Vsim Of Nursing Mental Health Davis Guided And Doc.. (1)

MENTAL HEALTH CASE 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 last night. His latest CIWA score was 25 and was given 10 mg of diazepam. His last set of vitals were temperature 37.2℃, heart rate 94 beats/min, respiratory rate 20 breaths/min, blood pressure 154/90 mmHg, and blood oxygen saturation 98%. ● R: Reassess his CIWA score. Continue medication orders (PRN diazepam for a CIWA score of 8 or greater). He will go to group therapy and an Alcoholics Anonymous meeting later today. He will also be evaluated by a psychiatrist later today. Mental Health Case: Andrew Davis Guided Reflection Questions Opening Questions How did the simulated experience of Andrew Davis’ case make you feel? ● This experience made me feel more comfortable with the CIWA scale and the different signs of withdrawals. Talk about what went well in the scenario. ● I was able to use therapeutic communication and decrease environmental stimuli to calm down the patient. I conducted a CIWA test and was able to learn more about the patient. Reflecting on Andrew Davis’ case, were there any actions you would do differently? If so, what were these actions and why? ● If possible I would have asked more about how he feels leading up to when he drinks and why he feels the need to. Scenario Analysis Questions* PCC What issues have you identified that could be barriers to a successful treatment for Andrew Davis? ● During the report it stated that Mr. Davis went to a 12 step meeting but left early saying he wasn’t like those people. If he doesn’t admit that he has a problem with alcohol then he can’t truly get the help he needs. How would you address the denial? ● I would be calm and matter of fact with him, showing that he may deny it but his action and body’s reaction to not having alcohol shows that he does have an alcohol addiction and he needs help. PCC/I Identify a support group that would be beneficial to Andrew Davis related to his position in the community. ● A 12 step program would be beneficial to Mr. Davis because a part of that program is to take responsibility for your actions and apologize to those he has hurt because of his addiction. PCC/I Identify support groups that would be beneficial to Andrew Davis’ family. ● A local support group for families of addicts S/PCC Andrew Davis is currently in Stage I of alcohol withdrawal. As he moves into Stage II (24 to 72 hours) and then into Stage III (after 72 hours), what behaviors should be assessed for and what safety measures should be initiated? ● Auditory and visual disturbances, nausea and vomiting, severe tremors, drenching sweats, acute panic state, pacing, thrashing, itching, pins and needs, burning or numbness, harshness or increased ability to frighten, sensitivity to light and sound, severe headache, disorientation. Concluding Questions How would you apply the skills and knowledge gained in the Andrew Davis case to an actual patient situation in different acute care units (emergency room, intensive care unit, obstetrics unit, etc.)? ● I would use the therapeutic communication skills, knowledge of withdrawal symptoms and CIWA assessment in different acute care units to best take care of my patient.