Patient Reflective Journal

Patient Description

– 55-year-old male, admitted on 02/13/20 with AMS (altered mental status)

– Arrived at the unit he was tremulous and hypertensive. He was mumbling incoherently

-The Pt was placed on the CIWA protocol (Clinical Institute Withdrawal Assessment for Alcohol)

-DNR/DNI

-Past medical hx of chronic pancreatitis

– alcohol use disorder with history of alcohol withdrawal seizures

-hypertension

– GER

– Barrett’s esophagus,

– bowel resection X2 for obstruction 

– Hypogonadism

-Appendectomy

-Full Code

Allergies:

-KNDA

Nurse of the future competency brief comments: please see attached PDF to discuss this part,

Professionalism

Please use appropriate nursing diagnosis using the Gordons functional health patterns and nursing interventions.

Nurse diagnosis

-Risk Anxiety related to cessation of alcohol intake evidence by jitteriness, irritability, tremors

-Risk for disturbed sensory perception related to disorientation to time, place, person and situation

-Risk for injury related to equilibrium/balancing difficulties, reduce muscle and hand/eye coordination

A little about the patient

Patient was admitted for AMS (altered mental status). Patient wife is concerning the he has been more altered over the past 2 days. She says he doesn’t make sense when speaking. He has not eaten for the past 2 days. She said his gait appears to be off as well. Patient mumbles incoherently and is not alert to time, person, place. Vital signs BP 180/101, Pulse 75, RR 20 O2 100% on RA Pain 0/10. Pt looks frail, malnourish, mumbling, tremulous. Patient is on aspiration precaution, seizure precautions. Patient is on tube feeding Javity 1.3

Reflective Journal

  1. Pt has been staying in the hospital for a week and the nutritionist mentioned the patient A1C was 7.3 (is a common blood test used to diagnose type 1 and type 2 diabetes and to monitor how well you’re managing your diabetes. The A1C test result reflects your average blood sugar level for the past two to three months). So, nobody knew the patient was diabetic.
  • The patient spent most of the time sleeping. The few times he opened his eyes. He was mumbling and was not oriented to place, time and person.
  • Professionalism
  • Get a better medical history from family members and read the medical records before, during the care of the patient.
  • Get a better medical history from family members and read the medical records before, during the care of the patient.

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