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Clinical WorksheetDate: 4/28/2020 Student Name: Angelina Hendley Assigned vSim: Andrew Davis IniIals: ADAge 56 yo Male Code Status: Full CodeDiagnosis: Alcohol Withdrawal Syndrome Length of Stay: TBD Allergies: No KnownHCP: Petra Popovic, RN Carol Walsh, MD Consults: PsychIsolaIon: None Fall Risk: PotenIal Transfer: PotentialIV Type: N/A LocaIon: N/A Fluid/Rate: PotenIal but no orders at this ImeCriIcal Labs: • Serum Albumin 3.1 • ALP 125 • AST 44 • Bilirubin 1.1 • ETOH 50Other Services: N/A Consults Needed: PsychWhy is your paIent in the hospital (Answer in your own words and include the History of present Illness): My paIent is here to safely detox from alcohol. He is also potenIally here to get a psych consult. He drinks a pint of vodka a day and his last drink was prior to the school board meeIng he was at prior to his arrival to the hospital. He has no significant medical history apart from an open reducIon internal fixaIon surgery to repair a humerus fracture 2 years ago. He has no known allergies.Health History/Comorbidity (that relate to this hospitalizaIon): Health history as stated above and no known comorbidiIes
Clinical WorksheetShi‘ Goals/ PaIent EducaIon Needs: 1. Asssess CIWA to properly begin sedaIon therapy 2. Educate paIent on medicaIon risks. Implant fall risks and seizure precauIons as necessary. 3. Reorient paIent to person/place/Ime as necessary if DT sets in 4. Reassess paIent on CIWA as o‘en as your facility protocol and medicate with benzodiazepines and PRN for nausea, vomiIng, pain, etcPath to Discharge: • Every paIent is different. Some paIents may be fully detoxed a‘er several days, and others might spend a couple of weeks in the hospital. SedaIon allows for the safe withdrawal from alcohol. Benzodiazepines are the drugs of choice in most regions because of their high therapeuIc safety index and anIconvulsant properIes. In conjuncIon with sedaIon therapy, a paIent will receive ﬂuids, electrolytes and have their blood and serum levels monitored closely. Once the paIent is stable on all fronts, they will sully get some type of inpaIent psychiatric care or else be refereed to an outpaIent psychiatric treatment program. From there they will discharged. The nurse should educate the paIent on seeking inpaIent care if a relapse was to occur and on all the community resources available to help stay sober (such as AA).