Concept Map-vsims 1 Med 20118 PDF

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Summary

Open book chapter quizzes for chapters dewitt...

Description

Concept Map

Assessment 56 yo male who voluntarily admitted himself to Alcohol Rehab Facility yesterday evening. Currently on the Acute detoxification unit A&O x3, 20 BPM, BP: 154/90, Pulse OX: 98% Pulse: 94, Temp: 99.0 F CIWA score was 1 on admission and at 0400 it increased to 7

Diagnosis & History Open reduction internal fixation surgery of humerus fracture x 2years ago intakes 1 pint of vodka Alcohol withdrawal syndrome

Medications Diazepam 10mg every 2 hrs PRN Thiamine 100mg orally daily 1800 Multivitamin 1 tablet orally daily 1800 B12 2000 mcg orally once daily 1800

NANDA Diagnosis

Sensory alterations related to alcohol sudden cessation as evidenced by tremors present

Lab Result

HGB: 14 HC: 42 WBC: * Platelets: 243 ETOH: 50 AST;44 Biliribuin: 1.1 ALP:125

Pathophysiology

Nursing Actions

Alcohol withdrawal syndrome occurs in individuals that discontinue alcohol intake after a prolonged period of time causing mild tremors.

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Jasmin Carbajal

Name_________________________________________________________ Date________________ Cohort____________

Concept Map-v1.1

Nursing Plan of Care

Medical Diagnosis:

Alcohol withdrawal syndrome

Nursing Diagnosis:

Sensory alterations related to alcohol sudden cessation as evidenced by tremors present

Goals/Expected Outcome (Include Time Frame):

Client will regain appropriate level of consciousness with absence of tremors within in my 12 hr shift.

Interventions

1. Monitor for signs and symptoms of depression or suicidal thoughts. 2. Provide a calm and safe environment free from noise and shadows 3. Provide education and resources for client and family members

Rationale

1. Sensory to light and sensory disturbances can lead to severe injury 2. Any signs of confusion and anxiety can prompt the client to attempt suicide 3. Support groups and counseling services may help the client and the family able to maintain daily functioning

Evaluation

1. Goal is met as evidence by no signs and symptoms of depression or suicidal thoughts 2. Goal is met as evidenced by client showing no signs and symptoms of anxiety 3. Goal is met as evidenced by family participating in counseling services

Evaluation of Goals (Met or Unmet):

Goal is met as evidenced by client regaining level of consciousness x4 with absence of tremors

Concept Map-v1.1...