ETOH Withdrawal or Delirium? Next Gen SKINNY Reasoning Case Study

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 able to tell you the year or why he is in the hospital or even that he is at the hospital. Dehydration and electrolyte imbalances (Potassium is 3.3 and mag is 1.4) Keeps climbing out of bed Confusion - Alertness and orientation is assessed as part of a mental status test to evaluate cognitive functioning. Alcoholic dementia caused from use and withdrawals. Notify MD right away. Perform a CIWA. Admin Ativan. - Dehydration and electrolyte imbalances can cause delirium, muscle weakness and cardiac issues - Pt. keeps climbing out of bed this is a safety issue. - Confusion is an early symptom of alcoholic dementia. 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 Pote