Nursing care of the patient undergoing alcohol detoxification

Nurses are challenged with the task of holistic care for the alcohol dependent patient. The objective of the study was to explore and describe the opinions of male patients regarding the holistic care in a selected detoxification unit in Gauteng. A quantitative, explorative and descriptive design was employed utilizing interviews with a structured questionnaire as method of data collection. After the data was analysed (frequencies were used) the results were presented according to the five client variables of the Neuman Systems Model. Positive and negative results on the physiological, psychological, socio cultural, developmental and spiritual needs of the client were identified. This article aims at identifying crucial holistic aspects of nursing care of the alcohol dependent patient. Introduction and background Patients who are admitted for alcohol detoxification, often present with withdrawal symptoms, other medical and alcoholrelated disorders, psycho social and spiritual problems, indi­ cating the total person affliction. The importance of medical and nursing supervision of patients while being detoxified, cannot be overemphasised as these patients are vulnerable to experiences such as elation, depression, anxiety, low self-es­ teem, and feelings of guilt (Ryan, 1995:95). Alcohol dependent patients are also prone to alcohol with­ drawal syndrome, a serious complication that can develop when the intake of alcohol has been reduced or stopped. The syn­ drome is a neuroadaptive state, due to chronic exposure to alcohol, and presents with symptoms such as anxiety, sweat­ ing, tachycardia, nausea, vomiting and tremor, and can progress to autonomic arousal, that can be complicated by hallucina­ tions, seizures and delirium tremens. The primary goal of medi­ cal intervention is therefore to prevent arrhythmia, seizures and death (Antai-Otong, 1995: 23-24; Bohn, 1993: 680-681; Carlson, Keske & Cortez, 1998:313-314, Mattick & Hall, 1996: 97-98). Apart from the aforementioned complications, alcohol also affects most of the body systems, including the neuro­ logical, gastrointestinal, cardiovascular and the immune sys­ tems (Bums, 1994: 298-301). According to Dossey (1995:517) spiritual distress is experienced, as addicted persons are also “...often totally out of touch with their feelings...” The literature also reveals the high-risk of suicide, and the development of delirium tremens which could be fatal, if not recognized and treated timeously (Antai-Otong, 1995:23-24). Considering the possibility of these severe complications as well as the total affliction on the person, and the special needs of these patients, a holistic approach to their nursing care is


Introduction and background
Patients who are admitted for alcohol detoxification, often present with withdrawal symptoms, other medical and alcoholrelated disorders, psycho social and spiritual problems, indi cating the total person affliction.The importance of medical and nursing supervision of patients while being detoxified, cannot be overemphasised as these patients are vulnerable to experiences such as elation, depression, anxiety, low self-es teem, and feelings of guilt (Ryan, 1995:95).
Alcohol dependent patients are also prone to alcohol with drawal syndrome, a serious complication that can develop when the intake of alcohol has been reduced or stopped.The syn drome is a neuroadaptive state, due to chronic exposure to alcohol, and presents with symptoms such as anxiety, sweat ing, tachycardia, nausea, vomiting and tremor, and can progress to autonomic arousal, that can be complicated by hallucina tions, seizures and delirium tremens.The primary goal of medi cal intervention is therefore to prevent arrhythmia, seizures and death (Antai-Otong, 1995: 23-24;Bohn, 1993: 680-681;Carlson, Keske & Cortez, 1998:313-314, Mattick & Hall, 1996: 97-98).Apart from the aforementioned complications, alcohol also affects most of the body systems, including the neuro logical, gastrointestinal, cardiovascular and the immune sys tems (Bums, 1994: 298-301).According to Dossey (1995:517) spiritual distress is experienced, as addicted persons are also "...often totally out of touch with their feelings..." The literature also reveals the high-risk of suicide, and the development of delirium tremens which could be fatal, if not recognized and treated timeously (Antai-Otong, 1995:23-24).Considering the possibility of these severe complications as well as the total affliction on the person, and the special needs of these patients, a holistic approach to their nursing care is imperative.
The prerequisites for the nurse to undertake any therapeutic programme, are adequate information, sufficient knowledge and training as well as the necessary skills to carry out the task (Cooper, 1994:36).Effective nursing care therefore demands adequate knowledge of, and insight into the etiology of alco hol dependency, its effects on the total person, and detoxifica tion regimens.Furthermore, the nurse is in contact with the patient for longer periods than other members of the multi dis ciplinary team, which affords her the opportunity to establish a sound therapeutic relationship.Thus enhancing the partner ship between patient and nurse, for a positive outcome of the set nursing goals (Riley, 1996:37).A successful therapeutic relationship is dependent on the ability of the nurse to utilize skills such as caring, trust, warmth, empathy, acceptance, con fidentiality and understanding (Sullivan, 1995:108-115).The nurse should plan and execute the nursing care of the patient undergoing alcohol detoxification comprehensively, skilfully and holistically.In order to describe the holistic approach to the nursing care of the alcohol dependent patient while being detoxified, the Neuman Systems Model was utilised as a conceptual frame work for this study.

