vSIM for Nursing Describe Disease Process Affecting Patient (Include Pathophysiology of Disease Process) Alcohol withdrawal occurs when reduced or quitting of alcohol after heavy and prolonged use. The most common sign of alcohol withdrawal is tremulousness, commonly called the shakes, or jitters, that begins 6-8 hours after alcohol cessation. Mild to moderate alcohol withdrawal includes agitation, lack of appetite, N/V, insomnia, impaired cognition, and mild perceptual changes. Both SBP and DBP increase, as does pulse, and body temperature. Psychotic and perceptual s/s begin in 8-10 hours. Withdrawal seizures may occur 12-24 hours and alcohol withdrawal delirium is a medical emergency that can result in death. Alcohol withdrawal delirium may result anytime within the first 72 hours (Halter, 2018, p. 420-421). Diagnostic Tests (Reason for Test & Results) ● BAC: to determine blood alcohol level in patient’s blood ● CIWA to help in assessment and management of alcohol withdrawal Patient Information Anticipated Physical Findings A.Davis is a 56 y.o male Primary DX: Alcohol withdrawal ● ● ● ● ● ● Hx: Alcoholism, Pt. states he drinks 1 ● DSM-5 Criteria for alcohol use pint of Vodka QD, disorder previous ORIF of humerus about 2 yrs ago. Pt denies use of recreational drugs, (Halter, 2018, p. 419-423). neg. for marijuana, neg. for opiates. ● ● ● ● ● ● ● ● Shakes or jitters Agitation Lack of appetite N/V Impaired cognition Mild perceptual changes Tachycardia Diaphoresis Fever Anxiety Insomnia Hypertension Delusions Visual Anticipated Nursing Interventions ● ● ● ● ● ● ● Safety promotion (primary focus) Promoting sleep Reintroduce healthy food and hydration Support and encouragement of self care Administer meds as necessary (Benzodiazepines, Anticonvulsants Assistance in goal setting Health teaching and promotion (social activities (ex: AA) vSIM ISBAR Activity Introduction (Your name, position (RN), unit you are working on) Hi Dr. Foulks this is Melissa. I am an RN in the Alcohol Rehab facility. Situation (Patient’s name, age, specific reason for visit) I have your patient, Andrew Davis here. He is a 56 y.o male who has voluntarily admitted himself for detox. Background (Patient’s primary diagnosis, date of admission, current orders for patient) He was admitted yesterday, 07/06/20 and is being treated today for alcohol withdrawal/detox. I am following your orders according to his CIWA score. Assessment (Current pertinent assessment data using head to toe approach, pertinent diagnostics, vital signs) His CIWA score was 26. VS show elevated BP, HR, and RR. (BP: 160/94, HR: 20 breaths/min, RR: 100/min). Mr. Davis is restless, pacing, sweaty on his forehead, and has tremors with arms extended. He was given Diazepam 10mg PO at 0800 He is showing moderate symptoms R/T to alcohol withdrawal Recommendation (Any orders or recommendations you may have for this patient) I will continue to monitor his behavior and VS according to your order. I would recommend that you come and evaluate him for further treatment. Patient Education Worksheet Name of Medication, Classification, and Include Prototype Medication: Thiamine 100mg PO QD Classification: Prototype: Vitamin B1 Safe Dose or Dose Range, Safe Route 5-10 mg 3 times daily Purpose for Taking This Medication Prevention of Wiernicke’s encephalopathy. Dietary supplement in patients with GI disease, alcoholism, or cirrhosis. Patient Education While Taking This Medication ● Encourage patients to comply with dietary recommendations of HCP. ● Educate that the best source of vitamins is from a well-balanced diet with foods from four basic food groups ● Teach pt foods high in Thiamine (whole grain and enriched), meats (prok), and fresh vegetables (loss is variable with cooking). ● Caution pts self-medication with Thiamine to stick to RDA (Vallerand & Sanoski, 2019). Name of Medication, Classification, and Include Prototype Medication: Multivitamin 1 tab PO QD Classification: Vitamins Prototype: B complex with B and C Safe Dose or Dose Range, Safe Route Read manufacturer RDA Purpose for Taking This Medication Treatment and prevention of vitamin deficiencies Patient Education While Taking This Medication ● Encourage patient to comply with recommendations of health care professionals. Explain that the best source of vitamins is a well-balanced diet with foods from the 4 basic food groups. ● Advise parents not to refer to chewable multivitamins for children as candy (Vallerand & Sanoski, 2019). Name of Medication, Classification, and Include Prototype Medication: Vitamin B12 2000mcg QD Classification: Vitamin Prototype: Vitamin B12 Safe Dose or Dose