Andrew Davis Care Plan .docx - Care Plan Guided Reflection and Documentation Assignment Assessment Physical General appearance motor behavior

Andrew Davis Care Plan .docx - Care Plan Guided Reflection...

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Care Plan, Guided Reflection and, Documentation Assignment Assessment Analysis (Nursing Diagnosis) Plan Physical General appearance & motor behavior; Physiological & self-care issues: health problems; compliance with prescribed meds; Eating habits, sleep patterns; ADLs, etc. Emotional Mood & affect; expressed emotions; facial expressions, etc. Cognitive Thought process (how) & content (what); clarity of ideas; ideations, orientation, insight, decision-making ability, etc . Social Relationships Support systems, etc. Spiritual 56-year old male. He is disheveled, a hint of alcohol to his breath and body. He is showing signs of anxiety and has mild tremors. He is sensitive to the light and complains of a headache. He is addicted to alcohol and going through withdrawal. Does not have an appetite currently. No difficult in sleep but sometimes wakes up and does not remember the prior night. Able to complete ADLs. CIWA score is 15 Stressed and anxious, wants to get better but fears he will not be able to. Wishes he could explain himself to his wife. Mood and facial expression congruent . Thought process is linear and focused. He is goal-directed on getting better and making it through the withdrawals. Speech is normoactive with appropriate volumes. He is alert and oriented to person, place, time, and event. He acknowledges that he has made poor decisions and wishes to change them. Son is supportive of his father getting better. Wife and daughters are upset with him and not speaking to him currently. Active in his church and neighborhood. Pastor and feels great sorrow and embarrassment for his actions Physical: risk for imbalanced nutrition: less than body requirements r/t symptoms of withdrawal Emotional: labile emotional control r/t use of alcohol AMB patient’s outburst during the school board meeting. Cognitive: Acute confusion r/t alcohol use AMB patients stating, “sometimes I wake up and can’t remember the night before, it’s scary.” Social: dysfunctional family process R/T alcohol abuse AMB wife and daughters not speaking to him. Spiritual: Risk for spiritual distress r/t alcohol addiction. Priority Risk for injury r/t alteration in sensory/perception function Goals/Outcome Criteria 1. The client will remain free from injury during stay in facility 2. The client will explain methods to prevent injuries in 2 days 3. The client will demonstrate behaviors that decrease the risk of injury Interventions (List) 1. The nurse will provide a safe milieu 2. the nurse will educate on different techniques and ways to remain free of injuries 3. The nurse will remove all possible hazardous items from patients’ room and place client near the nurse’s station. Med (generic & brand name): Diazepam (Diastat) Classification: anxiolytic Use: muscle spasm, anxiety, acute alcohol withdrawal. Prior to endoscopies, preop sedation, adjunct for seizures, status epilepticus, severe recurrent seizures, Tetanus.

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