A 42-year-old client is recuperating on the orthopedic unit two days after an open reduction and internal fixation of the tibia. During morning rounds, the client's spouse quietly shares, 'He gets very jittery and anxious if he misses his evening six-pack, and he hasn't had a drink since before the accident.' The client is currently restless, diaphoretic, and exhibiting mild bilateral hand tremors. Which of the following actions are appropriate for the nurse to take? (Select all that apply.)
- Perform an evaluation of the client's manifestations using a validated clinical scoring tool.Answer
- BInstruct the nursing assistant to monitor the client's cognitive orientation and vital signs every 60 minutes.
- CExplain to the spouse, "It was crucial for you to disclose this habit during the intake process so we could have avoided this complication."
- Implement environmental safety measures by padding the bed rails and verifying that airway clearance equipment is functional.Answer
- EDocument the manifestations as a typical sympathetic nervous system response to the recent orthopedic trauma.
- Inform the prescribing provider about the new assessment findings and the collateral information provided by the family member.Answer
Answer
The correct actions include performing a standardized withdrawal assessment, implementing seizure precautions, and notifying the provider.
The appropriate actions prioritize client safety, objective clinical measurement, and interdisciplinary collaboration. Establishing seizure precautions protects the client from potential injury, as the risk for withdrawal seizures peaks around 24 to 48 hours after the last drink. Utilizing a validated assessment tool provides quantifiable data to guide symptom-triggered pharmacological therapy. Finally, notifying the provider is essential to obtain the necessary prescriptions to manage the withdrawal process safely.
Step-by-Step Solution
Key Concept
Alcohol Withdrawal Syndrome Management and Prioritization