100%(1)1 out of 1 people found this document helpful
This preview shows page 1 - 4 out of 9 pages.
vSIM for Nursing Describe Disease Process Affecting Patient (Include Pathophysiology of Disease Process) Alcohol withdrawal occurs when reduced or quitting of alcohol after heavy and prolonged use. The most common sign of alcohol withdrawal is tremulousness, commonly called the shakes, or jitters, that begins 6-8 hours after alcohol cessation. Mild to moderate alcohol withdrawal includes agitation, lack of appetite, N/V, insomnia, impaired cognition, and mild perceptual changes. Both SBP and DBP increase, as does pulse, and body temperature. Psychotic and perceptual s/s begin in 8-10 hours. Withdrawal seizures may occur 12-24 hours and alcohol withdrawal delirium is a medical emergency that can result in death. Alcohol withdrawal delirium may result anytime within the first 72 hours (Halter, 2018, p. 420-421). Diagnostic Tests (Reason for Test & Results) Patient Information Anticipated Physical Findings ●BAC: to determine blood alcohol level in patient’s blood ●CIWA to help in assessment and management of alcohol withdrawal ●DSM-5 Criteria for alcohol use disorder (Halter, 2018, p. 419-423). A.Davis is a 56 y.o male Primary DX: Alcohol withdrawal Hx: Alcoholism, Pt. states he drinks 1 pint of Vodka QD, previous ORIF of humerus about 2 yrs ago. Pt denies use of recreational drugs, neg. for marijuana, neg. for opiates. ●Shakes or jitters ●Agitation ●Lack of appetite ●N/V ●Impaired cognition ●Mild perceptual changes ●Tachycardia ●Diaphoresis ●Fever ●Anxiety ●Insomnia ●Hypertension ●Delusions ●Visual Anticipated Nursing Interventions ●Safety promotion (primary focus) ●Promoting sleep ●Reintroduce healthy food and hydration ●Support and encouragement of self care ●Administer meds as necessary (Benzodiazepines, Anticonvulsants ●Assistance in goal setting ●Health teaching and promotion (social activities (ex: AA)
vSIM ISBAR Activity Introduction (Your name, position (RN), unit you are working on) Hi Dr. Foulks this is Melissa. I am an RN in the Alcohol Rehab facility. Situation (Patient’s name, age, specific reason for visit) I have your patient, Andrew Davis here. He is a 56 y.o male who has voluntarily admitted himself for detox. Background(Patient’s primary diagnosis, date of admission, current orders for patient) He was admitted yesterday, 07/06/20 and is being treated today for alcohol withdrawal/detox. I am following your orders according to his CIWA score. Assessment(Current pertinent assessment data using head to toe approach, pertinent diagnostics, vital signs) His CIWA score was 26. VS show elevated BP, HR, and RR. (BP: 160/94, HR: 20 breaths/min, RR: 100/min). Mr. Davis is restless, pacing, sweaty on his forehead, and has tremors with arms extended. He was given Diazepam 10mg PO at 0800 He is showing moderate symptoms R/T to alcohol withdrawal Recommendation (Any orders or recommendations you may have for this patient) I will continue to monitor his behavior and VS according to your order. I would recommend that you come and evaluate him for further treatment.
Patient Education Worksheet Name of Medication, Classification, and Include Prototype Medication: