Nursing Clinical setting

AlcoholWithdrawal.docx

Home >Biology homework help >Nursing Clinical setting

45 years old patient’s Diagnosed with Alcohol Withdrawal

Important Instruction about the Assignment

· You will then formulate your differential diagnoses list, develop a plan of care, and submit a written clinic note documenting your care of this patient. Your differential diagnoses list should consist of 4 diagnoses, including 1 of which is your final diagnosis.

· Please briefly describe your rationale and reasoning for why you would include or rule out a diagnosis in your working diagnosis list. Provide 6 research nursing and medical references for your rationale.

· The paper should always have an introduction statement that explains what the paper will entails.

· Remember to include a cover page and use the most recent update APA formatting for references.

· Refer to the SOAP NOTE TEMPLATE for details on how this assignment will be graded.

· For this paper, you must provide 12-15 pages well written evidence-based research paper according to the rubric guidelines, follow the APA format formatting for references and support your paper with at least 5 to 7 nursing or medical evidence-based research articles not older than 7 yrs.

· please take time to read and review it, if the paper is not up a master’s degree level standard, I will not accept the work. I just want to be clear about that before I assigned it to anyone. This is an advanced degree work that requires a very strong writer with the background and experience in Nursing and Medical field and a very well-developed English and written expertise.

Alcohol Withdrawal Patient’s Soap Note

Hint 1 (Alcohol Withdrawal) is the patient primary diagnosis.

Anthony Washington is a 42-year-old African American man who came to the clinic with of complaint of not feeling well. Patient symptoms started 8 hours after abrupt stoppage of heavy drinking. Patient symptoms includes sweating, shakiness, hallucination, anxiety and agitation. The patient has a history of alcoholism. Patient has been heavily drinking for the last 6 months after a long period of being sober. He has been sobered for the last 2 years prior to picking up a drink 6 months ago. his relapse started due to stress at work. Patient also smokes marijuana occasionally; he does not do any other drugs. patient also presented with a state of confusion with hallucination, tachycardia and hypertension however afebrile. Based on the Clinical assessment and physical findings which include some state of confusion with hallucination, tachycardia and hypertension however afebrile. Patient assessment also reviewed elevated blood pressure of 136/92, with a pulse of 112.

Chief Complaint:

Patient presented with a complaint of feeling unwell. “I started feeling sick around few hours ago after I stopped drinking. I feel nauseas, sick, sweaty and confused. I started drinking 6 months ago after dealing with a lot of stress from work and home. I have been sobered for the last 2 years prior to 6 months ago.” Patient symptoms includes sweating, shakiness, hallucination, anxiety and agitation. The patient has a history of alcoholism. Patient has been heavily drinking for the last 6 months after a long period of being sober. He has been sobered for the last 2 years prior to picking up a drink 6 months ago. his relapse started due to stress at work. Patient also smokes marijuana occasionally; he does not do any other drugs. patient also presented with a state of confusion with hallucination, tachycardia and hypertension however afebrile. Based on the Clinical assessment and physical findings which include some state of confusion with hallucination, tachycardia and hypertension however afebrile. Patient assessment also reviewed elevated blood pressure of 136/92, with a pulse of 112.

Reliability and Source of History:

The patient is slightly hallucinating however alert and able to answer most of the questions.

Subjective and Objective Data.

Documented in the I-Human Dashboard.

Assessment

The primary diagnoses is Alcohol withdrawal. Other potential hypothesis for this patient includes Drug withdrawal, hypoglycemia, delirium, Wernicke syndrome, or alcohol intoxication. The patient primary diagnosis will be based on her subjective and objective data, nurse practitioner objective data, laboratory information data and physical assessments.

The Patient main diagnosis is Alcohol Withdrawal.

Rationale for Choosing Alcohol withdrawal

The patient other potential hypothesis diagnoses include:

· Drug Withdrawals (Benzodiazepine or Opioids)

· Hypoglycemia

· Delirium

· Wernicke Syndrome

· Alcohol intoxication

Drug Withdrawals (Benzodiazepine): is