The Neuman systems model and the alcohol dependent patient
The Neuman Systems Model is predominantly holistic in na ture, and wellness oriented, viewing the client as an open sys tem, in constant interaction with the environment.Stressors and the reaction to stressors are important factors on which the model is based (Neuman, 1995:22).The model is invaluable to nursing practice, as it is geared towards the alleviation of stressors experienced by the client through primary, second ary and tertiary interventions to retain, attain and maintain op timal client stability (Neuman, 1995:23).There are four major concepts inherent within the Neuman Systems Model, i.e. cli ent, environment, health and nursing (Cross, 1990: 265-267;Fawcett, 1995:224-234;Lancaster, 1996:200-206;Neuman, 1995: 23-37).

Figure 1 Neuman client system
The client is the first concept and is viewed within a "...sys temic perspective, holistically and multi dim ensionally" (Neuman, 1995:24).This view is characterized by the continu ous flow of input, process, outcome and feedback indicating the organised complexity, as well as all elements contained within the system that are in interaction, concerning stress and the reaction to stressors.The holistic component of the client refers to the fact that all the parts are integrated and function ing in an organised interrelated whole (Neuman, 1995:45-46).The client (or client system), may be applied to an individual, a group or a community, "...or even a social issue" such as alco hol dependancy (Fawcett, 1995: 225).The client is comprised of five interrelated and integrated variables in constant inter action with the environment: The interrelationships of these aforementioned variables are the determining factors regarding the amount of resistance of the client system to stressors.
Each client has "....varying degrees of development and a wide range of interactive styles and potential" (Neuman, 1995: 28).The spiritual variable in particular, which may never be recog nised or developed, is considered to be on a continuum of complete unawareness, but has the potential or can be con sciously recognised and developed as an entirety with a posi tive influence on optimal client wellness.The client system is continuously subjected to stressors and the reaction to stres sors.Neuman (1995: 23) defines stressors as "....tension pro ducing stimuli or forces occurring within both the internal and external environmental boundaries of the client/client system".The effect of stressors on the client is dependent on the strength as well as the number of stressors at any given time (Reed, 1993:12-13).
The graphical illustration of the client system depicted in Fig ure 1 can be related to the alcohol dependent patient.The ineffectiveness of the normal line of defence will allow the invasion of stressors on the inner lines of resistance.
The inner lines o f resistance are those represented by the inner broken lines surrounding the basic structure.These lines are involuntarily activated when stressors invade the normal line of defence.The function of these lines is the protection of the basic structure's integrity.The ineffectiveness of these lines will result in the depletion of energy with the possibility of ensuing death.
In the situation of the alcohol dependent patient, the flexible line of defence was ineffective in preventing the penetration of stressors to the normal line of defence, causing stressor reaction on all five of the client variables: physiological -with drawal symptoms, alcohol related medical conditions; psycho logical -adverse emotional feelings, such as depression, anxi ety, anger and fear; socio cultural -broken relationships, un employment, rejection by society; developmental -ineffective coping skills, cognitive impairment; spiritually -feelings of hopelessness, despair, powerlessness.
It is at this point that secondary intervention is necessary, to prevent the stressors from penetrating the inner lines of resist ance.and consequently invade the basic structure that may lead to serious illness or even death.
The affliction of the stressors on all five the client variables, necessitates a holistic approach to the nursing care of these patients.A comprehensive nursing assessment is therefore im perative to address all the affected variables.The nurse-patient relationship is of utmost importance in order to involve the pa tient in the setting of nursing goals, implementation and evalua tion of the nursing care plan.The nurse must be multi-skilled to ensure optimal input, process, outcome and feedback to retain, attain and maintain the stability of the client system (patient).
