100%(16)16 out of 16 people found this document helpful
This preview shows page 1 - 2 out of 4 pages.
vSim ISBAR Activity Student WorksheetIntroduction(Your name, position (RN), unit you are working on)(RN) Acute Detoxification Unit.SituationPatient’s name, age, specific reason for visitAndrew Davis, 56-year-old man, voluntarily admitted himself to the alcohol rehabilitation facility.BackgroundPatient’s primary diagnosis, date of admission, current orders of patientBackground- 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.alcoholintake 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 WithdrawalAdmission – 05/11/2020 at 4:00 PMOrders- 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. AssessmentCurrent pertinent assessment data using head to toe approach, pertinent diagnostics, vital signsMr. 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. Davisdenied feeling sick to his stomach, but had no desire to eat.Clinical Institute Withdrawal Assessment of Alcohol Scale. Score 24RecommendationAny orders or recommendations you may have for this patient Continue with CIWA scale every 2h for 8 horas, If CIWA is less than 8assess 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