Question Diagnosis: Wernicke’s Korsakoff syndromeT-98.2f, BP 210/100, P-112, SPo2 95% RAComplaint: confusion, ataxia, tremors, N/V, loss of muscle coordinationMedication: thiamine IV, Vitamin B12, D5NS @ 250/hr., Ativan (1mg for CIWA less than 8, 2mg for CIWA greater than 8)Labs: Magnesium 1.6, CK 18,487, Lactic 3.5, Vitamin B12 150, ALT 75, AST 126 Case overview:When given a patient, look at the data and determine your first priority. This PT has bp of 210/100 which is at risk for a hypertensive crisis which could kill him faster than being dizzy. This should be your first goal to decrease and the Ativan is one of the medications, but you can’t give that without a CIWA number (do routine CIWA’s). How about seizure pads to protect the PT. The lactic acid and vitamin B12 are not within normal range and BP/pulse should be your first priority because stroke and MI are more important than confabulation, confusion, and vomiting. Assessment Data (Include at least three-five subjective and/or objective pieces of data that lead to the nursing diagnosis)Goals & Outcome (Two statements are required for each nursing diagnosis. Must be Patient and/or family focused; measurable; time-specific; and reasonable.) Nursing Interventions (List at least three nursing or collaborative interventions with rationale for each goal & outcome.)Rationale (Provide reason why intervention is indicated/therapeutic; provide references.)Outcome Evaluation & Replanning(Was goal met? How would you revise the plan of care according the patient’s response to current plan ?)OBJECTIVE: SUBJECTIVEStatement #1 Short Term: Statement #2 Long Term:1. 2. 3. 4. 5. 6. 1. 2. 3. 4. 5. 6. Outcome #1Short Term: Outcome #2Long Term:List patient mediations, indications, and nursing considerations for this patient Medication, Dose, RouteIndications for MedicationNursing Consideration for Patient/ Side Effects List Patient abnormal lab values, normal ranges, and why they are altered. Abnormal Lab ValueNormal RangeCause of Abnormal Lab Value List all Patients Nursing Diagnosis in priority Order and explain why. Nursing DiagnosisExplanation References: Health Science Science Nursing NURSING 115 Share QuestionEmailCopy link Comments (0)
Question Diagnosis: Wernicke’s Korsakoff syndromeT-98.2f, BP 210/100, P-112, SPo2 95% RAComplaint: confusion, ataxia, tremors, N/V, loss of muscle coordinationMedication: thiamine IV, Vitamin B12, D5NS @ 250/hr., Ativan (1mg for CIWA less than 8, 2mg for CIWA greater than 8)Labs: Magnesium 1.6, CK 18,487, Lactic 3.5, Vitamin B12 150, ALT 75, AST 126 Case overview:When given a patient, look at the data and determine your first priority. This PT has bp of 210/100 which is at risk for a hypertensive crisis which could kill him faster than being dizzy. This should be your first goal to decrease and the Ativan is one of the medications, but you can’t give that without a CIWA number (do routine CIWA’s). How about seizure pads to protect the PT. The lactic acid and vitamin B12 are not within normal range and BP/pulse should be your first priority because stroke and MI are more important than confabulation, confusion, and vomiting. Assessment Data (Include at least three-five subjective and/or objective pieces of data that lead to the nursing diagnosis)Goals & Outcome (Two statements are required for each nursing diagnosis. Must be Patient and/or family focused; measurable; time-specific; and reasonable.) Nursing Interventions (List at least three nursing or collaborative interventions with rationale for each goal & outcome.)Rationale (Provide reason why intervention is indicated/therapeutic; provide references.)Outcome Evaluation & Replanning(Was goal met? How would you revise the plan of care according the patient’s response to current plan ?)OBJECTIVE: SUBJECTIVEStatement #1 Short Term: Statement #2 Long Term:1. 2. 3. 4. 5. 6. 1. 2. 3. 4. 5. 6. Outcome #1Short Term: Outcome #2Long Term:List patient mediations, indications, and nursing considerations for this patient Medication, Dose, RouteIndications for MedicationNursing Consideration for Patient/ Side Effects List Patient abnormal lab values, normal ranges, and why they are altered. Abnormal Lab ValueNormal RangeCause of Abnormal Lab Value List all Patients Nursing Diagnosis in priority Order and explain why. Nursing DiagnosisExplanation References: Health Science Science Nursing NURSING 115 Share QuestionEmailCopy link Comments (0)
