vSim ISBAR Activity Student WorksheetIntroduction(Your name, position (RN), unit you are working on)Melanie Torres Maria MartinezClaudia Martinez BSN StudentAcute Dextoxification UnitSituationPatient’s name, age, specific reason for visitMr. Davis is a 56-year-oldman who voluntarily admitted himself to the alcohol rehabilitation facility yesterday afternoon. He is currently on the acute detoxification unit. Mr. Davis has been on the unit for about 16 hours.
BackgroundPatient’s primary diagnosis, date of admission, current orders of patientMr. Davis is a member of the school board and the pastor of a large church. Yesterday he was removed from a school board meeting by security guards after becoming angry and directing racial and ethnic slurs at students and their family members. His wife afterward asked him to move out of their home, and this led to the admission. Mr. Davis had an open reduction internal fixation surgery to repair a humerus fracture 2 years ago, but otherwise, he has no significant medical history and no known allergies. He reports that his alcohol intake is approximately 1 pint of vodka perday and his last drink was prior to the school boardmeeting. He denies using recreational drugs and tested negative for opiates and marijuana. He does not smoke.Primary Diagnosis:Alcohol WithdrawalAdmission:02/25/20Orders:Lab test or Magnesium and phosphate daily for next3 days. Thiamine 100mg orally daily,vitamin B12 2000mcgorally once daily, multivitamin, regular diet, perform CIWA every hour for 72 hrs if score is more than 8, if less than 8 perform every every hour for 8 hrs.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. Davis denied feeling sick to his stomach, but had no desire to eat.Clinical Institute Withdrawal Assessment of Alcohol Scale. Score 23
RecommendationAny orders or recommendations you may have for this patient He is due for reassessment of the CIWA score in our treatment room. He has an order for as-needed