100%(1)1 out of 1 people found this document helpful
This preview shows page 1 - 2 out of 13 pages.
Alcohol Abuse EMRPatient reports that “Wife left and took my sons, but we’ll work that out. She said it because of my drinking.”Family history of alcohol abuse (father and grandfather)History of child abuseIV site, right hand hepLockISBAR given to the provider.Situation: At 0200, discovered client lying at foot of bed, disheveled, saline lock dangling from arm. Client awake and responsive. Background: 45 year-old-white male who had MVA yesterday at approximately 1400. Admitted by ambulance in acute alcohol intoxication with abrasions and accompanied by police. History of gastritis and esophagitis. Transferred to medical-surgical unit. No change in status prior to this time. Assessment: Alert to person and place, but not time. States he has nausea with dry heaves. Moderate tremor of upper extremities. Appears moderately anxious and restless. No auditory or visual disturbances. States: “I feel the bugs all over me.” Reports mild headache. Vital signs: BP 160/94; T 37.9; P 106, and R 24, which are elevated from midnight findings. CIWA score of 23.