Académique Documents
Professionnel Documents
Culture Documents
1. Anxiety/Fear
Nursing Diagnosis
Anxiety/Fear
May be related to
Possibly evidenced by
Desired Outcomes
manageable level.
Express sense of regaining some control of situation/life.
Demonstrate problem-solving skills and use resources effectively.
Nursing Interventions
Rationale
physiologically or environmentally
ongoing basis.
Nursing Interventions
Rationale
medication wear off.
alcoholism.
Reduces stress.
Enhances sense of trust, and
explanation may increase
when possible.
Reorient frequently.
Barbiturates: phenobarbital, or
pentobarbital (Nembutal).
Nursing Interventions
Rationale
depressants and REM sleep cycle
inhibitors.
Process wherein SO and family
members, supported by staff, provide
information about how patients
Arrange Intervention
2. Sensory-Perceptual Alterations
Nursing Diagnosis
Sensory-Perceptual Alterations
May be related to
Possibly evidenced by
visual/auditory hallucinations
Fear/anxiety
Desired Outcomes
Rationale
Speech may be garbled, confused, or
commands.
Nursing Interventions
Rationale
and hallucinations.
tactile.
during sleep.
depression.
attempts of suicide.
whenever possible.
as indicated.
stimuli.
Nursing Interventions
patient or topics unrelated to the
patient that do not include the
patient.
Rationale
conversation, which can aggravate
hallucinations.
necessary.
glucose, ABGs.
Nursing Interventions
Rationale
liver. Hypoxemia and hypercarbia are
common manifestations in chronic
alcoholics who are also heavy
smokers.
Reduces hyperactivity, promoting
relaxation and sleep. Drugs that have
coordination
Desired Outcomes
Rationale
Prompt recognition and intervention
Nursing Interventions
Rationale
gait, if possible.
Nursing Interventions
Rationale
activities as needed.
Provide for environmental safety
when indicated.
(Tranxene);
Haloperidol (Haldol);
Thiamine;
Nursing Interventions
Rationale
alcohol abuse) may lead to neuritis,
Werneckes syndrome, and
Korsakoffs psychosis.
Reduces tremors and seizure activity
Magnesium sulfate.
by decreasing neuromuscular
excitability.
Desired Outcomes
Rationale
Hypertension frequently occurs in
acute withdrawal phase. Extreme
hyperexcitability, accompanied by
catecholamine release and increased
Nursing Interventions
Rationale
Long-term alcohol abuse may result
in cardiomyopathy or HF. Tachycardia
is common because of sympathetic
dysrhythmias.
balance.
cardiopulmonary resuscitation.
Nursing Interventions
Rationale
25%.
Electrolyte imbalance: potassium,
electrolyte levels.
indicated
(Tenormin);Potassium.
Tracheobronchial obstruction
Presence of chronic respiratory problems, inflammatory process
Decreased energy/fatigue
Desired Outcomes
Rationale
Frequent assessment is important
because toxicity levels may change
rapidly. Hyperventilation is common
during acute withdrawal phase.
Kussmauls respirations are
respirations.
Nursing Interventions
Rationale
changes.
adjuncts available.
necessary.
respiratory depression.
Monitors presence of secondary
indicated