ETOH Withdrawal or Delirium?
Next Gen SKINNY Reasoning Case Study
.
Stanley Harris, 90 years old
Primary Concept
Intracranial Regulation
Interrelated Concepts (In order of
emphasis)
● Clinical judgment
NCLEX Client Need Covered NCSBN Covered
Categories in Case Clinical in Case
Study Judgment Study
Model
Safe and Effective Care Environment Step 1: Recognize Cues ✔
● Management of Care ✔ Step 2: Analyze Cues ✔
● Safety and Infection Control Step 3: Prioritize Hypotheses ✔
Health Promotion and Maintenance Step 4: Generate Solutions ✔
Psychosocial Integrity Step 5: Take Action ✔
Physiological Integrity Step 6: Evaluate Outcomes ✔
● Basic Care and Comfort
● Pharmacological and
Parenteral Therapies
● Reduction of Risk Potential ✔
● Physiological Adaptation
This study source was downloaded by 100000842980116 from CourseHero.com on 03-18-2022 03:55:19 GMT -05:00
https://www.coursehero.com/file/74238982/ETOH-Withdrawal-Delirium-Case-Studydocx/
, Present Problem:
You are the nurse taking care of Stanley Harris, a 90-year-old was admitted yesterday evening for syncope after
falling at home where he lives alone. His head CT was negative for intracranial hemorrhage and no other
injuries were sustained. He is admitted for dehydration and electrolyte imbalances of potassium 3.3 and
magnesium of 1.4 on admission. The day shift nurse reports that Mr. Harris received a liter of Lactated Ringer’s
over her eight-hour shift and is alert and oriented x4.
Upon your initial assessment on the evening shift, Mr. Harris is extremely pleasant. He correctly states that he
is in the hospital because he fell and correctly states the date. He seems to be a little forgetful –unable to recall
that you were the same nurse who admitted him yesterday until you remind him. As you are leaving the room,
the patient’s daughter approaches you and says, “You know, every time my dad gets hospitalized, he gets
agitated and confused after a night or two. I just wanted to warn you in case he gets out of hand later tonight.”
Around 8 PM, the nursing assistant notifies you that Mr. Harris is trying to pull out his peripheral IV catheter
and keeps climbing out of bed. You go in to assess him and notice that he is confused, sweaty, and trembling.
He is difficult to redirect and keeps saying, “Why won’t you people let me have something to drink?” even
though he has ice water available at the bedside. When you ask him where he is, he states that he is in his
garage. He is not able to tell you the year or why he is in the hospital.
1. What data from the present problem is RELEVANT and must be NOTICED as clinically significant by
the nurse? (NCSBN: Step 1 Recognize cues/NCLEX: Reduction of Risk Potential)
RELEVANT Data from Present Problem: Clinical Significance:
Patient was A&O x4 on admission but now is not - Alertness and orientation is assessed as part of a mental status test to
able to tell you the year or why he is in the evaluate cognitive functioning. Alcoholic dementia caused from use
hospital or even that he is at the hospital. and withdrawals. Notify MD right away. Perform a CIWA. Admin
Ativan.
Dehydration and electrolyte imbalances - Dehydration and electrolyte imbalances can cause delirium, muscle
(Potassium is 3.3 and mag is 1.4) weakness and cardiac issues
- Pt. keeps climbing out of bed this is a safety issue.
Keeps climbing out of bed - Confusion is an early symptom of alcoholic dementia.
Confusion
Recognizing a potential problem, you promptly
collect a full set of VS:
Current VS: P-Q-R-S-T Pain Assessment:
T: 97.5 F/36.4 C (oral) Provoking/Palliativ
e:
P: 114 (regular) Quality: Denies
R: 20 (regular) Region/Radiation:
BP: 140/93 Severity:
O2 sat: 97% room air (RA) Timing:
2. What VS data is RELEVANT and must be NOTICED as clinically significant by the nurse? (NCSBN: Step 1
Recognize cues/NCLEX: Reduction of Risk Potential)
RELEVANT Data from Present Problem: Clinical Significance:
- Pulse: 114 - Elevated heart rate an indication of alcohol withdrawal
- Respirations: 20 - If the patient’s respirations and temperature begin to increase, we
This study source was downloaded by 100000842980116 from CourseHero.com on 03-18-2022 03:55:19 GMT -05:00
https://www.coursehero.com/file/74238982/ETOH-Withdrawal-Delirium-Case-Studydocx/
Next Gen SKINNY Reasoning Case Study
.
