The nurse is caring for P.R., a 54 year old male who was admitted to the hospital with a diagnosis of Alcohol Withdrawal. It has been 2 days since his last alcoholic drink and he is experiencing delirium tremens. During the periods when he is awake, he is oriented x1 to name only. He is combative and has an order for Lorazepam 2mg IVP every 4-6 hours PRN for anxiety and visual/auditory hallucinations. Also, when he is combative, his blood pressure, pulse, and respirations increase. He is being monitored closely. Currently, he has an IV infusion of Normal Saline 0.9% infusing at a rate of 100ml per hour. When awake, the doctor wrote an order for Lactulose 30ml PO TID

His past medical history includes hypertension, malnutrition, and liver cirrhosis. His current VS are as follows: BP 146/88, P 96, R 24, T 99.2 at the change of shift. You noted wrist restraints on the patient’s bedside table but the outgoing nurse did not report the use of restraints. In addition, the patient’s anxiety appears to be increasing and the prior nurse did not report to you when the last dose of Lorazepam was given.

No family members are available to obtain additional information.

1. What information was lacking in the prior nurse’s report?
2. What interventions should you as the incoming nurse incorporate into the plan of care for this patient?
3. Will this patient require more frequent documentation by the nurse, and, if so, what should be documented?
4. What kind of specific data would you want to report to the oncoming nurse assigned to J.R’s care?