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Nursing Care Plan for Alcohol Dependence

- The patient, a 39-year-old male, presented with poor coordination and slurred speech and was admitted with a diagnosis of denial related to personal vulnerability due to delayed refusal of healthcare attention to his detriment. - The student nurse assessed the patient and noted restlessness, fatigue, weakness, loss of consciousness, and a facial grimace. Vital signs were elevated. - The nursing care plan aims for the patient to acknowledge his alcohol abuse and accept responsibility, regain a healthy state through an alcohol-free lifestyle, and participate in lifestyle changes to live without drugs through realistic planning and goal-setting.

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684 views2 pages

Nursing Care Plan for Alcohol Dependence

- The patient, a 39-year-old male, presented with poor coordination and slurred speech and was admitted with a diagnosis of denial related to personal vulnerability due to delayed refusal of healthcare attention to his detriment. - The student nurse assessed the patient and noted restlessness, fatigue, weakness, loss of consciousness, and a facial grimace. Vital signs were elevated. - The nursing care plan aims for the patient to acknowledge his alcohol abuse and accept responsibility, regain a healthy state through an alcohol-free lifestyle, and participate in lifestyle changes to live without drugs through realistic planning and goal-setting.

Uploaded by

karl de guzman
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd

NURSING CARE PLAN

Patient’s Initials: L.D Chief Complaint: Poor Coordination and Slurred Speech Name of Student Nurse:
Age & Gender: 39 yrs. Old/Male

Birthdate: August 23, 1983 Admitting Diagnosis: Denial r/t personal vulnerability Level/Block/Group:
AEB delay in refusal of healthcare attention to the
detriment of health/life
Address: Lucao District, Dagupan City, Hospital/Area:
Pangasinan, Philippines Patient’s Home
Date of Confinement: 03/17/2022 Clinical Instructor:
Date: 03/17/2022

ASSESSMENT NURSING GOAL/PLAN OF CARE NURSING INTERVENTIONS


DIAGNOSIS

Subjective Data: • Denial r/t After nursing interventions, the patient is INDEPENDENT:
 “Hindi ako lasing, personal expected to: - Determine how the patient like to be
okay lang talaga ako vulnerability AEB addressed.
ano ba kayo“ as delay in refusal of Short – Term:
verbalized by the healthcare - Verbalize awareness of relationship of - Demonstrate a positive attitude by
patient. attention to the alcohol abuse to current situation. isolating the individual from unwanted
detriment of behavior.
Objective Data: health/life - Can engage in therapeutic program
 Restlessness - Answer questions truthfully and provide
 Fatigue - Verbalize acceptance of responsibility for accurate data. When you make a
 Weakness own behavior. commitment, keep it.
 Loss of conscious
Long – Term: - Provide information regarding effects of
 Facial Grimace addiction on mood and personality.
Vital Signs taken: - Can regain and maintain healthy state with
 BP- 160/90 mmHg an alcohol-free lifestyle. - Provide positive feedback for expressing
awareness of denial in self and others.
 HR- 68 bpm
- Can demonstrate behaviors, lifestyle
 RR- 16 cpm changes to regain and maintain appropriate COLLABORATIVE:
 Temp- 37.5 degrees weight. - Review definition of drug dependence
Celsius and categories of symptoms (patterns of
- Set goals and participate in realistic planning use, impairment caused by use, tolerance
for lifestyle changes necessary to live without to substance).
drugs.
- Provide information about addictive use
versus experimental, occasional use;
biochemical or genetic disorder theory

- Encourage and support patient’s taking


responsibility for own recovery

- Encourage family members to seek help


whether or not the abuser seeks it.

- Maintain firm expectation that patient


attend recovery support and therapy
groups regularly.

- Administer medications such as


Disulfiram (Antabuse) since the drug can
be helpful in maintaining abstinence from
alcohol while other therapy is undertaken.

SOURCE:
[Link]
nursing-diagnosis-care-plan

NURSING CARE PLAN Patient’s Initials: L.D Age & Gender: 39 yrs. Old/Male Chief Complaint: Poor Coordination and Slurred Spee
drugs. - Provide information about addictive use versus experimental, occasional use; biochemical or genetic disorder theor

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