The Challenges of Working with Intoxicated Patients

There are times—especially around the holidays—that nurses find themselves in situations in which they have to work with intoxicated patients. This isn’t easy by any means. And it’s probably not something that you learned about in nursing school.

With New Year’s Eve right around the corner, we asked Rebecca Schwuchow, RN, CFRN, Education Coordinator, and Tom Syzek, MD, FACEP, VP of e-Learning Solutions for The Sullivan Group (a company that helps reduce patient errors and increase patient safety) about the best ways to deal with patients who are intoxicated.

During the holiday season, nurses may be faced with working with patients who are intoxicated. What are the most important things to keep in mind when working with these patients?

Intoxicated patients should be considered “high-risk” when they appear in an Emergency Department. Their intoxication often masks other concomitant medical, traumatic, overdose, and behavioral conditions that can be easily overlooked if the care team focuses solely on the immediately apparent drama of intoxication and ignores the need for a careful, thorough evaluation.

The safety of the intoxicated patient, as well as the staff caring for the patient, are the paramount concerns.

What should nurses be aware of with these patients?

They should not assume that alcohol is the only cause of intoxication and must consider the presence of other legal and illegal substances that cause intoxication—including opioids, sedatives, hallucinogens, and even poisons.

Emergency physicians and nurses are presented with additional medicolegal issues regarding intoxicated patients. Frequently, these patients are combative and disruptive, and may even refuse care. Other times they present with an altered level of consciousness. Determining who is simply drunk, and who may be suffering from a co-morbid illness, such as head injury, co-ingestion, or sepsis, represents a challenging diagnostic dilemma for the health care provider. The emergency department nurse and entire team must be extremely diligent in providing the highest quality of patient care in diagnosing coexisting, life-threatening disorders, and, at the same time, protecting patients’ constitutional rights.

What can they do to size up how to approach assisting them?

The ED nurses and entire staff should have a coordinated, teamwork approach to the management of intoxicated patients that insures the safety of the patients and staff. These patients can easily and suddenly become combative during their ED visit, and plans should be made in advance how to provide safety and security for all involved—while at the same time performing adequate medical evaluation and treatment. To ensure patient and staff safety, the ED staff must be prepared to apply physical or chemical restraint when warranted.

Intoxicated patients warrant a thorough history and physical. A full set of vital signs, including a core temperature, is essential. It is imperative that these patients be undressed to view all body surface areas for injury.

Nurses, physicians, physician assistants, and nurse practitioners caring for intoxicated patients must be aware that they may present with a wide variety of life-threatening conditions including:

Trauma
Hypoglycemia
Hypothermia
Sepsis
Electrolyte abnormalities
Ethanol withdrawal
Wernicke-Korsakoff syndrome
Co-ingestions

Furthermore, chronic alcoholics may suffer from low magnesium and other electrolyte abnormalities, clotting disorders, hepatic encephalopathy, or untreated infections.

What do nurses need to watch out for? What problems can come up?

As mentioned above, nurses need to insure a safe environment for the patient and themselves while caring for intoxicated patients. Second, nurses must work with the entire care team to evaluate for all potential threats to limb or life in patients who are intoxicated. For example, the intoxicated patient who has blunt head trauma should be considered to have an intracranial bleed until proven otherwise. The drunk patient with neck pain has an unstable cervical fracture until proven otherwise. The bottom line: assume that the intoxicated patient is hiding some potentially life-threatening pathology until proven otherwise.

What additional information is important for nurses to know about working with intoxicated patients?

Emergency Departments have become the “drunk tank” and the health care safety net for society. Intoxicated patients found in alleys, along roadways, and wandering the streets are brought to the ED for evaluation. This burden, whether emergency physicians and nurses like it or not, has become routine. The reasoning behind it is simple—intoxicated patients are high-risk. Thus, management of these patients can be both complicated and frustrating.

Nurses and the entire care team should be keenly aware of their own potential for cognitive and affective bias towards the intoxicated patient which can easily get in the way of appropriate clinical decision making. Regardless of their own objections, intoxicated patients warrant rapid, meticulous evaluation and aggressive treatment when indicated. Physicians, physician assistants, nurse practitioners, and nurses must not assume that intoxication is the etiology of a patient’s altered mental status.

There is little debate about the management of the patient with a severely altered level of consciousness or in a comatose state. Attention to the ABCs (i.e., airway, breathing, and circulation) is the first priority. The team should recognize that intoxicated patients are a high-risk group for serious injury and should make these patients a priority.

Finally, it is difficult to detect every traumatic injury, coexisting medical problem, or co-ingestion during the initial evaluation of an intoxicated patient. A period of observation may be necessary to identify hidden or subtle problems before a patient can be safely discharged.

This highlights one area in emergency medicine where physician/nursing teamwork is critical: the entire staff must recognize the intoxicated patient as a high-risk situation.