You are a nurse working the night shift on a medical
unit in a 200 bed community hospital. On a Saturday
morning at 4:00 A.M., the Emergency Department (ED)
nurse calls to notify you that you will be receiving a
patient who was brought to the ED at 2:30 A.M. by the
local ambulance service. The patient was found at a rest
area off of the interstate. At 4:10 A.M. the ED nurse and
an orderly arrive on the unit with the patient, Mr. Ed
Mason. He is intoxicated, is mumbling incoherently, and
is combative. You assist the ED nurse and orderly in
placing Mr. Mason in his bed. The ED nurse informs
you, â€œWeâ€™ve seen Mr. Mason in the ED before – he is an
alcoholic. We usually keep him a few hours and then
release him but, this time he is worse. Heâ€™s never been so
out of it before.â€ The nurse notifies you that his Blood
Alcohol Content (BAC) is 200mg% and that she forgot to
bring the patientâ€™s chart, which includes the physicianâ€™s
orders, with them. Sheâ€™ll send the chart up to the nursing
unit when they return to the ED.
Section I: Pathophysiology
Discuss the effects of chronic alcohol consumption
on physiological systems, particularly the Central
Section II: Assessment
Mr. Mason has been placed in his bed. While awaiting
the chart with the physicianâ€™s medical orders you perform
a rapid baseline assessment. Which of the following
assessments should be performed by the nurse
AT THIS TIME? Select as many assessment options as desired.
Write a rationale for each assessment selected.
1. General physical assessment
2. Color of lips and nailbeds
3. Gag reflex
4. Skin color
5. Amount and color of of sputum
6. Medical history
7. Blood pressure and pulse
8. Bruises and scars
9. Medication history
10. Inspection of the abdomen
Section III: Intervention
Based on the previously assessed data, what would be the most appropriate INITIAL nursing intervention?
Choose only ONE intervention. Defend your choice of initial intervention.
1. Give magnesium sulfate injection as per standing
2. Place side rails up and bed in low position.
3. Order a meal tray from dietary as per the patientâ€™s
4. Encourage the patient to drink a minimum of 100
ml of fluid per hour.
5. Initiate deep breathing exercises q 1 – 2 h.
6. Write a nursing order to maintain this patient on
strict and accurate I and O.
7. Put mitts on Mr. Masonâ€™s hands so that he will
not scratch his skin.
8. Perform an accurate baseline weight measurement.
You obtain the patientâ€™s chart on the unit. The following
brief medical history is on the chart: Mr. Mason is a 45
year old welder who has a history of heavy alcohol intake
and sporadic employment. His alcoholic binges appear
to coincide with the times he is unemployed. He has
been drinking since the age of 13 and his alcohol intake
has escalated over the past 30 years to the point that he
now consumes a fifth of whiskey every 2 days.
Section IV: Nursing Diagnosis
Based on the analysis of the data provided in the
previous section related to Mr. Mason, list THREE nursing
diagnoses, high risk diagnoses, or collaborative problems
in PRIORITY order. Give rationales for each of your
What other information about this case would you
like to have that was not provided that would help in
making decisions regarding this patientâ€™s care?