Andrew David Clinical Replacement Packet.docx - vSim ISBAR Activity Introduction(Your name position(RN unit you are working on Student Worksheet(RN

Andrew David Clinical Replacement Packet.docx - vSim ISBAR...

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vSim ISBAR Activity Student Worksheet Introduction (Your name, position (RN), unit you are working on) (RN) Acute Detoxification Unit. Situation Patient’s name, age, specific reason for visit Andrew Davis, 56-year-old man, voluntarily admitted himself to the alcohol rehabilitation facility. Background Patient’s primary diagnosis, date of admission, current orders of patient Background - Mr. Davis had an open reduction internal fixation surgery to repair a humerus fracture 2 years ago, has no significant medical history and no known allergies. alcohol intake is approximately 1 pint of vodka per day and his last drink was today in the morning, denies using recreational drugs and tested negative for opiates and marijuana. He does not smoke. Mr. Davis scored 24, which was above 8 and was a parameter for diazepam 10 mg. I administered 10 mg diazepam for alcohol withdrawal. I continued with mental status exam and I educated on alcohol withdrawal, medication, and treatment. Patient verbalized nervousness and understanding. Primary diagnosis - Alcohol Withdrawal Admission – 05/11/2020 at 4:00 PM Orders- Regular diet, Reassessment CIMA, Thiamine 100mg orally once daily, Vitamin B12 2000 mcg orally once daily, Multivitamin with Mineral once daily, Diazepam 10mg PRN every 2h. Group therapy, Alcoholics A. meeting, go to be evaluated by Psychiatric. Assessment Current pertinent assessment data using head to toe approach, pertinent diagnostics, vital signs Mr. Davis BP is 160/94, Pulse rate 100/min, rhythm is regular and strong, 20 resp/min, equal and unlabored. Mr. Davis is alert and oriented x4. temperature, 37.2°C (99.0°F and blood oxygen saturation, 99%. Mr. Davis has a tremor are moderately with his arms extended, he has a sweaty forehead, moderately severe headache 4/10. Mr. Davis is restless and irritated with the questionnaire. He is anxious about him not being able to stop drinking. He has no hallucinations, no nausea or vomiting, Mr. Davis denied feeling sick to his stomach, but had no desire to eat. Clinical Institute Withdrawal Assessment of Alcohol Scale . Score 24 Recommendation Any orders or recommendations you may have for this patient Continue with CIWA scale every 2h for 8 horas, If CIWA is less than 8 assess every 4 h for 72h. and administer diazepam 10 mg prn q 2 h for score above 8. Encourage the patient to join the group therapy

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