Andrew Davis Documentation Assignment.,WELL EXPLAINED WITH CORRECT ANSWERS .

1. Document your findings related to the focused assessment of Mr. Davis’s alcohol withdrawal symptoms. Include his responses to your assessment. Some of the alcohol withdrawal symptoms that Mr. Davis showed was headache, sensitivity to light, sensitivity to noise, moderate tremors when patient’s arms are extended, anxiety and slight agitation, fidgety and diaphoresis on forehead. 2. Document your findings related to the assessment of Mr. Davis using the Clinical Institute Withdrawal Assessment of Alcohol Scale. Include his responses to your assessment. No nausea/vomiting, no tactile disturbances, no auditory disturbances, moderate tremor with patient’s arms extended, mild light sensitivity, beads of sweat obvious on forehead, moderate severe headache, moderately anxious and guarded, moderately fidgety and restless, oriented and can do serial additions. 3. Referring to your feedback log, document all nursing care provided and Mr. Davis’s response to this care. Introduced self to the patient, obtained patient’s vital signs, used therapeutic communication to speak with patient, assessed his pain conducted a CIWA alcohol scale to figure out withdrawal level of the patient, administered diazepam 10 mg to patient, educated him on withdrawing from alcohol, CIWA results, substance abuse, medications and plans post discharge. I also supported the patient about having a difficult time, his decision to get help, his responsibilities and his supportive son. 4. Document all patient teaching regarding assessments and safety issues provided to Mr. Davis, and his response to the teaching. I educated the patient on his CIWA results, medications, substance abuse, short term goals and his discharge plans. He was open to the education and wanted to learn more. 5. Document your handoff report in the SBAR format to communicate Mr. Davis’s future needs. Andrew Davis is 56 yo male who voluntarily admitted himself to the alcohol rehabilitation facility yesterday afternoon, he is currently in the acute detoxification unit. He was removed from a school board meeting where he was yelling racial and ethnic slurs at students and their family members. He reports his alcohol intake as approximately 1 pint of vodka a day and his last drink was prior to the school board meeting. PT is AOx3, vitals are within normal limits, CIWA score is 25, moderate/severe headache, light and noise sensitivity, restless and anxious. Vitals should be monitored and conduct CIWA every hour since score is rising.