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Zorluk: Çok zorSubstance Use and Other Disorders

A practical nurse (PN) is collecting data on a 71-year-old client admitted 72 hours ago for a pelvic fracture. The medical record notes a remote history of severe alcohol use disorder, but the family states the client "stopped drinking years ago." The PN observes the client is intensely agitated, profoundly diaphoretic, and exhibiting coarse bilateral hand tremors. The client suddenly points to a shadow in the corner and shouts, "Keep those rats away from my bed!" Current vital signs are: blood pressure 168/96 mm Hg, heart rate 124 bpm, and respiratory rate 26 breaths/minute. Which action should the PN take first?

  1. Keep the room well-lit to minimize visual illusions, ensure the bed is in the lowest position, and immediately notify the registered nurse (RN).Cevap
  2. B
    Independently evaluate the client using the unit's withdrawal scale and administer an intravenous push benzodiazepine.
  3. C
    Document the episode as expected age-related hospital confusion and dim the room lights to reduce sensory overstimulation.
  4. D
    Ask the client, "Why are you seeing rats when you know there are absolutely no animals allowed in the hospital?"

Cevap

Keep the room well-lit to minimize visual illusions, ensure the bed is in the lowest position, and immediately notify the registered nurse (RN).
The client is exhibiting classic signs of alcohol withdrawal delirium (delirium tremens), a life-threatening medical emergency that typically peaks 48 to 72 hours after the last drink. Visual hallucinations and illusions (misinterpreting shadows as rats) are common. The PN's priority is to provide a safe environment by keeping the room well-lit to reduce shadows and illusions, maintaining the bed in a low position to prevent falls, and immediately escalating the acute change in condition to the RN for comprehensive assessment and medical intervention.

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1
Analyze the client's clinical presentation and timeline in relation to their medical history.
The client is 72 hours post-admission with severe autonomic hyperactivity (tachycardia, hypertension, diaphoresis) and visual hallucinations. This timeline and symptom cluster strongly indicate alcohol withdrawal delirium (delirium tremens), despite the family's report.
Accurate recognition of subtle cues and life-threatening complications is required for prioritizing care.
2
Evaluate the environmental needs for a client experiencing withdrawal hallucinations and illusions.
A well-lit room reduces shadows, which decreases the incidence of visual illusions. Keeping the bed in the lowest position promotes physical safety and prevents fall injuries.
Client safety and harm reduction are the immediate priorities during a delirious episode.
3
Determine the appropriate scope of practice for the practical nurse (PN) in this scenario.
The PN must immediately escalate this acute, life-threatening change to the registered nurse (RN) for advanced assessment and pharmacological intervention.
Managing an acute medical emergency and initiating intravenous protocols independently fall outside the PN's scope of practice.

Anahtar Kavram

Management of acute alcohol withdrawal delirium (delirium tremens) and practical nursing scope of practice.
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Konular

Substance Use and Other Disorders

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