The focus of this article will be on the client system of the Neuman Model as discussed in figure 1.The concepts of the environ ment, health and nursing are briefly outlined as follows: The environment as the second concept is defined by Neuman (1995:30) as ".... all internal and external factors or influences surrounding the identified client or client systems".Environ mental stressors may influence the client in a negative manner at any particular point in time.The same principle applies when the client influences the environment.Not all stressors are necessarily harmful as the adjustment of the client system has the ability to change the mode of response to environmental forces.As the client is viewed as an open system, the mecha nisms of input, process, outcome and feedback between the client and the environment are considered to be circular in nature, of which the relationship is com plem entary or reciprocative and therefore produces an outcome of correc tion or regulation of the system.Neuman (1995:31) identified three categories of environments, i.e. internal, external and created environments: • the internal environment, constitutes all the interac tive influences within the client system boundaries, which are referred to as intra personal stressors e.g.physical or emotional pain • the external environment refers to all the interactive influences outside the boundaries of the client sys tem.The concept "external environment" is divided into the (1) interpersonal -(relationships between the client and others), and the (2) extra personal (those forces at a distal range from the client (unfamiliar sur roundings, financial crisis).• the created environment as a concept was added by Neuman in 1989(Lancaster, 1996:204)."The created environment developed unconsciously by the client is a symbolic expression of system wholeness" (Neuman 1995: 31).As an open system, the created environment has the ability to exchange energy with the internal and external environments.The created environment is spontaneously created, and although unconsciously motivated, offers a coping mechanism to deal with environmental stressors.
Stressors affecting the internal (intra personal) environment of the alcohol dependent patient are for example alcohol-related medical disorders and psychological disturbances.The exter nal environment refers to the interpersonal forces which are affected by stressors such as broken relationships and loss of social roles, and the extra personal forces which are affected by stressors such as unfamiliar surroundings, i.e. the detoxifi cation unit and financial crisis.
The ineffectiveness or lack of coping skills are an indication of the affliction of stressors on the created environment.
Health as the third concept, is equated by Neuman (1995:32) as the health status of the client to the level of wellness, indicat ing optimal stability of the client system Neuman (1995:46) places health on a continuum from wellness to illness, which is dynamic and therefore constantly in a state of change.Wellness constitutes the harmonious balance of all the subsystems and parts of the whole system.The wholeness of the client is deter mined by the interrelationships of all five client variables in its reaction to stressors.Illness is represented by disharmony of the subpart of the system whole (Neuman, 1994:47).Neuman (1995:33) refers to wellness or system stability as negentropy when more energy than required is generated and entropy when less energy than required is generated.
The concept 'reconstitution' is also incorporated into the Neuman model and refers to the maintenance of the stability of the client system after the appropriate treatment was adminis tered and system maintenance achieved.The alcohol depend ent patient may be classified as an individual who has been affected by stressors on all five client variables as well as the three environments and has therefore been exposed to illness or entropy, needing secondary intervention to return to stabil ity and reconstitution.
The fourth concept, nursing, is viewed by Neuman (1995:47) as a unique profession, concerning itself by addressing all five client variables.The goal of nursing is therefore to implement specific actions to retain, attain and maintain optimal client wellness, and thereby facilitate a linkage of the client, environ ment, health and nursing (Neuman, 1995: 33).
The nurse is an intervener in assisting the client to reduce the reaction to stressors (Lancaster, 1996:201).Neuman (1995:33-35) identifies three levels of prevention as intervention -pri mary, secondary and tertiary.
• primary intervention can be instituted at any time when a stressor risk is known, for example, health education on the prevention and early detection of alcohol de pendency.• secondary intervention can be implemented at any given time after the occurrence of symptoms to strengthen the inner lines of resistance, in an endeavour to protect the basic structure, for example alcohol detoxification.• tertiary intervention is implemented to maintain system stability after reconstitution has been achieved through secondary intervention, for example, the adjustment of the alcohol dependent patient after detoxification to be re-integrated into society as a productive citizen.

