Abstract
Sam,* a 49-year-old patient admitted to the hospital for his fifth detoxification from alcohol abuse, began to have diaphoresis and tremors. He knew from experience that the shaking would only increase unless he obtained his medication, Librium, as needed (PRN). Sam began asking nursing staff if he could get his Librium, and staff said to him, "Find your nurse." He began approaching staff members asking, "Are you my nurse?" His anxiety increased as each one said, "No, not today." or "Look on the assignment board." Sam's long, oily hair and dirty clothes gave off a distinct odor and disheveled appearance. After what felt like an eternity for Sam, someone finally yelled out, "Who is Sam's nurse today?" The staff then figured out that since the beginning of the shift, patient assignments had been reorganized by the charge nurse, and Sam's new nurse didn't know Sam had been reassigned to her. Sam was in tears by the time his nurse, Cindy, came to him.