Mental Health Case: Andrew Davis

Mental Health Case: Andrew Davis Documentation Assignments 1. Document your findings related to the focused assessment of Mr. Davis’s alcohol withdrawal symptoms. Include his responses to your assessment. ● Mr. Davis reported visual and auditory disturbances, a severe headache, tremors when holding his hands in front of him, diaphoresis, agitation, and anxiety. 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. ● nausea/vomiting: 0 none ● tremors: 4 moderate, with patient’s arms extended ● anxiety: 4 moderately anxious or guarded, so anxiety is inferred ● agitation: 4 moderately fidgety and restless ● paroxysmal sweats: 4 beads of sweat obvious on forehead ● orientation & clouding 0 oriented ● of sensorium ● tactile disturbances 0 none ● auditory disturbances 2 mild harshness or ability to startle ● visual disturbances 3 moderate sensitivity ● headache 4 moderately severe 3. Referring to your feedback log, document all nursing care provided and Mr. Davis’s response to this care. ● Nursing care for Mr. Davis included taking vitals, assessing pain, performing a CIWA assessment, patient education on substance abuse, results of the CIWA assessment, medication, short term goals, and diazepam medication administration. 4. Document all patient teaching regarding assessments and safety issues provided to Mr. Davis, and his response to the teaching. ● Patient teaching regarding the CIWA assessment included explaining the various protocols of the CIWA (Clinical Institute Withdrawal Assessment), what was scored, and how it was scored. The patient was educated on alcohol withdrawal symptoms and what safety measures needed to be put in place when withdrawing from alcohol. Education was given in a nonjudgmental and supportive manner. The patient responded well and was receptive to the teaching. 5. Document your handoff report in the SBAR format to communicate Mr. Davis’s future needs. ● S: Mr. Davis, a 56 year old man that voluntarily admitted himself to the alcohol rehabilitation facility yesterday afternoon. He is currently in the acute detoxification unit. He has been on the unit for about 16 hours. ● B: Mr. Davis is a member of the school board and a pastor. Yesterday he was removed from a school board meeting after becoming angry and screaming racial and ethnic slurs. He has three children, two of whom do not speak to him. Other than a ORIF surgery 2 years ago to repair a humerus fracture, he has no other significant medical history. He reports his alcohol intake is 1 pint of vodka / day. His last drink was at the school board meeting. He does not smoke and tested negative for opiates and marijuana. ● A: He is currently oriented x3. He was restless and did not sleep much