Question

Based on the subjective data and objective data develop a care plan with a nursing diagnosis, 3 outcomes, 3 implementation with rationale and an evaluation.

Subjective data: patient stated, “I fell from a branch, this is how I got this” patient points to an abrasion on the bridge of his nose. “I want to stop drinking”

Objective data: patient had an abrasion on the bridge of his nose. Patient also had excoriation son his back, legs, and arms. Patient continuously got up to use the bathroom as well as to search for unnecessary items; aimlessly walks. Upon standing patient’s upper extremities tremor.

Answer 1

Nursing care plan

Nursing Diagnosis	Outcome	Implementation	Rationale	Evaluation
Ineffective health maintenance related to alcohol abuse as evidenced by patient verbalization and injury during intoxication	The patient’s injury and withdrawal symptoms are treated. The patient verbalizes the ill effects of alcohol. The patient identifies and verbalizes ways to remain sober on a daily basis.	Apply Dressing for wounds and Administer benzodiazepines as per order. Educate the patient on ill effects of alcohol abuse. Help patient identify triggers to alcohol intake and measures to prevent alcohol intake.	To treat injury and withdrawal symptoms To help patient identify the harms of abusing alcohol To help patient take measures to remain sober	The patient’s injury and withdrawal symptoms are treated. The patient is aware of effects of alcohol abuse and takes measures to remain sober.