JMJ Marist Brothers

Notre Dame of Marbel University

College of Arts and Sciences – Nursing Department
Alunan Avenue, Koronadal City, South Cotabato

Patient’s Name: Patient R Age: 28 Sex: M

Chief Complaints:______________________________________________________ Diagnosis: Alcohol Use Disorder and Alcohol Withdrawal
Date Admitted: June 8, 2021 at 11:30 AM

ASSESSMENT CUES NEEDS NURSING BACKGROUND NURSING OBJECTIVES INTERVENTIONS RATIONALE EVALUATION
DIAGNOSIS INFORMATION
June 9, 2021 @ 8:00 P Risk for injury Risk for injury is a At the end of 8 hours Independent: Independent: June 9, 2021 @ 4:00 PM
AM H related to condition in which a nursing interventions, 1. Established rapport. 1. To gain cooperation. Goal Partially Met
Y autonomic patient is vulnerable to the patient will remain 2. Approached in a calm and 2. To promote a feeling of
Subjective: S hyperactivity After 8 hours of nursing
physical damage due to free from physical therapeutic manner. trust and safety.
I secondary to interventions the patient
environmental injuries and maintain 3. Used simple and brief words 3. To be easily
“I feel light O alcohol remained free from
conditions interacting safety. when giving instructions. understood and
headedness” as L withdrawal physical injuries and
verbalized. O with the patient’s Specifically: 4. Assessed VS before rendering prevent agitation.
maintained safety.
G adaptive and defensive interventions. 4. To have a baseline data
Objective: I 1. Display a and for future ● Displayed a
resources, which may 5. Provided a quiet
C decrease in comparisons.
- BP: 140/100 compromise health. For environment conducive for decrease in B/P:
A B/P, PR, RR
patients who have treatment. 5. To promote relaxation 130/100 mmHg,
mmHg L and Temp to
prolonged intake of 6. Performed TSB. and rest. PR: 96 bpm, RR: 20
- PR: 120 bpm normal range.
alcohol, they are 2. Display an 7. Instructed to move slowly 6. To help reduce cpm, and temp:
- RR: 25 cpm N
E predisposed to increase in O2 when changing positions. temperature. 37.9°C. However,
- Temp: 38.5°C
E developing withdrawal sat to normal 8. Instructed SO to raise side 7. To prevent dizziness. B/P and Temp are
- 02 Sat: 95% range.
D syndromes. Withdrawal rails in left unattended, lower 8. To ensure safety and not in normal
- (+) tremors 3. Recall and
symptoms may include and maintain bed at lowest prevent fall or injury. range as with PR
- (+) difficulty demonstrate
autonomic hyperactivity level, and accompany when 9. For safety precaution and RR.
sleeping 3 safety
manifestations such as measures to walking. for possible seizure ● Displayed an
- (+) restlessness
hypertension, prevent 9. Instructed to prepare a towel attack. increase in O2 sat:
- (+) nausea
tachyarrhythmias, possible at bedside. 10. To lower RR and 96%.
- (+) vomiting x 1 injury.
peripheral 10. Encouraged to do deep promote relaxation to ● Recalled and
- (+) hallucinations
- (+) anxious vasoconstriction, and breathing exercises. reduce anxiety. demonstrated 3
hyperthermia or 11. Encouraged to rest. 11. To regain energy. safety measures to
hypothermia. With the 12. Monitored I and O. 12. To assess for prevent possible
manifestations of 13. Monitored VS. dehydration since the injury such as
autonomic hyperactivity patient is vomiting and raising the side
along with other signs experiencing rails if unattended,
and symptoms such as diaphoresis. lowered bed at
tremors, insomnia, 13. To assess therapeutic lowest level, and
diaphoresis, anxiety, response to asked SO to
nausea and vomiting, interventions done. accompany him
including episodes of when going
hallucinations, plus the Dependent Dependent: somewhere.
vital signs as follows 1. Administered diazepam 1. To reduce anxiety,
B/P: 140/100 mmHg, (Valium) 5mg q8 as ordered . possibility of seizure
PR:120 bpm, RR: 25 attack and withdrawal
symptoms.
cpm, T: 38.5°C and O2
sat of 95%, the patient
may predisposed from
having seizure. If these
manifestations persist
the patient will have a
possibility to have a
seizure attack which will
indicate a risk for injury,
thus, ensuring patient’s
safety is essential.

References:

Benarroch, E. (2014).
Autonomic
Hyperactivity. Oxford
medicine online.
Retrieved on June 10,
 2021 from
https://oxfordmedicine.
com/view/10.1093/med
/9780199920198.001.00
01/med-
9780199920198-
chapter-13

Doenges, M.E, et. Al.

Nurse’s Pocket Guide
Edition 14. F.A. Davis
Company. Philadelphia,
Pennsylvania. 2008.

Student’s Name: Precious Olivet V. Dongon, SN

Clinical Instructor: Bianney Mae A. Ranes, RN, MAN