VSIM Worksheet_AndrewDavis.pdf - CONCEPT MAP WORKSHEET...

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Unformatted text preview: CONCEPT MAP WORKSHEET DESCRIBE DISEASE PROCESS AFFECTING PATIENT (INCLUDE PATHOPHYSIOLOGY OF DISEASE PROCESS) Alcohol withdrawal syndrome occurs after reducing or quitting alcohol after heavy and prolonged use. This classic sign of alcohol withdrawal is tremulousness that begins 6-8 hours after alcohol cessation. Alcohol withdrawal delirium can occur in 2-3 days after cessation of alcohol. PATIENT INFORMATION DIAGNOSTIC TESTS (REASON FOR TEST AND RESULTS) -CBC to assess for iron deficiency. Patients with alcohol abuse disorder are malnourished and can be at risk for iron deficiency. -CMP to assess for electrolyte imbalance -Alcohol level to assess level of alcohol intoxication -Liver function tests to assess liver function and liver cirrhosis -Serum Albumin to assess for nutrition status of the patient Andrew Davis is a 56-year-old man who voluntarily admitted himself to the alcohol rehabilitation facility yesterday afternoon. He is currently on the acute detoxification unit and has been on the unit for about 16 hours. ANTICIPATED PHYSICAL FINDINGS -abdominal cramping -vomiting -tremors -restlessness -insomnia -transient hallucinations or illusions -anxiety -increased blood pressure, resp rate, and temperature -tonic-clonic seizures ANTICIPATED NURSING INTERVENTIONS -Maintain a safe environment to prevent falls and implement seizure precautions as necessary. -Provide one-to-one observation for withdrawal manifestations. -Maintain adequate nutrition and fluid balance. -Create a low-stimuli environment. -Administer medications as prescribed to treat the effects of intoxication or to prevent or manage withdrawal. -Promote emotional support and reassurance to the client and family. -Educate the client and family about addiction and initial treatment goals of abstinence. -Begin to develop motivation and commitment for abstinence and recovery -Encourage attendance at self-help groups. vSim ISBAR ACTIVITY INTRODUCTION STUDENT WORKSHEET Jacqueline Lam, student nurse, acute detoxification unit Your name, position (RN), unit you are working on SITUATION Andrew Davis, 56-year-old, alcohol rehabilitation Patient’s name, age, specific reason for visit BACKGROUND Patient’s primary diagnosis, date of admission, current orders for patient ASSESSMENT Current pertinent assessment data using head to toe approach, pertinent diagnostics, vital signs RECOMMENDATION Any orders or recommendations you mayhave for this patient Diagnosis: Alcohol withdrawal syndrome Date of admission: 08/19/2020 -Lab tests to be performed in the morning, CMP, Mg, and phosphate levels daily for 3 days. -Administer thiamine 100 mg orally once daily -Vitamin B12 2000 mcg orally once daily -Multivitamin with minerals 1 tablet, orally once daily -Regular diet -Assessment of CIWA score every hour for the next 8 hours -Administer 10 mg of diazepam orally every 2 hours for CIWA score of 8 or more. is AOx3. He went to a 12-step meeting yesterday but left early stating Patient that he was “not like those people” and felt he could not benefit from the meeting. He was restless last night and had difficulty sleeping. His behavior is appropriate and he engages appropriately with staff. CIWA score of 1 on admission that has no changed to CIWA score of 20. The patient has been treated with diazepam. Vital signs are unchanged from prior. V/S HR 100, BP 160/94, RR 20, Sp02 99% on RA, and temp 97F. CBC is within the normal range,. CMP reveals a decreased albumin level of 3.1, elevated ALP of 125, elevated AST of 44, and bilirubin of 1.1. ETOH level of 50. Lab findings are suggestive of liver cirrhosis. Continue to monitor the patient since diazepam was administered not too long ago. CIWA score due for reassessment in an hour. Diazepam is ordered PRN for CIWA score of 8 or greater. Andrew is scheduled for therapy today and Alcohol Anonymous meeting. He is pending evaluation by psychiatric later as well. PATIENT EDUCATION WORKSHEET NAME OF MEDICATION, CLASSIFICATION, AND INCLUDE PROTOTYPE MEDICATION: Diazepam CLASSIFICATION: Benzodiazepines PROTOTYPE: Diazepam SAFE DOSE OR DOSE RANGE, SAFE ROUTE Orally, 10 mg 3–4 times in first 24 hr, then decrease to 5 mg 3–4 times daily. IM, IV, 10 mg initially, then 