Perform thorough nursing history and head-to-toe assessment and document to establish baseline of patient's condition for future comparison and to ensure continuity and consistency of care among nursing staff.- Monitor and record level of consciousness (LOC), temperature, heart rate and rhythm, and blood pressure at least every 4 hours, or more often if necessary, to detect deterioration from possible hypoxia or decreased cardiac output.
- Report complaints of anxiety, confusion, dizziness, or syncope promptly; these may indicate neurological decline.
Include patient in plan of action to promote self-care.- Use appropriate safety measures to protect patient from injury. Avoid physical restraints to prevent agitating patient.
- Provide positive feedback when patient assumes responsibility for own behavior to reinforce effective coping behaviors.
- Convey attitude of acceptance, separating individual from unacceptable behavior. Promotes feelings of dignity and self-worth.
- Provide nonjudgmental care. Monitor for changes in behavior (restlessness, increased tension). Agitation can lead to compromised patient safety.
- Assist patient in assessing current life situation and impact of substance use. Allows patient to see the relationship between substance use and physical problems.
- Assess patient's support system. Family involvement can help patient feel more in control.
Encourage patient to attend support and therapy groups regularly. Attendance fosters healing relationships and maintenance of a long-term substance-free existence.- Refer the patient to a mental health specialist and/or social worker for follow-up treatment after hospitalization. Continuing therapy is usually necessary to assist the patient to cope with health care status.
Suggested NIC Interventions
Anxiety Reduction; Behavior Modification; Self-Esteem Enhancement; Substance Use Treatment; Substance Use Treatment: Alcohol Withdrawal; Substance Use Treatment: Drug Withdrawal |