6.9 Learning Activities

Alcohol Withdrawal Case Study^[1]

Use the following information to answer questions 1-6

Handoff Report

0053: This is a 54-year-old, David Nguyen, admitted to the medical-surgical unit for acute pancreatitis. Currently, he is experiencing alcohol withdrawal and reports mild nausea, restlessness, insomnia, tremor, diaphoresis, palpitations, and headache. He also exhibits mild confusion and agitation. Abdominal assessment reveals distention and tenderness upon palpation. His vital signs are: BP 140/90 mmHg, HR 110 bpm ,RR 20 breaths/min, Temp 99.5°F (37.5°C), O2 Sat 98% on room air.

He rates his pain level as 6 out of 10. Last dose of pain medication was administered four hours ago. Continue to monitor and treat pain per order and assess for signs of alcohol withdrawal delirium. Initiate fall risk precautions and round hourly on the client.

Diagnoses

• Acute pancreatitis
• Alcohol withdrawal
• Diabetes Mellitus Type 2
• Depression
• Pain (6/10)
• Risk for falls

Plan

• Manage pain and monitor for effectiveness of interventions
• Closely monitor for signs of alcohol withdrawal delirium and administer medications as ordered per CIWA protocol
• Monitor blood glucose levels and manage diabetes
• Implement fall risk precautions
• Provide a calm and quiet environment to promote rest and reduce agitation
• Consult with a social worker to address social support and alcohol dependence
• Educate the client about the risks of alcohol consumption, particularly in relation to his current health conditions
• Encourage the client to participate in a support group for alcohol dependence

1. Based on the handoff report, which assessment finding is MOST important for the nurse to validate during the initial assessment of Mr. Nguyen?

a. History of diabetes mellitus

b. Report of headache

c. Mild confusion and agitation

d. Abdominal distention and tenderness

2. Which of the following is a PRIORITY nursing diagnosis for Mr. Nguyen?

a. Risk for unstable blood glucose level

b. Ineffective coping related to alcohol dependence

c. Risk for injury related to confusion and agitation

d. Imbalanced nutrition: Less than body requirements

3. In planning care for Mr. Nguyen, which intervention should the nurse implement to address his risk for falls?

a. Place the client in a room farthest from the nurses’ station.

b. Request a prescription for physical therapy assessment.

c. Encourage family members to stay with the client at all times.

d. Use bed alarms as part of a comprehensive fall prevention program

4.  The nurse is preparing to administer Mr. Nguyen’s medications. Which of the following medications should the nurse anticipate administering FIRST?

a. Insulin aspart subcutaneously

b.  Chlordiazepoxide

c.  Sertraline by mouth

d. Hydromorphone intravenous

5.  Thirty minutes after administering Chlordiazepoxide (Librium) to Mr. Nguyen, he is resting quietly in bed. What is the nurse’s BEST action?

a.  Continue to monitor Mr. Nguyen’s vital signs, results of the Clinical Institute Withdrawal Assessment for Alcohol Scale (CIWA-Ar), and for signs of alcohol withdrawal.

b. Administer the PRN hydromorphone (Dilaudid), as the client is now calm and will remain still.

c. Remove the bed alarm as it is no longer needed because the medication has taken effect.

d. Notify the provider that the medication was effective.

6.  The nurse recognizes which outcome is EFFECTIVE in evaluating the goal of healthy coping in Mr. Nguyen?

a. Client expresses desire to participate in a group session about alcohol use disorder.

b. Client remains free from falls throughout the shift.

c. Client verbalizes understanding of his medication regimen for diabetes mellitus.

d. Client’s blood glucose levels remain within the target range.