Stanley Harris, 90 years old
Primary Concept
Intracranial Regulation
Interrelated Concepts (In order of
emphasis)
● Clinical judgment
NCLEX Client Need Covered NCSBN Covered
Categories in Case Clinical in Case
Study Judgment Study
Model
Safe and Effective Care Environment Step 1: Recognize Cues ✔
● Management of Care ✔ Step 2: Analyze Cues ✔
● Safety and Infection Control Step 3: Prioritize Hypotheses ✔
Health Promotion and Maintenance Step 4: Generate Solutions ✔
Psychosocial Integrity Step 5: Take Action ✔
Physiological Integrity Step 6: Evaluate Outcomes ✔
● Basic Care and Comfort
● Pharmacological and
Parenteral Therapies
● Reduction of Risk Potential ✔
● Physiological Adaptation
This study source was downloaded by 100000842980116 from CourseHero.com on 03-18-2022 03:55:19 GMT -05:00
https://www.coursehero.com/file/74238982/ETOH-Withdrawal-Delirium-Case-Studydocx/
, Present Problem:
You are the nurse taking care of Stanley Harris, a 90-year-old was admitted yesterday evening for syncope after
falling at home where he lives alone. His head CT was negative for intracranial hemorrhage and no other
injuries were sustained. He is admitted for dehydration and electrolyte imbalances of potassium 3.3 and
magnesium of 1.4 on admission. The day shift nurse reports that Mr. Harris received a liter of Lactated Ringer’s
over her eight-hour shift and is alert and oriented x4.
Upon your initial assessment on the evening shift, Mr. Harris is extremely pleasant. He correctly states that he
is in the hospital because he fell and correctly states the date. He seems to be a little forgetful –unable to recall
that you were the same nurse who admitted him yesterday until you remind him. As you are leaving the room,
the patient’s daughter approaches you and says, “You know, every time my dad gets hospitalized, he gets
agitated and confused after a night or two. I just wanted to warn you in case he gets out of hand later tonight.”
Around 8 PM, the nursing assistant notifies you that Mr. Harris is trying to pull out his peripheral IV catheter
and keeps climbing out of bed. You go in to assess him and notice that he is confused, sweaty, and trembling.
He is difficult to redirect and keeps saying, “Why won’t you people let me have something to drink?” even
though he has ice water available at the bedside. When you ask him where he is, he states that he is in his
garage. He is not able to tell you the year or why he is in the hospital.
1. What data from the present problem is RELEVANT and must be NOTICED as clinically significant by
the nurse? (NCSBN: Step 1 Recognize cues/NCLEX: Reduction of Risk Potential)
RELEVANT Data from Present Problem: Clinical Significance:
Patient was A&O x4 on admission but now is not - Alertness and orientation is assessed as part of a mental status test to
able to tell you the year or why he is in the evaluate cognitive functioning. Alcoholic dementia caused from use
hospital or even that he is at the hospital. and withdrawals. Notify MD right away. Perform a CIWA. Admin
Ativan.
Dehydration and electrolyte imbalances - Dehydration and electrolyte imbalances can cause delirium, muscle
(Potassium is 3.3 and mag is 1.4) weakness and cardiac issues
- Pt. keeps climbing out of bed this is a safety issue.
Keeps climbing out of bed - Confusion is an early symptom of alcoholic dementia.
Confusion
Recognizing a potential problem, you promptly
collect a full set of VS:
Current VS: P-Q-R-S-T Pain Assessment:
T: 97.5 F/36.4 C (oral) Provoking/Palliativ
e:
P: 114 (regular) Quality: Denies
R: 20 (regular) Region/Radiation:
BP: 140/93 Severity:
O2 sat: 97% room air (RA) Timing:
2. What VS data is RELEVANT and must be NOTICED as clinically significant by the nurse? (NCSBN: Step 1
Recognize cues/NCLEX: Reduction of Risk Potential)
RELEVANT Data from Present Problem: Clinical Significance:
- Pulse: 114 - Elevated heart rate an indication of alcohol withdrawal
- Respirations: 20 - If the patient’s respirations and temperature begin to increase, we
This study source was downloaded by 100000842980116 from CourseHero.com on 03-18-2022 03:55:19 GMT -05:00
https://www.coursehero.com/file/74238982/ETOH-Withdrawal-Delirium-Case-Studydocx/
