Scenario: ETOH Sim Jerry Brown

Please review the following PRIOR to your simulation experience:

Read the following:

• Chapter 14 Substance Use and Addiction Disorders & ANS II Textbook: Nursing Management of a Client during a Seizure and after a Seizure.
• Review background information and patient report below
• Complete the questions below and bring with you to the Alcohol Withdrawal Simulation

Background Information

Mr. Brown is a 57-year-old Native American Male who currently works in a factory. He has a history of kidney stones and excessive consumption of alcohol and has been arrested for DUI once in the past. He has been married for 36 years and has a son who is 34 and a daughter who is 32.

Reviews of Systems

Overall state of health: Unplanned 10-pound weight loss over last 3 months; denies fever, chills,

night sweats

Skin, hair, nails: psoriasis: reports using sunscreen rarely

Head & neck: occasional “tension” headaches; denies sensitivity to light & sound with headaches

Eyes, ears, nose, mouth & throat: wears reading glasses; last vision exam-1/08; last hearing exam-2/06;

last dental exam-5/10, seasonal allergies

Respiratory system: denies exposure to toxins or pollutants: denies smoking

Cardiovascular: occasional dyspnea with exertion climbing more than 2 flights of stairs

Peripheral vascular: reports long-term standing (5-6 hours/day) at work

Gastrointestinal: current abdominal pain, nausea and vomiting; indigestion after eating spicy food

Urinary: history of kidney stones

Male genitalia: performs TSE “every few months”

Musculoskeletal: occasional stiffness in joints in morning

Neurologic: occasionally feels guilty about not spending more time with my wife and kids

Hematologic: denies easy bleeding or bruising

Endocrine: unplanned 10-pound weight loss over last 3 months

Mr. Brown presents to his physician’s office complaining of abdominal pain, nausea and vomiting. During the interview, he reveals to the nurse that he is currently unemployed after losing his job when alcohol was found in his locker following a minor work accident. He denies drinking any of the alcohol.

• What type of assessment could be implemented to assess Mr. Brown’s potential for alcohol abuse?
• Could Mr. Brown symptoms of abdominal pain, nausea and vomiting be a result of alcohol abuse? Explain.
• What type of education may be helpful for Mr. Brown related to alcohol abuse?

Mr. Brown comes back to the physician’s office the following week with the same complaint of abdominal pain, nausea and vomiting. His hands are shaky and his face appears flush. He tells you that he has been arrested for a second DUI. He tells you he has not had a drink for three days. The physician tells you to have Mr. Brown go to the ED for assessment of abdominal pain, nausea and vomiting.

• What should the nurse include in the SBAR to the ED Nurse?
• Is Mr. Brown experiencing s/s of alcohol withdrawal?
• What Lab test do you think they will order for Mr. Brown in the ED?

Alcohol Withdrawal Simulations

You are the nurse assigned to care for Mr. Brown on the medical floor. He is scheduled to have a KUB at 10am. You will receive report from the night nurse prior to starting your shift. Below is data from Mr. Brown’s medical record.

Physical Assessment: Upon Hospital Admission

Vital signs: T-34.8 C, P-94, RR-20, BP- 102/65

Overall state of health: cachexic-appearing male, appears older that stated age: Awake: holding abdomen in pain.

Skin, hair, nails: pale, skin warm & dry without lesions; hair & nails WNL

Head & neck: WNL; thyroid nonpalpable & without bruits

Eyes, ears, nose, moth & throat: Snell-O.D. 20/30 with glasses. O.S. 20/30 with glasses, pupils 3mm, PERRLA, ears, mouth & the throat WNL

Respiratory system: respirations 20, unlabored & even; lungs CTA: Resonant percussion tones over lung fields

Cardiovascular: no visible lifts or heaves, no thrills, regular rate (94) & rhythm: S3,S4

Gastrointestinal: abdomen rotund, hypoactive BSx4, tenderness to palpation in LUQ and mid-epigastric region; liver palpated 4 cm below right costal margin, firm and moderately tender.

