NURS 238 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 th