The patient, Jermaine Jones, was brought to the emergency department by his wife Denise 30 minutes...

The patient, Jermaine Jones, was brought to the emergency department by his wife Denise 30 minutes ago. She reported that he had been drinking a few beers and took one of her prescription tablets, alprazolam, for anxiety. When she got back an hour later he was having trouble talking clearly and responding to her questions. His wife says that she has been getting increasingly worried about his mental condition over the last few days.

Mr. Jones is a 34-year-old African American male who was diagnosed with depression 2 years ago and was prescribed sertraline 50 mg orally one time daily in the morning. His wife reports that he has been having a difficult time coping with the 1-year anniversary of his father's death. According to his wife he has been 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 at arrival. Normal saline is infusing at 100 mL/hr. I have drawn a blood sample for BMP, CBC, and a serum alcohol level as ordered by Dr. Alvarez. The results should be ready any minute now.

Dr. Alvarez put orders in the patient's chart based on my initial assessments but has yet to see the patient. The patient is due for vital signs and other assessments listed in the chart. Please notify Dr. Alvarez if there are any changes in the patient's condition 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 is elevated?

3. What other test do you recommend the dr should order?

Solutions

Expert Solution

Nursing diagnosis

Anxiety related to physiological withdrawal evidenced by Fear of unspecified consequences
Sensory-Perceptual Alterations related to psychological stress evidenced by disorientation to time, place, person, or situation
Risk for Injury related to alcohol intake with varied autonomic nervous system responses to the system’s suddenly altered state evidenced by reduced muscle and hand/eye coordination

A serum alcohol level is ordered. How will you know if it is elevated?

A blood alcohol test measures the level of Alcohol in the blood. Alcohol, also known as ethanol, is the main ingredient present in the 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. Person will have difficulty while walking and speaking and other symptoms may include confusion, nausea, and drowsiness.
At risk for serious complications: Above 0.40 percent Blood alcohol 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 long term drug use and history of alcoholism

Nightingale answered 1 year ago

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