Nurses' Notes
0700: The client reports the last alcohol use occurred about 36 hours ago. The admission history states that the client slept poorly and woke several times overnight. The client is anxious but answers questions appropriately. A prior record shows a generalized seizure during alcohol withdrawal two years ago. At 0730, the client eats half of breakfast without vomiting. The client follows one-step directions and accepts oral fluids. At 0830, the client remains oriented to person, place, date, and situation. The nurse administers medication according to the withdrawal protocol. At 0930, pulse is 126/min with heavy sweating despite treatment, and blood pressure is 174/102 mm Hg. The client reports mild sensitivity to hallway noise. At 1000, the client walks with assistance and follows safety instructions. The nurse documents that the resting pulse was 82/min during the initial assessment. At 1130, the client develops new disorientation and reports seeing insects on the wall. The client states that appetite is better than it was yesterday. Seizure precautions and close observation are continued.
看護記録
0700：患者は最後の飲酒が約36時間前と報告。入院歴には患者は睡眠が浅く、夜間に数回目を覚ましたと記載。患者は不安だが質問に適切に答える。以前の記録には2年前のアルコール離脱時の全身性けいれんがある。0730、患者は朝食の半分を嘔吐なく摂取。患者は一段階の指示に従い、経口水分を受け入れる。0830、患者は人物、場所、日付、状況に対する見当識が保たれている。看護師は離脱プロトコルに従って薬剤を投与。0930、治療にもかかわらず脈拍126/分、多量の発汗、血圧174/102 mm Hg。患者は廊下の騒音に軽度の過敏を訴える。1000、患者は介助で歩行し、安全指示に従う。看護師は初期評価時の安静時脈拍は82/分と記録。1130、患者は新たな見当識障害を発症し、壁に虫が見えると報告。患者は食欲は昨日より良いと述べる。けいれん予防策と注意深い観察を継続。