The patient, Jermaine Jones, w
The patient, Jermaine Jones, was brought to the emergencydepartment by his wife Denise 30 minutes ago. She reported that hehad been drinking a few beers and took one of her prescriptiontablets, alprazolam, for anxiety. When she got back an hour laterhe was having trouble talking clearly and responding to herquestions. His wife says that she has been getting increasinglyworried about his mental condition over the last few days.
Mr. Jones is a 34-year-old African American male who wasdiagnosed with depression 2 years ago and was prescribed sertraline50 mg orally one time daily in the morning. His wife reports thathe has been having a difficult time coping with the 1-yearanniversary of his father’s death. According to his wife he hasbeen taking his medication for depression as prescribed.
Mr. Jones is drowsy, but arousable and oriented to person only.His pupils are equal, round, and reactive to light accommodation,and he’s able to move all extremities. His speech is slurred.Vitals signs are: BP: 112/66, HR: 96, RR: 12/min, and SpO2 at 96%on room air. I started a 20-gauge IV in his right forearm atarrival. Normal saline is infusing at 100 mL/hr. I have drawn ablood sample for BMP, CBC, and a serum alcohol level as ordered byDr. Alvarez. The results should be ready any minute now.
Dr. Alvarez put orders in the patient’s chart based on myinitial assessments but has yet to see the patient. The patient isdue for vital signs and other assessments listed in the chart.Please notify Dr. Alvarez if there are any changes in the patient’scondition and after you have evaluated Mr. Jones.
1. List your top 3 nursing diagnosis for this patient
2. A serum alcohol level is ordered. How will you know if it iselevated?
3. What other test do you recommend the dr should order?
Answer:
Nursing diagnosis
- Anxiety related to physiological withdrawal evidenced by Fearof unspecified consequences
- Sensory-Perceptual Alterations related to psychological stressevidenced by disorientation to time, place, person, orsituation
- Risk for Injury related to alcohol intake with varied autonomicnervous system responses to the system’s suddenly altered stateevidenced by reduced muscle and hand/eye coordination
A serum alcohol level is ordered. How will you know ifit is elevated?
A blood alcohol test measures the level of Alcohol in the blood.Alcohol, also known as ethanol, is the main ingredient present inthe alcoholic drinks
- Sober: 0.0 percent Blood alcohol content
- Legally intoxicated: 0.08 Blood alcohol content
- Very impaired: 0.08–0.40 percent Blood alcohol content. Personwill have difficulty while walking and speaking and other symptomsmay include confusion, nausea, and drowsiness.
- At risk for serious complications: Above 0.40 percent Bloodalcohol content. Person may be at risk for coma or death.
Test need to Recommend
Already ordered for
- Basic metabolic panel
- CBC
- Serum alcohol
Nurse should suggest to include
- Liver function test to rule out the liver damage due to longterm drug use and history of alcoholism
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