Primary Nursing Diagnosis

Altered thought processes related to CNS depression

OUTCOMES. Cognitive orientation; Cognitive ability; Electrolyte and acid-base balance; Fluid balance; Neurologic status; Safety behavior

INTERVENTIONS. Airway management; Aspiration precautions; Behavior management; Delusion management; Environmental management; Surveillance

40 Acute Alcohol Intoxication

^ PLANNING AND IMPLEMENTATION Collaborative

MEDICAL. Electrolyte replacement, especially magnesium and potassium, may be necessary. Dehydration is a common problem, and adequate fluid replacement is important. Intravenous fluids may be necessary. During periods of acute intoxication, use care in administering medications that potentiate the effects of alcohol, such as sedatives and analgesics. Calculate when the alcohol will be fully metabolized and out of the patient's system by dividing the blood alcohol level on admission by 20 mg/dL. The result is the number of hours the patient needs to metabolize the alcohol fully.

Anticipate withdrawal syndrome with any intoxicated patient. Formal withdrawal assessment instruments are available to help guide the use of benzodiazepines. If the patient is a dependent drinker, an alcohol referral to social service, psychiatric consultation service, or a clinical nurse specialist is important.

Pharmacologic Highlights

Medication or Drug Class

Dosage

Description

Rationale

Thiamine

100 mg IV

Vitamin supplement

Counters effects of nutritional

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