Literature review
The review of the literature was firstly, to gain knowledge of, and insight into the etiology of alcohol dependency as well as its effects on the physiological, psychological, socio cultural, developmental and spiritual variables of the person.Secondly, it was necessary to review the nursing care of the patient un dergoing alcohol detoxification, with specific reference to the holistic approach and the importance of the nurse-patient rela tionship.Thirdly, it was regarded as important to conduct an in-depth study of the Neuman Systems Model, because this model was utilised as a conceptual framework for this study.
Alcohol dependency is a complex, multi dimensional phenom enon, and the etiology of alcohol dependency is not always fully understood, despite studies by various researchers, who have focussed on possible predicting indicators such as ge netic factors, psycho social aspects and family background (Hewes & Janikowski, 1998:76).Vaillant (1995:7) is of the opin ion that the etiology of alcohol dependency should not be ascribed to one or another factor only, but one should rather understand all the variables in relation to the total clinical pic ture.
Nurses are well equipped to provide the various interventions required for the comprehensive care of the patient.The knowl edge of, and insight into the bio psycho social aspects of the human being, as well as the involvement of the patient in the setting of nursing goals are fundamental tools to empower the alcohol dependent patient to take responsibility for the effective management ofhis/her own health (Minicucci, 1994:379).
The effective nursing care of the alcohol dependent patient, while being detoxified, is dependent on the comprehensive, holistic assessment of the patient, i.e. physical, psychological, socio cul tural, developmental and spiritual (Gerace, 1993:363-366).
The prerequisites for the nurse to undertake any therapeutic programme, are adequate information, sufficient knowledge and training as well as the necessary skills to carry out the task (Cooper, 1994: 36).Effective nursing care therefore demands adequate knowledge of and insight into the etiology of alco hol dependency, its effects on the total person and detoxifica tion regimens.Furthermore, the nurse is in contact with the patient for longer periods than other members of the multi disciplinary team, which affords the opportunity to establish a sound therapeutic relationship and thereby enhancing the partnership between the patient and the nurse, for a positive outcome of the set nursing goals (Riley, 1996: 37).A success ful therapeutic relationship is dependent on the ability of the nurse to utilize skills such as caring, trust, warmth, empathy, acceptance, confidentiality and understanding (Sullivan, 1995: 108-115;Sundeen, Stuart, Rankin&Cohen, 1998:147-166).

Problem statement
The researcher was frequently approached by some of the patients during their stay within the detoxification unit, with issues such as: anxiety, depression, loneliness, boredom, con cerns regarding personal matters and demotivation to con tinue with the detoxification programme.The perception there fore was that the nursing care provided to these patients was probably not completely of a holistic nature.The question that came to the fore was: "To what extent is holistic care provided to the alcohol de pendant patient?" The purpose of the study The purpose of this study was to determine the extent of the holistic nature of nursing care provided to patients undergo ing alcohol detoxification and the feasibility of the adaptation of some aspects of the Neuman Systems Model to the nursing care of these patients.

The objective of this study
The objective of this study was to propose guidelines for nurses based on aspects of the Neuman Systems Model for the effective, holistic nursing care of patients undergoing al cohol detoxification.

