MH case study1111.docx - Mental Health Case Andrew Davis...

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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. The focused assessment of Mr. Davis’ alcohol withdrawal symptoms included his vital signs, BP 160/82; HR 92, SpO 2 99%, temp 99 F, RR 20/min. Mr. Davis c/o loudness in the room, stating, “Why is everyone so loud? I wish they would shut up!” and Mr. Davis c/o the brightness of the lights, stating, “The lights in here are too bright; they are hurting my head.” Mr. Davis denied feeling sick to his stomach, but had no desire to eat. Lastly, Mr. Davis c/o a headache that he stated, “won’t go away.” 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. The CIWA-Ar assessment was completed. It was found that Mr. Davis was moderately fidgety and restless. He did not have any tactile disturbances. He scored mild sensitivity to visual disturbances. He had moderate tremors when his arms were extended. Pespiration was visible on his forehead. Mr. Davis showed anxiety when he stated, “I don’t know what to do with my hands.” Mr. Davis was able to perform mathematical tests in his head, showing cognitive function. 3. Referring to your feedback log, document all nursing care provided and Mr. Davis’s response to this care. Feedback Log 0:00 Patient 0:00 You checked scene safety. It was correct to check scene safety in order to maintain your own safety. 0:06 You introduced yourself. 0:27 You washed your hands. 0:33 You identified the patient. 0:51 You asked if the patient had any known allergies. From vSim for Nursing | Mental Health. © Wolters Kluwer.
1:07 You asked the patient: Can you tell me a little bit more about what's going on with you today? It was appropriate to ask the patient what was going on with him to get an understanding of this. 1:22 The patient said: I don't think I can keep this up anymore. Everything is falling apart!\nYou answered: Of all the concerns you have, which is the most upsetting to you? \nYou used the therapeutic technique of focusing. 1:29 You asked the patient: Do you have any pain? The patient said: Yes, I have some pain. 1:36 You asked the patient: On a scale of 0 to 10, how would you rate your level of distress? The patient said: Seven. Why are you asking me so many questions? 1:46 You asked the patient: How would you rate your pain, on a scale of 0 to 10? The patient said: It's about a 4. 1:57 You asked the patient: What other pain management strategies have you used other than medications? The patient said: None. Just Tylenol.

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