A nurse is caring for a client in the emergency department (ED). Exhibit 1 Nurses' Notes 0600: Client presents with acute altered mental status. Client has a history of frequent ED visits for alcohol intoxication. Client states that they had an episode of binge drinking yesterday afternoon. Client awoke this morning on the living room floor trembling and flushed; remembers having intense dreams and was afraid they had a seizure so they called a family member to bring them to the ED. Client reports their average alcohol intake has been "two or three beers" after work each day and "more on the weekends" for the past 6 months. Client reports headache, nausea, agitation, and is noted to be diaphoretic. 0800: Client states "I've got bugs crawling on me. Get them off me!" Client tremulous and diaphoretic. Exhibit 2 History and Physical Alcohol use disorder Delirium tremens Nicotine use disorder Hypertension, diet and exercise controlled. Exhibit 3 Vital Signs 0600: Temperature 37° C(98.6° F) Heart rate 110/min Respiratory rate 20/min Blood pressure 140/90 mg Hg Oxygen saturation 98% on room air 0800: Temperature 37° C (98.6° F) Heart rate 114/min Respiratory rate 20/min Blood pressure 180/100 mg Hg Oxygen saturation 98% on room air Exhibit 4 Laboratory Results 0600: Blood alcohol concentration 80 mg/dL (0 to 50 mg/dL)
A nurse is caring for a client in the emergency department (ED).
Exhibit 1
Nurses' Notes
0600:
Client presents with acute altered mental status. Client has a
history of frequent ED visits for alcohol intoxication. Client
states that they had an episode of binge drinking yesterday
afternoon. Client awoke this morning on the living room floor
trembling and flushed; remembers having intense dreams and
was afraid they had a seizure so they called a family member to
bring them to the ED.
Client reports their average alcohol intake has been "two or
three beers" after work each day and "more on the weekends"
for the past 6 months.
Client reports headache, nausea, agitation, and is noted to be
diaphoretic.
0800:
Client states "I've got bugs crawling on me. Get them off me!"
Client tremulous and diaphoretic.
Exhibit 2
History and Physical
Alcohol use disorder
Delirium tremens
Nicotine use disorder
Hypertension, diet and exercise controlled.
Exhibit 3
Vital Signs
0600:
Temperature 37° C(98.6° F)
Heart rate 110/min
Respiratory rate 20/min
Blood pressure 140/90 mg Hg
Oxygen saturation 98% on room air
0800:
Temperature 37° C (98.6° F)
Heart rate 114/min
Respiratory rate 20/min
Blood pressure 180/100 mg Hg
Oxygen saturation 98% on room air
Exhibit 4
Laboratory Results
0600:
Blood alcohol concentration 80 mg/dL (0 to 50 mg/dL)
Trending now
This is a popular solution!
Step by step
Solved in 3 steps
