# Situation: A 52-year-old man is admitted to the surgical ward at 08:00 for an elective hernia repair scheduled in 3 days. His wife reports that he has drunk alcohol heavily every day for 10 years, and his last drink was at 22:00 the night before admission. He has no seizure disorder and takes no regular medicines. On admission he had no tremor and had slept normally, his pulse was 88/min, and his blood pressure was 136/84 mmHg. At 14:00 that day, 16 hours after his last drink, the nurse gathers the following findings. Which finding BEST indicates that his withdrawal is worsening?

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> subject: Nursing Practice V — Care of Clients with Maladaptive Patterns of Behavior; Care of Clients with Life-Threatening Conditions, Acute Multi-Organ Problems, High Acuity and Emergency Situations

## 문제

Situation: A 52-year-old man is admitted to the surgical ward at 08:00 for an elective hernia repair scheduled in 3 days. His wife reports that he has drunk alcohol heavily every day for 10 years, and his last drink was at 22:00 the night before admission. He has no seizure disorder and takes no regular medicines.

On admission he had no tremor and had slept normally, his pulse was 88/min, and his blood pressure was 136/84 mmHg. At 14:00 that day, 16 hours after his last drink, the nurse gathers the following findings. Which finding BEST indicates that his withdrawal is worsening?

## 보기

1. Pulse 114/min and blood pressure 164/98 mmHg **✔ 정답**
2. His hands show a fine tremor when he holds his arms out straight
3. He has mild nausea but has kept down half of his lunch tray
4. He slept only 3 hours and says he feels restless and irritable

**정답: 1**

## 해설

Rising heart rate and blood pressure are the key early indicators that alcohol withdrawal is intensifying and that severe complications may follow, so the change is reported for the withdrawal protocol to be adjusted. Insomnia, irritability, mild nausea, and a fine tremor are expected mild withdrawal signs in the first day.

## 심화 해설

Why Option 1 Is the Best Indicator of Worsening Withdrawal

Alcohol withdrawal reflects a state of central nervous system hyperexcitability that emerges when the chronic depressant effect of alcohol is suddenly removed. In a person who has consumed alcohol heavily for years, inhibitory signaling through GABA is down-regulated while excitatory signaling through glutamate is up-regulated. When alcohol is withdrawn, this imbalance becomes unmasked, producing autonomic overactivity, tremor, gastrointestinal upset, and psychological symptoms. The time course matters: this patient is now 16 hours after his last drink, which is within the early window when mild signs commonly appear but also when progression can begin.

Autonomic instability—specifically a rising pulse and rising blood pressure—is the most reliable early signal that withdrawal is intensifying rather than remaining mild. The admission vital signs were pulse 88/min and blood pressure 136/84 mmHg. At 14:00, the values have risen to pulse 114/min and blood pressure 164/98 mmHg. This is not merely a single elevated reading; it is a change from baseline in the direction of sympathetic overdrive. The Clinical Institute Withdrawal Assessment for Alcohol–Revised (CIWA-Ar) explicitly scores pulse and blood pressure as objective parameters, and higher scores on these items correlate with greater risk for serious withdrawal complications [1][2]. A rising score indicates that the withdrawal syndrome is moving along a continuum toward potential severe manifestations such as withdrawal seizures or delirium tremens.

Key point! A fine tremor, mild nausea, insomnia, restlessness, and irritability are all expected components of early alcohol withdrawal and do not by themselves indicate dangerous progression. They are consistent with a mild withdrawal picture that can often be managed with supportive nursing care and close monitoring [2]. In contrast, sustained elevation of heart rate and blood pressure beyond the patient's own baseline suggests that the autonomic nervous system is becoming increasingly unstable, which is the physiologic substrate for more severe withdrawal.

The distinction is clinically important because treatment decisions hinge on it. Early initiation of supportive care and, when indicated, benzodiazepine therapy is intended to prevent progression to serious withdrawal reactions [2]. If the nurse identifies only tremor or subjective complaints and does not recognize the significance of worsening vital signs, the opportunity to intervene before escalation may be missed. The CIWA-Ar framework supports this: the higher the patient's score, the greater the risk for experiencing serious withdrawal symptoms [1]. Among the four options, only option 1 represents a measurable worsening in the domains most predictive of severe withdrawal.

| Finding | Interpretation in Early Withdrawal | Significance for Worsening |
| --- | --- | --- |
| Pulse 114/min, BP 164/98 mmHg | Autonomic hyperactivity; sympathetic surge from loss of alcohol's depressant effect | Best indicator of progression; warrants protocol adjustment and close monitoring |
| Fine tremor with arms extended | Expected early sign of CNS hyperexcitability | Common in mild withdrawal; not specific for worsening |
| Mild nausea, kept down half of lunch | GI upset from withdrawal; no evidence of volume depletion or severe vomiting | Does not indicate dangerous escalation |
| Slept 3 hours, restless, irritable | Psychological and sleep disturbance typical of early withdrawal | Subjective and expected; less predictive than vital sign changes |

Watch out! A single elevated blood pressure reading can occur for many reasons, including pain or anxiety. What makes option 1 compelling is the combination of both pulse and blood pressure rising from a documented baseline within a short time frame, in a patient with a clear history of heavy daily alcohol use and no other identified cause. This pattern fits the expected trajectory of alcohol withdrawal and should trigger reassessment using a structured withdrawal scale and communication with the provider about adjusting the withdrawal protocol.References (research sources)

- [1]Alcohol withdrawal syndrome: assessment and treatment with the use of the Clinical Institute Withdrawal Assessment for Alcohol-revised.Research articlePuz CA, Stokes SJ (2005) · DOI: 10.1016/j.ccell.2005.04.001

- [2]Clinical assessment and pharmacotherapy of the alcohol withdrawal syndrome.Research articleNaranjo CA, Sellers EM (1986) · DOI: 10.1007/978-1-4899-1695-2_12

## 임상 시나리오

Early Detection of Worsening Alcohol WithdrawalMonitor autonomic changes, not just subjective symptoms
A rising pulse and blood pressure from baseline is the most reliable early sign that alcohol withdrawal is intensifying. Compare current vitals to admission values: this patient went from 88/min and 136/84 mmHg to 114/min and 164/98 mmHg at 16 hours after last drink.

Use the CIWA-Ar to score objective parameters including pulse and blood pressure. Higher scores on these autonomic items correlate with greater risk for severe withdrawal complications such as seizures or delirium tremens.

Expected mild signs in the first day include fine tremor, mild nausea, insomnia, and irritability. These alone do not indicate worsening severity unless accompanied by autonomic escalation.

CautionA single elevated reading is less meaningful than a change from baseline in the direction of sympathetic overdrive. Report upward trends in vital signs immediately so the withdrawal protocol can be adjusted before progression.

## 핵심 개념

- **Alcohol withdrawal syndrome** — CNS hyperexcitability from GABA down-regulation and glutamate up-regulation after chronic alcohol cessation
- **Autonomic instability** — Rising pulse and blood pressure indicating sympathetic overdrive and withdrawal progression
- **CIWA-Ar** — Clinical Institute Withdrawal Assessment for Alcohol-Revised, scoring objective parameters like pulse and BP
- **GABA-glutamate imbalance** — Chronic alcohol suppresses inhibitory GABA and enhances excitatory glutamate, unmasked upon withdrawal
- **Withdrawal timeline** — Early signs appear within hours; autonomic changes signal risk of severe complications

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