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Zorluk: ZorChemical and Other Dependencies / Substance Use Disorders

A 55-year-old client is admitted to the medical unit for treatment of a severe diabetic foot ulcer. The electronic health record indicates a history of alcohol use disorder, with the client's last alcoholic drink consumed approximately 60 hours ago. During the initial shift assessment, the nurse observes that the client has coarse bilateral hand tremors, profound diaphoresis, and new-onset disorientation to place. Current vital signs are: blood pressure 162/98 mmHg, heart rate 124 bpm, respiratory rate 24/min, and temperature 99.8°F (37.7°C). Which action is the highest priority for the nurse to take?

  1. Administer the prescribed intravenous lorazepam and immediately initiate seizure precautions.Cevap
  2. B
    Instruct the unlicensed assistive personnel to complete a standardized withdrawal assessment scale to determine symptom severity.
  3. C
    Notify the healthcare provider to request stat blood cultures and fluid resuscitation for suspected septic shock.
  4. D
    Reassure the client that the hospital is a safe environment and ask why they are feeling so disoriented.

Cevap

Administer the prescribed intravenous lorazepam and immediately initiate seizure precautions.
The client is exhibiting classic signs of alcohol withdrawal delirium (delirium tremens), which typically peaks 48 to 72 hours after the last alcohol intake. Symptoms include disorientation, marked autonomic hyperactivity (hypertension, tachycardia, diaphoresis), and coarse tremors. This is a life-threatening medical emergency. The priority is to administer a prescribed benzodiazepine (e.g., lorazepam) to depress the central nervous system, control agitation, and prevent seizures, while concurrently initiating seizure precautions to ensure client physical safety.

Adım Adım Çözüm

1
Analyze the client's timeline and history.
The client has a history of alcohol use disorder and had their last drink 60 hours ago.
Establishing the timeline is critical for identifying the stage of alcohol withdrawal. Delirium tremens typically peaks at 48 to 72 hours.
2
Evaluate the clinical presentation and vital signs.
The client is experiencing disorientation, severe tremors, diaphoresis, hypertension, and tachycardia.
These are classic manifestations of severe autonomic hyperactivity and central nervous system excitability characteristic of alcohol withdrawal delirium.
3
Differentiate the current symptoms from other potential medical complications, such as sepsis from the foot ulcer.
While infection is present, the specific combination of hypertension, severe tremors, and the 60-hour timeline points directly to withdrawal rather than septic shock (which often presents with hypotension).
Accurate differential assessment ensures the nurse addresses the most immediate, life-threatening neurological risk.
4
Determine the priority nursing intervention.
The nurse must administer central nervous system depressants (benzodiazepines) and protect the client from injury.
Pharmacological intervention is required to halt the progression of withdrawal symptoms and prevent fatal seizures.

Anahtar Kavram

Alcohol Withdrawal Delirium (Delirium Tremens) Management
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Konular

Chemical and Other Dependencies / Substance Use Disorders

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