PT is a 37 year old Caucasian male who presented to the Emergency Room this afternoon with signs of an opioid withdrawal.

BACKGROUND

PT has a history of opioid use disorder and admits to have struggled with this for the past 3 years. He had a heroin overdose in May 2023, but claims, "He is doing much better, and has it all under control now". PT has no known allergies or other significant medical history. When asked if he had any family he wanted to be contacted, he refused claiming, "no one even cares about me, all they do is judge. My family gave up on me a long time ago".

ASSESSMENT

Upon admission, PT appeared extremely restless, anxious, and irritable. He was sweating profusely and complained of flu-like symptoms. Piloerection was notable across his body. PT admits to having a runny nose and feeling "queasy" to his stomach. When asked about his last bowel movement, he said he had several loose BMs today. Several times, the PT shifted in his bed, rubbing up and down his arms and legs, and the PT had to be reminded to stay seated on the bed during the interview process. PT rates his pain a 6/10. A COWS score of 32 indicates moderately severe opioid withdrawal. Temp=99.5F, Resp= 22, BP= 150/90, HR= 110, SpO2=95% on room air.

RECOMMENDATION

Will continue to monitor V.S. Q15 mins (including respiratory and neurological assessments). Contact provider if PT begins to deteriorate or if any changes need to be made to the treatment plan. Provide PT education. Due to irritability, the PT should be placed in a private room, potentially 1:1 with a staff member in a low stimulation environment. Before discharge, PT should be educated on the potential resources, such as therapy, rehab, social services, emergency hotlines.

• Administer IV Fluids and begin PT on assigned diet.

• Monitor & assess for nausea, vomiting, and diarrhea.

• Draw up labs (BMP, CBC) and notify provider if there are any abnormal values.

These actions are done in order to prevent fluid & electrolyte imbalances that can occur due to dehydration, vomiting, and diarrhea.

• Administer prescribed medications to help with PT's pain.

• Monitor PT's response to the medication and assess pain level an hour after medication administration .

• Educate PT on medication interventions, considerations and side effects.

• Provide cool rags and pillows to increase PT's comfort level.

If the PT's pain is decreased, it may help normalize his vital signs (decreased H.R. and B.P.) and may lessen his irritability

• Before discharge, educate the PT on available community/social resources.

• Provide information on rehab facilities, emergency hotlines, support groups, and therapy to help PT cope with familial strain, perceived loneliness, and substance abuse.

We want to prevent future substance overdoses and provide the PT with support, so he is more likely to recover