dose Drs Signature Start Date Name DOB Non Prescription (P.R.N.) Medications DATE TIME MEDICATION & DOSE Med Review Due: Med Reviewed: GIVEN BY DATE TIME MEDICATION & DOSE GIVEN BY Paractamol 1g qid prn DRUGS WITH VARIABLE DOSE Alcohol Withdrawal Assessment Reporting Record 840998912 Version 01 Page 7 of 17 DRUG DRUG ROUTE ROUTE DATE TIME DOSE DOCTOR GIVEN BY DATE TIME DOSE DOCTOR GIVEN BY Guide to the use of Alcohol Withdrawal Scale (AWS) If the prisoner's history or presentation suggests a possibility of alcohol withdrawal, the prisoner should be commenced on the AWS. If a possibility of benzodiazepine or barbiturate withdrawal is suggested then the AWS may be used to monitor the prisoner whist they are managed on their decreasing Diazepam or Phenobarbitone regime. On Admission 1. Take and record vital observations on the AWS record to act as base line data. 2. If the prisoner is showing signs and symptoms of the withdrawal syndrome; please continue recording data on the AWS record. 3. If the prisoner is not withdrawing, please transfer to the general purpose observation record. 4. Observe informally (no recording of data) 2/24 for signs of change; e.g. decreasing or increasing agitation or any other significant behavour (e.g. increase anxiety, increased thirst, beginnings of nausea and vomiting). Formal, recorded observations to be done tds or 4/24 according to the RN's or Doctor's clinical judgement. Mild Withdrawal is considered to be a score of 1 - 5 1. Take and record observations 4/24 and keep the prisoner in constant view and continue appropriate nursing care and counselling. 2. Provide a comfortable low stimulus, well lit environment. Monitor fluid intake (encourage oral fluid - H2O as tolerated). Administer vitamins (thiamine 100 mg daily in particular for alcohol withdrawal, parenterally or oral). 3. If the prisoner does not progress from the mild stage, after 24 hours, please continue on 4/24 down to tds observations according to the RN's or Doctor's clinical judgement. 4. Sedation for mild withdrawal is not usually necessary but my be indicated for prisoners unable to be managed in a prison hospital setting (i.e. alone Alcohol Withdrawal Assessment Reporting Record 840998912 Version 01 Page 8 of 17 in their cell). 5. If sedation is considered necessary, give Diazepam 5-10mg, every 6-8 hours for the first 48 hours. Dose will depend on the severity of withdrawal, body weight and the presence of any concurrent illness. Moderate withdrawal is considered to be a score of 6 - 10 1. Take observations 2/24. Notify the Doctor. 2. Continue appropriate nursing care and counseling. 3. Administer Diazepam 5-10 mg, every 2 hours until sedation is achieved, then stop. Review after 4 hours. No more than 60mg should be given within a 24 hour period without a Doctor's review. 4. Withdrawal seizures may occur at this point. Prisoners with a history Epilepsy, not on regular anticonvulsants, or who have suffered frequent seizures on withdrawal in the past, may have Carbamazepine 200mg tds added to their Diazepam regime by the Doctor. Major withdrawal is considered to be a score of more than 11 1. Notify the Doctor immediately. 2. Take and record observations 1/24, maintain reality based communication to assist with prisoner orientation. 3. Commence neurological observations 1/24 or, more frequent intervals according to the prisoners neurological status. 4. Manage with intensive nursing care in a prison hospital setting with facilities for resuscitation. Transfer if Centre facilities are inadequate. 5. Increase nursing support measures to deal with the physical and psychological manifestations of this stage i.e. dehydration, hypertension, tachyarrhythmias and acute mental disturbance. 6. Please be aware of potential seizure episodes and possibly impending Delirium Tremens (>15 AWS score). 7. Administer Diazepam 5-20mg every 1-2 hours prn until the prisoner is sedated and commence the prisoner on a decreasing Diazepam regime as per the Doctor's orders. Administer haloperidol 5-10mg as ordered for severe mental disturbance (psychosis). These medications may require intravenous administration by the attending Doctor. Notify the Doctor immediately if: 1. The blood pressure measurement indicates moderate Alcohol Withdrawal Assessment Reporting Record 840998912 Version 01 Page 9 of 1 to severe hypertension (> 110mm Hg diastolic) 2. The respiratory function becomes compromised. 