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Diagnosis: Wernicke’s Korsakoff syndrome
Diagnosis: Wernicke’s Korsakoff syndrome
T-98.2f, BP 210/100, P-112, SPo2 95% RA
Complaint: confusion, ataxia, tremors, N/V, loss of muscle coordination
Medication: thiamine IV, Vitamin B12, D5NS @ 250/hr, Ativan (1mg for CIWA less than 8, 2mg for CIWA greater than 8)
Labs: Magnesium 1.6, CK 18,487, Lactic 3.5, Vitamin B12 150, ALT 75, AST 126
| Assessment Data (Include at least three-five subjective and/or objective pieces of data that lead to the nursing diagnosis) | Goals & Outcome (Two statements are required for each nursing diagnosis. Must be Patient and/or family focused; measurable; time-specific; and reasonable.) | Nursing Interventions (List at least three nursing or collaborative interventions with rationale for each goal & outcome.) | Rationale (Provide reason why intervention is indicated/therapeutic; provide references.) | Outcome Evaluation & Replanning(Was goal met? How would you revise the plan of care according the patient’s response to current plan ?) |
| OBJECTIVE: SUBJECTIVE | Statement #1 Statement #2 | 1. 2. 3. 4. | 1. 2. 3. 4. | Outcome #1 Outcome #2 Outcome #3 |
- List patient mediations, indications, and nursing considerations for this patient
| Medication, Dose, Route | Indications for Medication | Nursing Consideration for Patient/ Side Effects |
- List Patient abnormal lab values, normal ranges, and why they are altered.
| Abnormal Lab Value | Normal Range | Cause of Abnormal Lab Value |
- List all Patients Nursing Diagnosis in priority Order and explain why.
| Nursing Diagnosis | Explanation |
References: