Anthony Washington is a patient that is admitted due to alcoholic withdrawals. Below is a Ihuman case study that reviews his diagnosis and it presents the data and information that identifies his diagnosis.
Patient: Anthony Washington
Primary Diagnosis: Alcohol Withdrawals
Status/Condition: Stable Code Status: Full Code Allergies: NKDA
Admit to Unit: 2E ICU (333-333-3333)
Activity Level: Bed Rest with Bathroom Privileges
Diet: Mechanical Soft
IVF: Normal Saline 75 ml/hr
Critical Drips: None
Respiratory:
- oxygen at 2L nasal cannula if pulse ox <93%
- Incentive Spirometry q 4
Medications:
Omeperzole 20 mg by mouth BID for GERD
Thiamine 250 mg IV daily for high risk thiamine deficiency
Analgesics:
Mild pain (0-3 on the numeric pain intensity scale) or Fever
- Acetaminophen 325mg (2 tablets)by mouth q 6 hrs PRN mild pain or temp >101Moderate Pain rate (4-6)
- Morphine 2mg slow IV P for moderate pain if unable to tolerate oral meds Severe Pain rate (7-10)
- Morphine 4mg slow IV P for severe pain if unable to tolerate oral meds
DO NOT EXCEED 3 grams of acetaminophen in 24 hours
- Zofran (ondansetron HCI) 4 mg IV q6 hrs PRN nausea and vomiting Comments: Give over 2 to 5 minutes
- MOM 30 ml by mouth PRN constipation
- Colace 100 mg by mouth daily stool soft
- Pepcid 20 mg, Oral, Tab, BID
Comments: May give by IV route if unable to swallow.
- Pepcid 20 mg, IV Push, Injection, BID
Comments: May give by IV route if unable to swallow.
- Lorazepam loading dose 4 mg now; then 2 mg every 4 hours as needed for withdrawal symptoms
- Haldol 5 mg IV every 4 hours as needed for psychosis
- Magnesium sulfate 24 Meq IV over 2 hours
- Potassium Phosphate 30 mmol IV now
Nursing Orders:
- Vital signs and CIWA-AR q 2 hours
- Notify MD of systolic> 180, diastolic < 50, HR < 50, pox < 92% or resp >26,Temp > 101.5
- Daily weight
- Keep HOB >30 unless contraindicated
- Continuous cardiac telemetry
- Universal Fall Precaution
- Seizure Precaution
- Maintain peripheral IV 20-18g
- DVT prophylactic
- Breaded skin assessment every shift
Follow Up Lab tests:
Magnesium
Phosphorus BMP
Diagnostic testing:
- Head CT to diagnose or rule out Wernicke's encephalopathy
- CBC anemia, WBC for infection or infection risk, platelets for bleeding risks
- CMP electrolyte status, liver damage status, glucose for hyper/hypoglycemia; Creatinine for kidney function
- UA
- EKG heart arrhythmia and tachycardia
- Vitamin B1 possible thiaminedeficiency
- Urine drug screen to assess for recent substance abuse
Consults:
- Psychologist Consult for anger management and coping skills
- Substance Abuse Consult alcohol dependency possible detox unit
- Dietician consult poor nutritional status
Patient Education and Health Promotion:
- Alcohol dependency counseling; detox, AA, other community resources
- Anger management
- Education for health diet and poor nutritional intake due to alcoholism
- Health maintenance and caring for personal needs: bathing, oral care, cleaning clothes
- Coping skills and relationships
Discharge planning and required follow-up care:
- Follow up with PCP in one-week post-discharge
- Follow up with all consulting providers as instructed
Scientific Rationale:
- In patients at high risk of thiamine deficiency, parenteral thiamine250-500mg/day should be given for 3-5 days, followed by oral thiamine 250-300mg/day to prevent Wernicke's encephalopathy
- Delirium tremens (DTs) is one of the most severe manifestations of alcohol withdrawal. It occurs after a period of heavy drinking, typically in those with a history of chronic alcohol use and those who have previously experienced severe alcohol withdrawal symptoms, 5 % of people will experience DTs.
- Benzodiazepines are the mainstay of therapy in the United States and are the primary agents used as substitutes and cross-tolerant medications for alcohol withdrawal syndrome. Benzodiazepines can be administered by using fixed-schedule or symptom-triggered regimens with or without loading.
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