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Clinical WorksheetDate:4/29/2020 Student: Tyler Bennett Assigned vSIM: Andrew Davis MH Initials: ADAge:56 maleM/FCode Status:Diagnosis: Alcohol withdrawal syndromeLength of stay:Allergies: NKAHCP:Consults:Isolation: StandardFall Risk: highTransfer:IV Type:Location:Fluid Rate:Critical Labs:Serum Albumin: 3.1, ALP-125, AST-44,bilirubin-1.1, ETOH-50Other services:Consults Needed:Why is your patient in the hospital (Answer in your own words and include the History of present illness): voluntarily came in for rehabilitation from alcoholHealth History/Comorbities (That relate to this hospitalization):no health history other than and ORIF to humerus 2 years ago.Shift Goals/Patient Educaiton Needs:1.Help pt with the tremors2.Help pt with anxiety3.Keep pt safe,substance abuse, 4.Maintain airway provide pt education about CIWA-Ar results and medicationPath Discharge: education on alcoholism, manage anxiety and stressors
Path to Death or Injury: Aspiration, respiratory arrest Clinical WorksheetAlerts:What are you on alert for with this patient? (Sign & Symptoms)