Range, Safe Route PO: 1000-2000 mcg/day Purpose for Taking This Medication Tx of Vitamin B12 deficiency, Megaloblastic anemia R/T Vitamin B12 deficiency Patient Education While Taking This Medication ● Encourage the patient to comply with diet recommenda best source of vitamins is a well-balanced diet with best source of vitamins is a well-balanced diet with foods from the four basic food groups. ● Foods high in vitamins include meats, seafood, egg yolk, and fermented cheeses: few vitamins are lost with ordinary cooking. ● Patients self-medicating with vitamin supplements should be cautioned not to exceed RDA. Effectiveness of megadoses for treatment of various medical conditions is unproved and may cause side effects. ● Emphasize the importance of follow-up exams to evaluate progress (Vallerand & Sanoski, 2019). Name of Medication, Classification, and Include Prototype Medication: Diazepam 10mg PO Q2H prn Classification: Benzodiazepines Prototype: Valium Safe Dose or Dose Range, Safe Route Antianxiety: 2-10 mg 2-4 times daily Purpose for Taking This Medication Adjunct in the management of anxiety disorder Patient Education While Taking This Medication ● Instruct patient to take medication as directed and not to use more than prescribed or increase dose if less effective after a few weeks without checking with a healthcare professional. Review package insert for Diasts rectal gel with patient/caregiver prior to adAbrupt withdrawal of diazepam may cause insomnia and seizures. Athise patient that sharing of this medication may be dangerous. ● Medication may cause drowsiness, clumsiness, or advise patients to avoid driving or activities requiring alertness until response medication is known. ● Caution patient to avoid taking alcohol or other CNS depressants concurrently with this medication (Vallerand & Sanoski, 2019) Clinical Worksheet Date: 05/23/20 Student Name: Donna Soto Assigned vSIM: Sabina Vasquez Initials: A.D Age:65 y.o M/F: Male Code Status: Full code Diagnosis: Alcohol withdrawal Length of Stay: TBD Allergies: NKDA HCP: J. Foulks Consults: Psychothe rapy, Neurologi st, Social work Isolation: Standard Fall Risk: High Transfer: TBD IV Type: N/A Location: Alcohol Rehab Unit Fluid/Rate: N/A Critical Labs: CMP, Blood levels of Mg, Phos., Ethanol, and Vit. B12. Serum Alb, ALP, AST, BILI, EtOH Other Services: Consults Needed: Psychotherapy, Neuro, Social work. Referral to AA meetings Why is your patient in the hospital? (Answer in your own words and include the history of the present illness) Patient self admitted for alcohol abuse, alcohol withdrawal. Health History/Comorbidities (that relate to this hospitalization): Hx of alcohol abuse, previous Sx of ORIF of humerus (side unknown) about 2 yrs ago. Shift Goals/Patient Education Needs: 1. Decrease patients anxiety level (monitor Diazepam at therapeutic level) 2. Minimize effects of alcohol withdrawal 3. Discuss alternative modes to decrease stress Path to discharge: Patient is managed through the detox process in the inpatient setting (about 24 hrs), Diazepam levels are kept at a therapeutic level, patient’s Thiamine is kept at a therapeutic level, patient able to discuss reasons for alcohol use, patient able to notice effects that alcohol use has on life/work/church life/family. A.D understands alternatives to managing stress and anxiety. As well as, is open to discussing AA meeting attendance. Path to death or injury: Patient goes from alcohol withdrawal, to alcohol delirium, to Korsakoff’s syndrome. A.D’s alcohol use is too extensive to the point of damage to organs, cirrhosis of liver, and progression to Korsakoff’s syndrome due to Thiamine levels remaining below therapeutic value. Alerts: What are you on alert for with this patient? (S&S) 1. Increased diaphoresis 2. Serum Thiamine level 3. Increased agitation What assessments will you focus on for this patient? (How will I identify the above signs and symptoms?) 1. CIWA score, visual assessment 2. Monitor of labs 3. Assessment of patient’s mood and attitude towards treatment and any thoughts about hurting himself. List complications that may occur r/t dx, procedure, comorbidities: 1. Korsakoff’s syndrome R/T thiamine deficiency 2. Electrolyte imbalance 3. Neuro changes R/T alcohol withdrawal What nursing or medical interventions may prevent the above alert or complications? 1. Maintain therapeutic level of thiamine for this pt. 2. Monitor electrolytes (ex: s/s dysrhythmias, tachycardia, N/V, confusion) 3. CIWA score evaluations 4. Neurological checks prn Management of Care: What needs to be done for this patient today? 