3. Any arrhythmias are detected or suspected. 4. The consciousness level is less than 2 on the Level of Consciousness Scale (AWS, Item 12) or less than 10 on the Glasgow Coma Scale. 5. The prisoner sustains any injury. 6. The BAL is very high (greater than or equal to 0.3g/100 mls) 7. The accounting nurse is concerned about the prisoner's condition. RATING SCALE GUIDE FOR THE ALCOHOL WITHDRAWAL SCALE Item 1 - Perspiration 0. No abnormal sweating. 1. Moist skin. 2. Localised beads of sweat on face, arms, chest etc. 3. Whole body wet from perspiration. 4 Profuse maximal sweating, clothes and linen are wet. Item 2 - Tremor 0. No tremor. 1. Slight intentional tremor. Alcohol Withdrawal Assessment Reporting Record 840998912 Version 01 Page 10 of 1 2. Constant slight tremor of upper extremities. 3. Constant marked tremor of extremities. Item 3 - Agitation 0. Rest, normally during day, no signs of restlessness. 1. Slight restlessness, cannot sit still for long. 2. Moves constantly looks tense, wants to get out of bed, but obeys requests to stay in bed. 3. Constantly restless, gets out of bed for no obvious reason, returns to bed if taken. 4. Maximally restless, aggressive and disruptive, ignores requests to stay in bed. Item 4 - Anxiety 0. Calm. 1. Slight apprehension, focuses on self. 2. Mild anxiety. · expressing feelings of concern · evidence of increased arousal · increased questioning · increased awareness and attending · mild restlessness 3. Moderate anxiety. · increased level of arousal with expectation of a threat to self · verbalises expectation of danger · tremulous voice, pitch changes · increased rate and quantity of verbalisation · pacing · increased muscle tension, hand tremor · sleep and eating disturbance · increased vital signs · narrowed focus of attention 4. Severe anxiety (panic). · expresses feelings of unfocused severe dread or concern · inappropriate or absence of verbalisation · purposeless activity or immobilisation · perceptual focus scattered, fixed in inability to focus on reality Alcohol Withdrawal Assessment Reporting Record 840998912 Version 01 Page 11 of 1 · · · · increased vital signs increased muscle tension dilated pupils distinct pallor Item 5 - Pulse and Temperature 0. Pulse rate below 90 per min, temperature 37c. 1. Pulse rate 90 - 109 per min, temperature 37.1 - 37.5C 2. Pulse rate 110 -129 per min, temperature 37.6 - 38C. 3. Pulse rate 130 -149 per min, temperature 38.1 - 38.4C (Usually tremor of extremities occur at this stage). 4. Pulse rate above 149 per min, temperature above 38.5 C. Note, score as one item: if pulse is 115 and temp is 37.4, score from the higher value e.g. score 2 (not 1). Item 6 - Blood Pressure Diastolic Rating Guide 0. Diastolic less than 95 mm Hg 1. 95 - 105 mm Hg - Mild Hypertension 2. 110 - 115 mm Hg - Moderate Hypertension 3. 120 mm Hg and above - Severe Hypertension Item 7 - Perceptual Disturbance 0. No evidence of perceptual disturbance. 1. Distortions of real objects, aware that these are not real if pointed out (Illusions). 2. Appearance of totally new objects on perceptions, aware that these are not real if pointed out. 3. Believes that the hallucinations are real but still orientated in place and person. 4. Believes self to be in a non-existent environment, is preoccupied and cannot be diverted or reassured. Item 8 - orientation 0. The patient is fully orientated in time, place and person. Alcohol Withdrawal Assessment Reporting Record 840998912 Version 01 Page 12 of 1 1. 2. The patient is orientated in person, but not sure where he is, or what time it is, but can be orientated if place and time can be pointed out. Orientated in person but disoriented in place and time, despite cognitive information. 3. Doubtful personal orientation, disorientated in time and place; (there may be short periods of lucidity). 4. Disorientated in time, place and person, no meaningful contact can be obtained. A.W.S. Total 1-5 = Mild Withdrawal 6 - 10 = Moderate Withdrawal 11 or > = Major Withdrawal 15 or > = ? Impeding Delirium Tremens Item 9 - Bal 1. Record the Blood Alcohol Level (BAL). 