Case study - Substance use disorder (SUD): Nursing

Nurse Jacob works on a medical-surgical unit and is caring for Dallas, a 62-year-old patient with a history of substance use disorder, who was admitted three days ago for alcohol detoxification. After settling Dallas in his room, Nurse Jacob goes through the steps of the Clinical Judgment Measurement Model to make clinical decisions about Dallas’ care by recognizing and analyzing cues, prioritizing hypotheses, generating solutions, taking action, and evaluating outcomes. 

First, Nurse Jacob recognizes important cues, including Dallas’ vital signs, which are temperature 98.6 F or 37 C, heart rate 105 beats per minute, respirations 20 breaths per minute, and blood pressure 140/90 mmHg. He also notices Dallas' hands are trembling, he’s sweating, and he has IV fluids infusing in his left antecubital peripheral IV.  

Nurse Jabob: Hi Dallas, how are you feeling? 

Dallas: I have a pounding headache, I can’t concentrate, and I just can’t relax.  

Nurse Jacob: I understand. Are you hearing or seeing anything that isn’t normally there?  

Dallas: No, I’m not hallucinating, I just feel super nervous, I can’t explain it.  
  Next, Nurse Jacob analyzes these cues. He reviews the electronic health record, or EHR, and notes that, prior to admission, Dallas was drinking about ten shots of vodka per day.  

Nurse Jacob completes the Clinical Institute Withdrawal Scale-Alcohol Revised, or CIWA-Ar, and tallies Dallas’ CIWA score as 15, indicating moderate withdrawal symptoms.  

Nurse Jacob knows that the maximum CIWA score is 67, and as withdrawal symptoms become more severe, the score increases. 

Nurse Jacob recognizes that when patients with alcohol use disorder stop drinking abruptly, they can develop symptoms like anxiety, irritability, tachycardia, diaphoresis, and auditory and visual hallucinations, and they can develop delirium tremens, a severe complication that can lead to seizures and death.  

Nurse Jacob realizes Dallas needs effective management of his alcohol withdrawal. 

Now, using the information he's gathered, along with Dallas’ medical history, Nurse Jacob chooses a priority hypothesis of anxiety.