Methodology
This was a descriptive survey aimed at identifying the re sponses of patients regarding their nursing care during alco hol detoxification.The conceptual framework for the study was based on the Neuman Systems Model, and it was neces sary to apply the six guidelines of Fawcetts (1995:464).
The target population of this study was all patients in a se lected detoxification unit in the RSA.Non-probability sam pling was done and an accidental sample was used because at admission it most most convenient to collect patients that are available for research purposes (Huysamen, 1994:44).Conven ience sampling was therefore done whereby 30 male patients who were admitted into a twelve-bedded detoxification unit for the first time participated in a structured interview.

Validity and reliability Validity
The validity of the instrument was based on the content.Fur thermore the instrument was pretested on two patients from the same category as the respondents.The interview schedule complied with face and content validity, that is "the degree to which the items in an instrument adequately represent the uni verse of the content (Huysamen, 1994:116).

Reliability
The set interview schedule was used for all patients admitted to the same facility for the first time for alcohol detoxification.

Instrumentation and data collection
An interview schedule consisting of closed and open-ended questions was designed by the researcher.The closed ended questions were mainly on biographic data.The open-ended questions sought information on the opinions about nursing care during detoxification.The interview schedules were de vised to include aspects of the five client variables as outlined in the Neuman Systems Model.The interview schedule was divided into the admission phase, experience of the detoxifica tion unit and biographical data.
Structured individual interviews were used to collect data.Ap pointments were scheduled with each participant for the inter view to take place on discharge from the detoxification unit.Each interview lasted for approximately forty five minutes and interview schedules were completed while respondents an swered questions.

Permission and ethical considerations
Permission for conducting the study was granted by the man agement of the treatment centre.Identification of the treatment centre was protected.Each respondent (patient) granted writ ten informed consent and was assured of the protection of their identity (anonymity).Confidentiality was assured.Volun tary participation and freedom to withdraw without permission were emphasized in the orientation to the consent from, the purpose of the interview as well as the benefits for future pa tients were also specified in the consent to be interviewed.

Lim itations
Thirty male patients who were admitted for alcohol detoxifica tion for the first time were interviewed to establish their experi ences and opinions at the time of admission, during detoxifica tion -including the nursing care they received, as well as the physical and psychological environment of the detoxification unit.Interviews were scheduled for the day of discharge from The study was thus limited to only one alcohol detoxification unit in South Africa.Similar circumstances may prevail at other detoxification units, but these should be verified by reserach as the findings of this study can not be generalised to other such facilities.

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igure 3 the respondents were very anxious and 7% experienced diffi culty during the procedure is understandable, as withdrawal symptoms as well as confrontation with the problem of alcohol dependency, may have been of significance.Despite these adverse experiences, it can, however, be assumed that some stressor relief may have taken place.

•
There was a high positive response of 97% from the respondents in relation to the first interview with the ward sister (Figure 3), which is indicative of a good rapport between the nurse and patient that addressed the socio cultural needs of the patient.In this situation the nurse engaged into negotia tion with the patient, in setting nursing goals, during which the establishment of a sound therapeutic relationship was evident.The first interview can be linked to the Neuman Model, as the nurse assessed and explored the patient's created environ ment as well as her own in order to come to an agreement regarding the proposed nursing care plan.

•
Of the thirty respondents, 83% experienced withdrawal symptoms {psychological variable) on admission.Respond ents were requested to describe these symptoms, which are depicted in Figure 4. Tremor, anxiety, abdominal discomfort, feelings of "head pressure", sweating and thirst, and craving for alcohol were the most common symptoms.Alcohol with drawal symptoms can be considered to be major multiple stres sors affecting all five client variables on the intra-, inter-, extra personal, as well as the created environment.
The physiological stressors are considered to be intra per sonal, which in turn, have an intra personal effect on the psy chological variable.The physical inability of the patient, for example, to cope with self-care causes embarrassment and frus tration and thereby increases the anxiety levels.Other psycho logical disturbances such as fear and anger cause difficulty with interpersonal relationships.Developmentally, the patient is in need of guidance and support from the nurse to increase coping skills, whereas all the adverse emotional feel the patient from even giving a thought to a meaningful purpose in life.