Urinary: history of kidney stones

Male genitalia: performs TSE “every few months”

Musculoskeletal: joints and muscles symmetrical bilaterally without swelling, warmth or tenderness; Full ROM of UE & LE against gravity with full resistance

Neurologic: CN II-XII intact; smooth, coordinated gait, negative Romberg, RAMs smooth & intacted, sensation to UE & LU intact bilaterally; DTRs +2 bilaterally

Laboratory Data:

Albumin 2.2g/dl (3.5-5.0 g/dl)

Total Protein 5.3g/dl (60-8.0 g/dl)

AST 84units/l (8-38units/l)

ALT 55units/l (10-35 units/l)

Total bilirubin 2.0mg/dl (0.1-1.2 mg/dl)

PT 15.5 seconds (10-13 seconds)

PTT 75 seconds (60-70 seconds)

HgB 13.0g/dl (13.5-18.0 g/dl)

HCT 0.38 (0.40-0.54)

Plts 135,000ul (150,000-400,000 ul)

WBCs 4.5ul (4.5-10.0 ul)

Potassium 3.3mEq/l (3.5-5.3 mEq/l)

Magnesium 1.8 mEq/l (1.5-2.5 mEq/l)

Sodium 140mEq/l (135-145 mEq/l)

Calcium 9.4mEq/l (9-11 mEq/l)

Pre-Scenario Questions:

Please be prepared for your Alcohol Simulation by completing the following information:

• Role Definitions:
  • Primary Nurse
  • Secondary Nurse
  • Charge Nurse
• Identify some causes for a client to present with an altered level of consciousness.
• What assessment techniques can be utilized when a client presents with an altered level of consciousness?
• What nursing interventions should be implemented if the client presents with an altered level of consciousness.
• What safety measures should be implemented if the client presents with an altered level of consciousness?
• Define Delirium Tremens (DTs).
• What is the cause of DTs?
• What is the s/s of DTs?
• What is the treatment for alcohol withdrawal?
• Why should a client withdrawing from alcohol be placed on seizure precautions?
• Develop a plan of care for your patient who has been placed on seizure precautions.
  • Identify s/s of seizures activity.
  • Prioritize safety interventions for a client who is on seizure precautions.
  • Please review your ANS II Textbook: Hinkle, J. L., & Cheever, K. H. (2018). Brunner & Suddarth’s textbook of medical-surgical nursing. p 1997 on the nursing management of a client during a seizure and after a seizure.
    • What assessment techniques should be utilized during a seizure?
    • What documentation requirements are essential during a seizure?
    • What is the nurse’s role regarding documentation after the client has experienced a seizure?
  • Please review your ANS II Textbook: Hinkle, J. L., & Cheever, K. H. (2018). Brunner & Suddarth’s textbook of medical-surgical nursing. p 1998. Review Chart 66-4: Care of the Patient During and After a Seizure.
    • What safety measures are essential to keep the client safe during a seizure?
    • Describe the nursing care of a client after a seizure.
• Is it necessary to call a Rapid Response for a patient experiencing a seizure? Explain.
• Identify 3 safety interventions that are essential for your patient who is experiencing a seizure.
• What is the treatment for alcohol withdrawal seizures?
  • Lorazepam
    • Prepare a medication card for Lorazepam.
    • How do you prepare (in the syringe) and administer Lorazepam IVP to an unresponsive patient who is experiencing an alcohol withdrawal seizure?
    • What is the rate of administration?
    • Open lab time is available to practice IVP mediation administration.
• How do you manage the care of a patient post seizure?
  • How do you position your patient post seizure?
• Develop a teaching plan for Mr. Brown who will be discharged on the medication Disulfiram.
  • What is the action of Disulfiram?
  • Contraindication/Precautions
  • Adverse Reactions/Side Effects
  • Route/Dosage
  • Patient/Family Teaching