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I Alcohol
1 BehavioralUntt
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A 1
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01 of stay:
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Nursing Diagnosis and Categories of Care
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Time Dimension
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Goals/Actions
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Time Dimension
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Goals/Actions
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Time Dimensions
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Goals/Actions
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Risk for
injury (varied autonomic and sensory responses)
Referrals
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Day 1
Day 1
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Verbalize understanding of unit
policies, procedures, and safety concerns relative to individual
Cooperate with therapeutic
regimen
RN-NP or MD If indicated:
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Day 3
Day 4
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Vital signs stable I&O balanced Display marked decrease in
objective symptoms
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Day 7
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Discharge:
Be free of injury resulting from alcohol
withdrawal
Display no objective symptoms of
withdrawal
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Internist
Cardiologist
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Diagnostic
studies
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Day 1
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Neurologist
Blood alcohol level Drug screen (urine
and blood)
If indicated:
Chest x-ray Pulse oximetry
ECG
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Day 2
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SMA 20: serum Mg,
amylase
Urinalysis
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Day 4
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Repeat of selected
studies as indi-
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Additional assess-
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Day 1
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VS, temperature, respiratory
status/breath
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Day 2-3
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VS q8h if stable
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Day 4-7
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VSqd
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Day 1-4
Ongoing
Stage I
Stage II
Stage III
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sounds q4h
I&O q8h
Motor activity, body language,
verbalizations, need for/type of restraint
Withdrawal symptoms:
Tremors, N/V, hypertension,
tachycardia, diaphoresis, sleeplessness
Increased hyperactivity,
hallucinations, seizure activity
Extreme autonomic hyperactivity,
profound confusion, anxiety,
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Marked decrease in objective
symptoms
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Day 6
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Discontinue I&O
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Medications Allergies:
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Day 1
Day 1-4
Day 2
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Librium 200 mg PO
Thiamine 100 mg
IM
Librium 160 mg PO
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Day 3
Day 4
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Librium 120 mg PO
Librium 80 mg PO
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Day 5
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Librium 40 mg PO
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Patient education
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Day 1
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Orient to room/ unit, schedule,
procedures
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Day 5
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Need for ongoing therapy
Goals/availability of AA program
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Day 7
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Schedule of followup visits if indicated
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Additional nursing actions |
Dayl |
Bedrest 12 hr if inwithdrawal
Position
change, HOB elevated Cough, deep breathe
Exercises if on bed rest
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Day 3-7 |
Activity as tolerated |
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Day 1-2
Assist with ambulation, self-care as needed
Encourage fluids if freeofN/V
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Ongoing |
Provide environmental safety measures
Seizure precautions as indicated
Reorient as needed
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Ineffective individual coping R/T personal vulnerability, situational crisis, inadequate coping methods |
Day 1-7 |
Participate in development/evaluation of treatment
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Day 3
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Verbalize understanding of relationship of alcohol abuse to current situation
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Day 7 |
Plan in place to
meet postdischarge needs
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Day 2-7 |
Interact in group sessions |
Day 6 |
Identify/make contact with potential resources, support groups |
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Referrals |
Day 1 |
Psychiatrist |
Day 5 |
Community classes:
assertiveness training
Stress management
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Day 2-7 |
Group sessions |
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Additional assessment |
Day 1 |
Understanding of current situation
Drinking pattern, previous withdrawal, other drug use, attitudes toward substance use
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Day 2-3
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Previous coping
strategies/consequences
Perception of drug use on life, employment, legal
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Day 1—2 |
History of violence
Relationships with others: personal, work/school
Readiness for group activities
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Day 3-7 |
Congruency of actions based on insight
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Medications |
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Day 5-7 |
Naltrexone 50 mg/day if indicated |
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Patient education |
Day 1 |
Physical effects of alcohol abuse
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Day 3-7 |
Human behavior and interactions with others/ transactional
analysis (TA)
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Day 7
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Medication dose, frequency, side Written instructions for therapeutic program |
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Day 1-2 |
Types/use of relaxation techniques |
Day 5-6 |
Community resources for self/ family
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Day 2 |
Consequences of alcohol abuse |
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Additional nursing actions |
Day 1—7 |
Support patient’s taking responsibility for own recovery
Provide consistent approach/ expectations for behavior
Set limits/confront inappropriate behaviors
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Day 2-5 |
Identify goals for change
Discuss alternative solutions
Provide positive feedback for efforts
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Day 2-7
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Support during confrontation by peer group
Encourage verbalization of feelings, personal reflection
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Altered nutrition: less than body requirements R/T poor intake, effects of alcohol on digestive system, and hypermetabolic response to withdrawal |
Day 2-7 |
Select foods appropriately to meet individual dietary |
Day 4 |
Verbalize understandings of effects of alcohol abuse and reduced dietary intake on nutritional status |
Day 7 |
Display stable weight or initial weight gain as appropriate, and laboratory results WNL |
Referrals |
Day 1 and prn |
Dietitian |
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Diagnostic studies |
Day 1 |
CBC, liver function
Serum albumin, transferrin
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Day 2-7
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Finger-stick glucose prn
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Additional assessments |
Day 1 |
Weight, skin turgor, condition of mucous membranes, muscle tone |
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Day 7 |
Weight |
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Day 1-2 |
Bowel sounds, characteristics of stools |
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Day 1-7 |
Appetite, dietary intake |
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•Z) Medications |
Day 1-7 |
Antacid ac and hs (e.g., Maalox)
Imodium 2 mg prn
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Day 2-7
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Multivitamin tablet qd
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Patient education |
Day 1-2 |
Individual nutritional needs
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Day 4
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Principles of nutrition, foods for maintenance of wellness
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Additional nursing actions |
Day 1 |
Liquid/bland diet as tolerated |
Day 2-7 |
Advance diet as tolerated |
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Day 1-7 |
Encourage small, frequent, nutritious meals/ snacks
Encourage good oral hygiene pc and hs
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