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
-CMP to assess for electrolyte
-Alcohol level to assess level of alcohol
-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
-transient hallucinations or illusions
-increased blood pressure, resp rate, and
-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
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
-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
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 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
-Avoid alcohol and other CNS depressants when taking this medication. Clinical Worksheet Date: 08/19/2020
Unknown Student Name: Jacqueline Lam
syndrome HCP: Length of Stay:
TBD pending consult
Yes Assigned vSim: Andrew Davis IV Type:
Fluid/Rate: Critical Labs:
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
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
Assist in goal setting to help the patient see beyond the current situation to
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
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
-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
View Full Document