NURSING CARE PLAN 12-1

12-2Care Plans - CustomizableMosby items and derived items 2011, 2007 by Mosby, Inc., an affiliate of Elsevier, Inc.Mosby items and derived items 2011, 2007 by Mosby, Inc., an affiliate of Elsevier, Inc.Lewis: Medical-Surgical Nursing, 8th Edition

Chapter 12: Addictive Behaviors

Care Plans - Customizable

eNCP 12-1: Nursing Care PlanPatient in Alcohol Withdrawal

Nursing Diagnosis: Ineffective protection related to sensorimotor deficits, seizure activity, and confusion as evidenced by altered level of consciousness and disorientation

PATIENT GOALS 1. Experiences no injury during alcohol withdrawal 2. Demonstrates decrease in tremors and psychomotor activityOUTCOMES (NOC)INTERVENTIONS (NIC) AND RATIONALESNeurologic StatusConsciousness ___Communication appropriate to situation ___Rest-sleep pattern ___Blood pressure ___Apical pulse rate ___Radial pulse rate ___Cognitive orientation ___Cognitive ability ___

_____________________Measurement Scale 1 = Severely compromised2 = Substantially compromised3 = Moderately compromised4 = Mildly compromised5 = Not compromised

Seizure activity ___

_____________________Measurement Scale1 = Severe2 = Substantial3 = Moderate4 = Mild5 = NoneEnvironmental Management: SafetyCreate a safe environment for the patient.Identify the safety needs of the patient based on level of physical and cognitive function and history of behavior to plan appropriate preventive measures.Remove environmental hazards (e.g., loose rugs and small, movable furniture) to minimize hazards and risks.Safeguard with side rails/siderail padding to physically limit mobility or access to harmful situations.

Substance Use Treatment: Alcohol WithdrawalMonitor vital signs during withdrawal to identify extreme autonomic nervous system response.Administer anticonvulsants or sedatives to prevent alcohol withdrawal delirium and relieve other symptoms during withdrawal.Administer vitamin therapy to prevent Wernickes syndrome.Provide emotional support to patient/family to decrease anxiety.

Seizure PrecautionsKeep suction, Ambu-bag, and oral or nasopharyngeal airway at bedside to establish respiratory function after seizure activity.Use padded side rails and keep side rails up to prevent injury during seizure activity.

Nursing Diagnosis: Sensory/perceptual alterations (visual, auditory, and tactile) related to neurochemical imbalance as evidenced by visual distortions, disorientation, and hallucinations

Patient Goals 1. Is oriented to person, place, and time 2. Experiences no hallucinationsOUTCOMES (NOC)INTERVENTIONS (NIC) AND RATIONALESDistorted Thought Self-ControlAsks for validation of reality ___Reports decrease in hallucinations or delusions ___Perceives environment accurately ___Exhibits logical thought flow patterns ___Exhibits reality-based thinking ___Exhibits appropriate thought content ___

_____________________Measurement Scale1 = Never demonstrated2 = Rarely demonstrated3 = Sometimes demonstrated4 = Often demonstrated5 = Consistently demonstratedDelirium ManagementMonitor neurologic status on an ongoing basis to determine appropriate interventions.Verbally acknowledge the patients fears and feelings to decrease anxiety.Provide patient with information about what is happening and what can be expected to occur in the future to assist in reality orientation.Maintain a well-lit environment that reduces sharp contrasts and shadows to reduce external stimuli.Remove stimuli, when possible, that create misperception in a particular patient (e.g., pictures on the wall or television) to reduce misinterpretation of environment.Inform patient of person, place, and time to promote orientation.Use environmental cues (e.g., signs, pictures, clocks, calendars, and color coding of environment) to stimulate memory, reorient, and promote appropriate behavior.

Nursing Diagnosis: Ineffective health maintenance related to inadequate coping mechanisms and resources as evidenced by abuse of alcohol

Patient Goals 1. Acknowledges a substance abuse problem 2. Identifies positive coping mechanisms and resources to use during alcohol abstinenceOutcomes (NOC)Interventions (NIC) and RationalesRisk Control: Alcohol UseAcknowledges personal consequences associated with alcohol misuse ___Recognizes changes in general health status ___Develops effective alcohol use control strategies ___Commits to alcohol use control strategies ___

_____________________Measurement Scale1 = Never demonstrated2 = Rarely demonstrated3 = Sometimes demonstrated4 = Often demonstrated5 = Consistently demonstratedSubstance Use TreatmentEncourage patient to take control over own behavior to change undesired behaviors.Discuss with patient the impact of substance use on medical condition or general health to promote acknowledgment of consequences of use.Identify constructive goals with patient to provide alternatives to the use of substances to reduce stress.Assist patient to learn alternative methods of coping with stress or emotional distress to reduce substance use.Identify support groups in the community for long-term substance abuse treatment to promote continued abstinence.