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Care Plan A. Davis .pdf (1)

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
Patient Information
Anticipated Physical
A.Davis is a 56 y.o
Primary DX: Alcohol
Hx: Alcoholism, Pt.
states he drinks 1
● DSM-5 Criteria for alcohol use pint of Vodka QD,
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
Lack of appetite
Impaired cognition
Mild perceptual
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
(Your name, position (RN), unit
you are working on)
Hi Dr. Foulks this is Melissa. I am an RN in the Alcohol
Rehab facility.
(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.
(Patient’s primary diagnosis, date
of admission, current orders for
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.
(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
(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
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,
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
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
Length of Stay:
J. Foulks
st, Social
Fall Risk:
IV Type:
Alcohol Rehab
Critical Labs:
CMP, Blood
levels of Mg,
Phos., Ethanol,
and Vit. B12.
Serum Alb,
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
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.
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,
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
Priorities for managing the patient's care
1. ​Review labs and notify HCP of any
2. Encourage rest periods, lower lights,
cluster care
3. Continued CIWA score assessments
4. Educate patient on alternatives to stress
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
● UAP/LVN can assist family with making
food choices from hospital menu
● UAP/LVN can apply cardiac monitor to
● 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,
Ineffective coping R/T
alcohol use AEB increased
use and impairment in life
functioning (Halter, 2017, p.
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.
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
-Cite all texts or resources used to
write interventions in APA forma​t
1. Emphasis on alcoholism
as a disease can lower
guilt and increase self
esteem (Halter, 2017, p.
2. Begins to decrease denial
and increase problem
solving (Halter, 2017, p.
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,
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
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.
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/