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Mr. Stewart, 49 years of age, and his wife arrive in the emergency department one evening, fearful that he has had a stroke. His right hand is limp, and he is unable to hyperextend his right wrist. Sensation to the fingertips in his right hand is impaired.
Mr. Stewart looks much older than his stated age; in fact, he looks about 65. His complexion is ruddy and flushed. History-taking is difficult. Mr. Stewart answers only what is asked of him, volunteering no additional information. He states that he took a nap that afternoon and that when he awakened he noticed the problems with his right arm.
Ms. Winkler, the admitting nurse, begins the assessment. Mr. Stewart reveals that he has been unemployed for 4 years because the company he worked for went bankrupt. He has been unable to find a new job but has a job interview in 10 days. His wife is now working full time, so the family finances are okay. They have two grown children who no longer live at home. As he relates this, momentarily his lips start to tremble and his eyes fill with tears.
He denies any significant medical illness except for high blood pressure, just diagnosed last year. His father has a history of depression, and his mother is a recovering alcoholic. Ms. Winkler shares with him the fact that depression and alcoholism run in families. She asks Mr. Stewart whether he knows this and whether it concerns him with regard to his own drinking. He says that he knows and that he does not want to think about it.
Ms. Winkler speaks with Mr. Stewart’s wife and asks whether there is anything that she would like to add. Mrs. Stewart’s shoulders slump; she sighs and says, “I have spent the entire day talking to a counselor at the local treatment center to see if I can get him in. He won’t admit that he has a problem.” Mrs. Stewart recounts a 6-year history of steadily increasing alcohol use. She says that she could not admit to herself that her husband was an excessive drinker. “He tried to hide it, but gradually I knew. I could tell from little changes that he was intoxicated. I couldn’t believe it was happening because he had been through the same thing with his mother. I thought I knew him. Actually, I guess I did when he was working. Being unemployed and unable to find a job has really devastated him. And now he’s going to job interviews intoxicated.”
She describes her feelings, which are like an emotional roller coaster – elated and hopeful when he seems to be doing okay, dejected and desperate when he loses control. Mrs. Stewart hates going to work for fear of what he might do while she is gone. She says she is terrified that one day her husband will get into a car wreck and kill himself, because he often drives when intoxicated. He tells her not to worry because the life insurance policy is paid up.
Meanwhile, the physician in the emergency department has examined Mr. Stewart. The diagnosis is radial nerve palsy. Mr. Stewart most likely passed out while lying on his arm. Because Mr. Stewart was intoxicated, he did not feel the signals that his nerves sent out to warn him to move (numbness, tingling). He was in this position for so long that the resultant cutoff of circulation was sufficient to cause some temporary nerve damage.
Mr. Stewart’s blood alcohol level (BAL) is 0.31%. This is three times the legal limit for intoxication in many states (0.1%). Even though he has a BAL of 0.31%, Mr. Stewart is alert and oriented, not slurring his speech or giving any other outward signs of intoxication. The difference between Mr. Stewart’s BAL and his behavior indicates the development of tolerance, a symptom of physical dependence.
Questions:
Identify at least five objective data observed while assessing this patient.
Identify two key diagnoses the nurse is most likely to record for this patient, and back each up with evidence.
Based on key diagnoses identified in the previous question, select appropriate long-term outcomes for this patient.