Clinical Replacement Packet.docx nns.docx - vSim ISBAR...

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vSim ISBAR Activity Student WorksheetIntroduction(Your name, position (RN), unit you are working on)Mary Frometa (RN)Rehabilitation Clinic SituationPatient’s name, age, specific reason for visitAndrew Davis 56-year-old man, Reason for visits is voluntarily admitted himself to the alcohol rehabilitationBackgroundPatient’s primary diagnosis, date of admission, current orders of patientAlcohol withdrawal syndrome Date of Admission: April 10, 202016:00 Laboratory tests to be performed now: complete blood count; comprehensive metabolic panel (CMP); blood levels of magnesium, phosphate, ethanol, vitamin B12,and folate; and urine toxicology screenLaboratory tests to be performed in the morning: CMP and blood levels of magnesium and phosphate daily for 3 days Thiamine 100 mg orally once dailyVitamin B12 2000 mcg orally once dailyMultivitamin with minerals 1 tablet orally once dailyRegular dietAlcohol Withdrawal Assessment Protocol Vital signs and CIWA-Ar score on admissionIf the initial CIWA-Ar score is less than 8, continue assessment every 4 hours for 72 hours.If the initial CIWA-Ar score is 8 or greater, continue assessment and vital signs every hour for 8 hours and then, if stable, every 2 hours for 8 hours and then, if stable, every 4 hours thereafter.If the CIWA-Ar score is less than 8 for 72 hours, discontinue the assessment.If the CIWA-Ar score is 8 or more at any time, administer diazepam as ordered.Call the provider for a CIWA-Ar score above 35. Diazepam 10 mg orally every 2 hours as needed for a CIWA-Ar score of 8 or greater.
Hold for excessive sedation or a respiratory rate less than 12 breaths/min. AssessmentCurrent pertinent assessment data using head to toe approach, pertinent diagnostics, vital signsVital signs Temperature, 37.2°C (99.0°F)Heart rate, 94 beats/miRespiratory rate, 20 breaths/min; Blood pressure, 154/90 mmHg; SpO2, 98%.He is currently oriented ×3 and is embarrassed about his behavior at the school board meeting. He went to a 12-step meeting yesterday but left early, saying that he was "not like those people" and felt he wouldn’t benefit from the meeting. He was restless last night and did not sleep much. Morning laboratory tests were also drawn at 06:00, when he woke up. Their results are available in the chart, together with the laboratory results from yesterday afternoon. His behavior is appropriate, and he engages appropriately with staff, although his affect is constricted. His CIWA-Ar score was 1 on admission. RecommendationAny orders or recommendations you may have for this patient He is due for reassessment of the CIWA scorein our treatment room. He has an order for as-needed diazepam for a CIWA score of 8 or greater, so he may need that soon. He is supposed to go to group therapy today and to an Alcoholics Anonymous meeting. He is going to be evaluated by a psychiatrist later todayPatient Education WorksheetName of medication, classificationMedication: Diazepam Classification: antianxiety agents, anticonvulsants, sedative/hypnotics, skeletal muscle relaxants (centrally acting)Safe dose or dose range, safe routeAntianxiety

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