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.
護理紀錄
0700：個案表示最後一次飲酒約在36小時前。入院病史記載個案睡眠不佳，夜間醒來數次。個案焦慮但能適當回答問題。先前紀錄顯示兩年前酒精戒斷期間曾發生全身性癲癇。0730時，個案吃完一半早餐，無嘔吐。個案能遵從單一步驟指令並接受口服液體。0830時，個案對人、時、地、情境仍具定向力。護理師依戒斷方案給藥。0930時，脈搏126/min，儘管治療仍大量出汗，血壓174/102 mm Hg。個案表示對走廊噪音輕微敏感。1000時，個案在協助下行走並遵從安全指示。護理師記錄初始評估時休息脈搏為82/min。1130時，個案出現新發生定向力障礙，並表示看到牆上有蟲。個案表示食慾比昨天好。持續採取癲癇預防措施及密切觀察。