5–10 mg in 3–4 hr as needed; larger or more frequent doses have been used. PURPOSE FOR TAKING THIS MEDICATION This medication is indicated for the management of symptoms from alcohol withdrawal PATIENT EDUCATION WHILE TAKING THIS MEDICATION -Instruct patient to take medication as directed and not to take more than prescribed or increase dose if less effective after a few wk without checking with health care professional. -Medication may cause drowsiness or sedation. Patient advised to avoid driving or operate machinery until aware of adverse effects -Avoid alcohol and other CNS depressants when taking this medication. Clinical Worksheet Date: 08/19/2020 Initials: A.D. Age: 56 M/F: Male Code Status: Unknown Student Name: Jacqueline Lam Diagnosis: Alcohol withdrawal syndrome HCP: Length of Stay: TBD pending consult with psychiatrist Allergies: NKA Consults: Psychiatrist Isolation: None Fall Risk: Yes Assigned vSim: Andrew Davis IV Type: Location: No IV Fluid/Rate: Critical Labs: ETOH 50 Albumin 3.1 ALP 125 AST 44 Bilirubin 1.1 Other Services: Consults Needed: Transfer: Why is your patient in the hospital (Answer in your own words and include the History of present Illness)?: The patient drank prior to his school boarding meeting, become angry and verbally aggressive at the meeting was escorted out. Then his wife asked him to leave the house. He normally drinks 1 pint of vodka. The patient voluntarily checked himself in for alcohol rehabilitation. Health History/Comorbities (that relate to this hospitalization): The patient has surgical history of ORIF repair 2 years ago. Shift Goals/ Patient Education Needs: 1. Patient educated about diazepam medication. 2. Patient educated about alcohol abuse disorder. 3. Shift goals include assessment of CIWA score every hour for 8 hours and follow CIWA Protocol. 4.Short-term goals that include substance abuse group meetings scheduled at various times throughout the day. Path to Discharge: Discussion of available resources in the community for client and family. Provide referral for support groups and Alcoholic Anonymous. Path to Death or Injury: Inconsistent attendance to support groups, group therapy or Alcoholics Anonymous Continuing to drink alcohol, increasing risk for delirium tremens Long-standing history of drinking alcohol also increases the risk for liver cirrhosis and liver failure Alerts: What are you on alert for with this patient? (Signs & Symptoms) Clinical Worksheet Management of Care: What needs to be done for this Patient Today? 1. Auditory and visual hallucinations 1. Promote safety and sleep 2. Anxiety 2. Assessment of CIWA score. 3. 3. Administer prescribed medications. 4. Provide adequate nutrition and intake of fluids Seizures What Assessments will focus on for this patient? (How will I identify the above signs &Symptoms?) 1. Ask the patient directly about auditory and visual hallucinations and provide a safe environment and one-to-one observation 2. Assess level of anxiety and CIWA score. 3. Implement seizure precautions to provide safety for the patient. 5. Encourage expression of feelings, thoughts, hopelessness, and spiritual distress. 6. Assist in goal setting to help the patient see beyond the current situation to instill hope and direction. Priorities for Managing the Patient’s Care Today 1. Provide a safe, low stimuli environment and promote sleep. 2. Provide adequate nutrition and intake of fluids. 3. Perform assessment of CIWA score every hour. List Complications may occur related to dx, procedure, comorbidities: 1. Delirium Tremens 2. 3. 4. Administer prescribed medications: thiamine, vitamin B12, and multivitamin. Administer diazepam 10mg every 2 hours for CIWA score of 8 or more. Wernicke-Korsa- koff syndrome Seizures What nursing or medical interventions may prevent the above Alert or complications? What aspects of the patient care can be Delegated and who can do it? -One-to-one observation can be delegated to CNA. -Vital signs can be performed by the UAP, but following the trend of vital signs cannot be delegated. -CIWA assessment, and medication administration cannot be delegated. 1. 2. Provide a safe, low stimuli environment and one-to-one observation. Continuously assess the patient for alcohol withdrawal symptoms for onset o 3. 4. ...
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