Mental Health Case: Andrew Davis Documentation Assignments

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. 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. 3. Referring to your feedback log, document all nursing care provided and Mr. Davis’s response to this care. 4. Document all patient teaching regarding assessments and safety issues provided to Mr. Davis, and his response to the teaching. 5. Document your handoff report in the SBAR format to communicate Mr. Davis’s future needs. Situation: Mr. Davis, 56- year-old-man, self-admitted for alcohol detoxication. It has been 14 hours since his last drink. Assessment: He is currently oriented ×3 and is angry with all the questions being asked. He went to a 12-step meeting yesterday but left early, saying that he was "not like those people" and felt he wouldn’t benefit from the meeting. He was restless last night and did not sleep much. He is restless and he is complaining of severe headache.. His CIWA-Ar score is 22. His last vital signs are as follows: temperature, 37.2°C (99.0°F); heart rate, 94 beats/min; respiratory rate, 20 breaths/min; blood pressure, 154/90 mmHg; and blood oxygen saturation, 98%. Recommendation: Continue with CIWA scale and administer diazepam 10 mg prn q 2 h for score above 8. Encourage the patient to join the group therapy as his headache subsides. Consult with the psychiatrist was order for later today, look for updated orders. .......................................................