John doe, approximately 50 years old, is admitted to your unit for observation from the emergencydepartment (Ed) with the diagnosis of rule out hepatic encephalopathy with acute alcohol (ETOH) intoxication

Question

This man was sent to the Ed by local police, who found him lying unresponsive along a rural road.
Examination and x-ray studies are negative for any injury and you are awaiting the results of the blood
alcohol level (BAL) and toxicology tests. He has no identification and is not awake or coherent enough
to give any history or to answer questions. He is lethargic, has a cachectic appearance, does not follow
commands consistently, and is mildly combative when aroused. He smells strongly of ETOH and has a
notably distended abdomen and edematous lower extremities. He has a Foley catheter and is receiving
an intravenous (IV) infusion of d5 ½ Ns with 20 mEq KCl and 1 ampule of multivitamins at 75 mL/hr.
Admitting orders are shown in the chart.

What do you need to do for John Doe, and what can you delegate to the nursing assistive personnel (NAP)?

Answer 1

• The registered nurse (RN) administers medications; starts, monitors, and adds meds to IV infusion
(the pharmacy department might add medications to IVs in some facilities); calls the physician
with any changes in patient condition and vital signs (VS); ensures that the laboratory tests are
ordered and samples drawn; inserts and monitors NGT drainage; and inserts the Foley catheter
and monitors urinary output.
• The NAP might take VS in some facilities, maintains HOB, feeds appropriate diet, and observes for
anything unusual such as difficulty swallowing or VS outside an acceptable range and reports to
RN. The NAP might obtain the stool specimen for occult blood and empty the Foley catheter during
each shift and report amounts to RN.