Question

Mike Simpson, a 65 year old, widowed man, with a previous diagnosis of schizophrenia; presents to the Emergency Department at 2100. He is a bit disheveled in appearance and his breath smells of alcohol. He is accompanied by his landlady. The landlady tells you that she found him earlier this evening trying to enter his apartment door. He was sweaty, his eyes where dilated, and his hands were trembling so badly that he could not get the key in the door. He kept calling her by his deceased wife’s name and saying he was trying to get into his office to do some work.

According to the landlady, Mike retired years ago, has lived in her apartments for several years since his wife passed away, and knows her real name.

His blood/alcohol level is 250mg/m upon arrival to the emergency department and his speech is not slurred. He can correctly identify himself but, also appears confused. He is unable to tell you the month or season. His nose and cheeks are red with tiny spider veins and his stomach distended and when he extends his hands out in front of him they are very tremulous.

His demeanor is polite and apologetic to you and the staff. He asks you several times to call his wife because he believes she is worried about him. He tells you she was at home earlier, but he left to have a few drinks and never returned home.

Mike tells you he has never had a problem with alcohol but scored high on the CAGE assessment test. He then admits to an “occasional drink every now and then.” He states he did have a few drinks earlier today but can’t say exactly when or how many. However, he is willing to stay at the hospital for a brief stay and tells you, “ I will stay here, but only if you think I have to. Do you think I have to? Can you call my wife and let her know I am okay?”

Answer the following questions:

1. List potential nursing diagnosis in this situation? Please provide a minimum of 3
2. What is the best response for the nurse to give Mike when he asks about needing to stay at the hospital?
3. What is the best response for the nurse to give Mike when he asks about someone calling to notify his wife of being at the hospital?
4. What medications would the nurse anticipate being ordered for the patient?

Answer 1

●Disturbed thought process related to stress,neurochemical changes as evidenced by loss of his wife secondary to schizophrenia

Ineffective coping related to poor or ni support as evidenced by problems in adaptive behavior

Intoxication related to excess intake of alcohol as evidenced by breath smell

●The best response to give is inform the patient empathetically that the provider will assess and initiate treatment for his current problems and discuss the need of any admission to him directly if necessary

●The best response is to reassure the patient and make him realize the present by explaining in a simple and understanding way.

●The medication which can be anticipated are

• Antipsychotic drugs (Haloperidol,Chlorpromazine)
• Anti tremor drugs