2. BAL Levels (measured in grams of ethanol per 100 millilitres blood). 3. Blood alcohol level must always be matched against the clients level of coherence and body movements. e.g. BAL of 0.05 to 0.08 plus apparently normal behaviour = possible mild to moderate level of tolerance. BAL of 0.08 to 0.15 and apparently normal behaviour = probable moderate level of tolerance. BAL of 0.15 or above, and apparently normal behaviour is diagnostic of a high level of tolerance. Alcohol Withdrawal Assessment Reporting Record 840998912 Version 01 Page 13 of 1 Estimate of Neuroadaptation By using the BAL and other relevant subjective and objective data the nurse can infer the degree of neuroadaptation of the prisoner and thus estimate what stage of the withdrawal continuum the prisoner is likely to reach. As the prisoner's degree of neuroadaptation increases so to does both their level of tolerance to alcohol and their risk of experiencing the alcohol withdrawal syndrome. The estimate of neuroadaptation is not charted on the AWS record but, highlighted in the nurse's recorded report. Item 10 - Blood Pressure 1. Take and record the measurement of the blood pressure in significant units, e.g. 120/85 (not 118/82) 2. In most cases a rising blood pressure will broadly correlate with a rise in the rating scale. 3. In some cases prisoners may suffer from hypertension unrelated to their withdrawal. This prisoner group will not respond to routine withdrawal management interventions and will require further assessment and appropriate treatment. 4. Also see Item 6 - Blood Pressure Item 11 - Respiration 1. Record the rate. 2. Intoxicated people or in moderate to severe withdrawal may display compromised respiration (e.g. dyspnoea, hyperpnoea, shallow breathing or reduced rate). 3. If respiration becomes compromised: Administer oxygen at 40% ie 6 L/minutes or if C.O.A.D. present 2L/minute. Position in cardiac position. Notify thedoctor. Record respiratory rate ¼ hourly. Item 12 - Consciousness 1. Alert, responds when spoken to, orientated and co-operative. 2. Confused to day, date and place, but responds when spoken to and obeys simple commands. 3. Stuporosed, no response to auditory stimuli, but responds to painful stimuli. Alcohol Withdrawal Assessment Reporting Record 840998912 Version 01 Page 14 of 1 4. 5. Semi-comatosed, no response to usual painful stimuli, response to peripheral reflexes, i.e. corneal, plantar, but gag reflex absent; incontinence of urine and faeces and some restlessness. Comatosed, no response to external stimuli, no reflexes present, may progress to depressed respiration. If consciousness level falls to below 2, use Glasgow Coma Scale and notify the doctor. Item 13 - Pupils 1. Observe the size and reaction to light of the pupils. 2. Record if the pupils are slow to react to light. 3. Record whether or not the pupils are equal in size or not. Drugs given 1. Indicate (using abbreviations if needed) if medication is administered. Such medication however, must be signed for on the Medication Chart. Alcohol Withdrawal Assessment Reporting Record 840998912 Version 01 Page 15 of 1 QUEENSLAND CORRECTIVE SERVICES NURSING ALCOHOL WITHDRAWAL SCALE RECORD Name:............................................................................... ... Date of Birth:.................................................................................. .. Date and Time of last drug use:.......................................... Blood Alcohol Level (BAL) on Admission:........................................................................ ... BASELINE OBS B.P. Supine: B.P. Erect: Pulse: Weight: ........................ ........................ ........................ ........................ DATE TIME PERSPIRATION TREMOR AGITATION ANXIETY PULSE & TEMP RATING BLOOD PRESSURE RATING PERCEPTION ORIENTATION A.W.S. TOTAL BLOOD ALCOHOL LEVEL BLOOD PRESSURE PULSE TEMPERATURE RESPIRATIONS CONSCIOUS LEVEL PUPILS SEDATIVE DRUGS GIVEN Alcohol Withdrawal Assessment Reporting Record 840998912 Version 01 Page 16 of 1 NURSES SIGNATURE ALCOHOL WITHDRAWAL SCALE RECORD: H&M Alcohol Withdrawal Assessment Reporting Record 840998912 Version 01 Page 17 of 1