•
The standard treatment for the alleviation of with drawal symptoms at the specific detoxification unit, is the ad ministration of psychotropic analgesic nitrous oxide (PAN) therapy, or sedation by oral oxazepam.The treatment of choice is dependent on the outcome of the assessment of each indi vidual patient.
PAN administered to patients is not in anaesthetic concentra tion, but in much lower pre-anaesthetic concentration.The patient is therefore conscious and coherent throughout the procedure and beyond.At no time does the patient become anaesthetised or is consciousness impaired.There are certain contra-indications to the administration of PAN such as bron-chospasm, asthma, chronic obstructive pulmonary disease, hallucinations, intoxication and impending delirium tremens.Six of the twenty five respondents who were experiencing with drawal symptoms received PAN therapy, with good effect.The tremor, anxiety, restlessness, "head pressure" and abdominal discomfort subsided.Depression lifted, raised blood pressure and increased pulse rate due to withdrawal symptoms returned to normal.
Nineteen (76%) of the respondents who did not meet the cri teria for the administration of PAN were sedated by oral ox azepam, 84% with good effect, 11% reasonable effect and 5% with no effect.scores.
Emotional distress has a negative effect on all the client vari ables, as well as the internal, external and created environ ments, for example, physically -the energy levels deplete, lead ing to fatigue; psychologically -a feeling of sadness prevails -socio culturally, the patient experiences loss of role func tions -developmentally, coping skills are ineffective, and spir itually -feelings of hopelessness, despair and powerlessness.It is interesting to observe from Figure 6 that 70% of the re spondents mobilised their created environment positively to alleviate adverse emotional feelings.The remaining 30%, how ever, utilised their created environment negatively, by choos- The positive outcome of the PAN therapy as well as the ox azepam respectively contributed to the alleviation of the multi ple stressors, by strengthening the inner lines of resistance of the client system, and therefore returned the system to stabil ity.This reconstitution allowed for improved coping skills, as well as increased receptiveness to the remainder of the nursing care plan.

Symptoms
The data also revealed that the purpose, procedure and ex pected outcome of both the PAN and oxazepam treatments were fully explained to the patients, indicating complete in volvement of the patient in the nursing care plan.
Adverse emotional (psychological) feelings such as empti ness and loss can appear when the alcohol which was the central part of the patient's life has been taken away (Gerace 1993: 369).It is evident from data depicted in Figure 5, that emotional feelings, in fact, do occur during detoxification of which depression (57%) and anxiety (50%) rated the highest ing self-isolation.
• Respondents were requested to express concerns re garding unresolved matters, such as family, friends, financial and other concerns as well as their liberty to approach the nursing personnel to discuss these concerns (Figure 7).As seen in Figure 7 various problems were experienced, of which family matters rated the highest score.Only 23% of the 30 respondents approached the nursing personnel and expressed some stressor relief by talking to someone.The respondents who did not approach the nursing personnel were of the opin ion that the nursing personnel would not be in a position to assist and they therefore chose to discuss these concerns with family members or therapists.This indicates the socio cultural needs of the patients which should be addressed.