1. Maintain therapeutic medication levels 2. Decrease stimuli and stress factors 3. Decrease any risk of injury or harm to himself Priorities for managing the patient's care today: 1. Review labs and notify HCP of any abnormalities 2. Encourage rest periods, lower lights, cluster care 3. Continued CIWA score assessments 4. Educate patient on alternatives to stress reduction 5. Administer meds prn What aspects of the patient care can be delegated and who can do it? Nursing Process ● UAP can assist patient with ambulation ● UAP can assist patient with bathing and bathroom needs ● UAP can offer comfort measures ● UAP can assist with obtaining VS or applying equipment for continuous VS and notify me of any abnormal values ● UAP/LVN can draw blood for lab work under my direction ● UAP can assist with turning patient Q2H (to prevent skin breakdown) and position changes ● UAP/LVN can assist family with making food choices from hospital menu ● UAP/LVN can apply cardiac monitor to patient ● UAP can sit in patient’s room to observe for safety Nursing Diagnosis -What two nursing priorities (nursing diagnosis/problem) guide your plan of care (psychosocial, physical, spiritual)? 1. Ineffective coping R/T alcohol use AEB increased use and impairment in life functioning (Halter, 2017, p. 426). Nursing Interventions -List of minimum of 2 nursing interventions per goal 1A. Identify with the patient the factors (genetics, stress) that contribute to chemical addiction (Halter, 2017, p. 426). 1B. Assist patient to identify negative effects of chemical dependency (Halter, 2017, p. 426). 2. Risk for injury R/T altered mental status AEB alcohol withdrawal manifestations and CIWA score of 26. 2A. Identify stage of AWS (alcohol withdrawal syndrome); i.e., stage I is associated with signs and symptoms of hyperactivity (tremors, sleeplessness, nausea and vomiting, diaphoresis, tachycardia, hypertension). Stage II is manifested by increased hyperactivity plus hallucinations and seizure activity. Stage III symptoms include DTs and extreme autonomic hyperactivity with profound confusion, anxiety, insomnia, fever (Vera, 2019). 2B. Monitor and document seizure activity. Maintain patent airway. Provide environmental safety (padded side rails, bed in low position) (Vera, 2019). Nursing Goals & Expected Outcomes -Discuss your evaluation and the expected outcome of each nursing intervention -Include 2 patient goals per nursing diagnosis (short and long term) 1. A. Davis will be able to discuss alternate stress relief methods (ex: exercise, talking with family, meditation, going to AA meetings). Rationale -Cite all texts or resources used to write interventions in APA format 1. Emphasis on alcoholism as a disease can lower guilt and increase self esteem (Halter, 2017, p. 426). 2. Begins to decrease denial and increase problem solving (Halter, 2017, p. 426). 3. Prompt recognition and intervention may halt progression of symptoms and enhance recovery or improve prognosis. In addition, recurrence or progression of symptoms indicates a need for changes in drug therapy and more intense treatment to prevent death (Vera, 2019). 4. Monitor and document seizure activity. Maintain patent airway. Provide environmental safety (padded side rails, bed in low position) (Vera, 2019). Response to Intervention -Summarize patient’s response to intervention 1. Client is able to discuss his reasons for use of alcohol (Halter, 2017). 2. Client is able to notice/identify the side effects (life altering) effects that alcohol will have on 2. Client will acknowledge consequences associated with alcohol use (Halter, 2017). 3. Client will commit to alcohol-use strategies (Halter, 2017). 4. The patient will have decreased risk of injury-no injury while admitted. him, his family, and interpersonal relationships. 3. After 3 weeks, patient states that he attends AA meetings every day. He is learning about his triggers and new coping skills. Wife and family attends Al-Anon (Halter, 2017). 4. Patient did not have an incidence of injury while under my care and denied thoughts of hurting himself. Citation Gulanick, M., and Myers, J.L. (2017). Nursing care plans: diagnoses, interventions, & outcomes (9th ed.). St. Louis, MO: Mosby, an imprint of Elsevier Inc. Halter, M.J. (2018). Varcarolis’ foundations of psychiatric-mental health nursing (8th ed.). St. Louis, MO: Mosby, an imprint of Elsevier Inc. Vallerand, A. H., & Sanoski, C. A. (2019). Davis's drug guide for nurses (16th ed.). Philadelphia, PA, PA: F.A. Davis Company. Vera, M. (2019, April 09). 5 Alcohol Withdrawal Nursing Care Plans. Retrieved July 12, 2020, from https://nurseslabs.com/5-alcohol-withdrawal-nursing-care-plans/