•
The majority of the respondents expressed positive opinions regarding the ward atmosphere, while 13% found the ward to be noisy.This finding could be an indication of the needed to return the system to stability.These findings indisocio cultural status of the patient.Noise in any inpatient cate the importance of addressing the developmental, psychofacility is not conducive to the well-being of patients.In the logical and social cultural needs of the patient. of the Neuman Systems Model, it can be deduced that noise acts as a stressor which may eg.disturb rest and sleep.
• Recreational activities during the detoxification pe riod, are considered to be vital for the promotion of the re socialisation process, cognitive stimulation and increased self esteem.The data revealed that 70% of the respondents partici pated in recreational activities while 30% chose not to do so.It was interesting to observe that the same percentage respond ents who chose self-isolation as a means to cope with adverse emotional feelings as mentioned before, also chose not to par ticipate in recreational activities.This behaviour may be in dicative of stressor persistence, for which intensive therapy is As the detoxification unit is a structured environment, cer tain rules regarding activities and conduct are applicable.Respondents were requested to express their opinion on the existing rules.Eighty percent found the rules accept able, while 20% felt the rules to be too rigid, especially regarding bedtime scheduled for 22:00.Once again all the client variables can be linked to the rules applicable to the structured environment.Physically -special times for medi cation, meals, rest, sleep and attention to personal hygiene; psychologically -an atmosphere of tranquillity and har mony; socio culturally -promotion of interaction and as sociation with From the findings it became clear that the alcohol dependant patient should be viewed holistically with physiological, psy chological, socio cultural, spiritual and developmental needs.
viewing and caring for the patient holistically.She/he should pay attention to crucial holistic aspects of nursing care of the alcohol dependent patient.

Recommendation Psychological
The findings of this study revealed the importance of and ne cessity for a holistic approach to the nursing care of the alco hol dependent patient while being detoxified.The findings also revealed that the perspectives contained within the Neuman Systems Model regarding the client, can successfully be ap plied to guide nurses in the caring of these patients.It is fur thermore imperative that nurses be knowledgeable, well trained and skilled to execute the nursing care plan for these patients in a holistic manner.
The role of the nurse should focus on the following crucial aspects of nursing care:

■ Physiological
The nurse should ensure a safe withdrawal from alcohol by focussing on the following nursing care actions: ♦ close observation ♦ safety and comfort of the patient ♦ assistance with activities of daily living ♦ adequate fluid intake and dietary require ments ♦ administration of medication, as pre scribed The alleviation of withdrawal symptoms will return the physiological variable to stability and thereby have a posi tive influence on the stability of the remaining four client variables.
The establishment of a sound nurse-patient relationship with the emphasis on empathy, trust, genuineness, acceptance and caring, will enhance the co-operation of the patient in the set ting of nursing goals, as well as total involvement in the nurs ing care plan.

■ Socio cultural
It is essential to promote the re-socialisation process of the patient by encouraging contact with family and friends, as well as association with fellow patients, to help the patient to build up damaged relationships and to eventually also be re-inte grated into society as a fully functioning citizen.

■ Spiritual
It is important for the nurse to recognise spiritual distress, and to address spiritual needs by guiding the patient in the expres sion of fear, feelings of guilt, concerns and other adverse feel ings in an acceptable manner.Furthermore, supportive care to the patient in overcoming hopelessness and despair in order to encourage a meaningful purpose in life.

■ Developmental
The nurse should make it her priority to guide the patient in obtaining coping skills.The patient should be developed to become an active citizen of his/her community able to deal with his/her problems in society.It is important for the nurse to understand the alcohol depend ent patient as a human being with special needs, requiring unconditional acceptance, empathy, caring and encouragement in his/her "... uphill battle for sobriety" (Dexter and Wash, 1995:156).It is necessary to recognise the adverse effects of alcohol dependency on the whole person and that effective and efficient nursing care of these patients while being detoxi fied, can only be successfully executed through a holistic ap proach.It is evident from the study that alcohol dependency is a com plex and multidimensional problem that affects all the client variables: physiological, psychological, sociocultural, devel opmental and spiritual.The disorder also has an impact on the client system's intra-inter-, and extrapersonal and created en vironments, indicating that the principles in the Neuman Sys tems Model are well suited to the nursing care of the alcohol detoxification patient.The study further found that there are certain prerequisites for nursing personnel caring for alcohol detoxification patients and that certain factors may have im pacted on the nursing care.Nursing personnel caring for the alcohol detoxification patient must have a knowledge of and insight into the effects of alco hol dependency on the total person.In addition, nurses need the social and cultural functions • developmental -the process of development through life • spiritual -the spiritual beliefs and its influences Figure 2 Initial interview and assessment Figure 4 Figure 5 Figure 6 Figure 7