MentalHealth_AndrewDavis_DA.docx - Simone Baker Mental...

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Simone Baker 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. 05/01/2020 @0800 Focus Assessment Alcohol Withdrawal Symptoms Respiration: 20breathes/min, Radial Pulse:100bpm, Blood pressure: 160/94, Pulse ox: 99%, temperature: 37.1C Pt states pain of a “4” in the form of a “headache”. States hes been taking “Tylenol” for relief for pain. Nonverbal cues: Pt appears restless and fidgety while seated, physical appearce slightly disheveled, observed visible beads of sweat on pt’s forehead. Arms extended and fingers spread pt showed signs of tremors. Pt was coorperative in interview and 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. 05/01/2020 @0809 CIWA- ar Assessment Tool Nausea rated 0: pt expressed no nausea or vomiting Tremor rated 4: moderate, with patients arms extended Paroxysmal Sweats rated 4: beads of sweat obvious on forehead Anxiety rated 4: moderately anxious, or guarded, so anxiety is inferred. Pt stated they “did not know what to do with my hands.” When asked if they are feeling anxious they stated “yes, I am anxious about drinking again” Agitation rated 4: moderately fidgety and restless as observed visually by nurse Tactile disturbances rated 0 none: pt expressed no itching, pins and needles, burning, or numbness Auditory disturbances rated 3: moderate harshness as indicated by pt’s sensitivity to sound saying “its loud in here” when there is little noise. Visual disturbances rated 3: moderately sensitive. Pt states the “lights are too bright” and hurt his head, but do not indicate any change in color of the light. Headache rated a 4: moderate as stated in a pain assessment when asked to scale pain from 0-10. Pt scored “4”. From vSim for Nursing | Mental Health. © Wolters Kluwer.
Orientation and clouding sensorium rated 0: pt oriented x3 person, place, and time. Pt able to do serial addition. When asked please add 7 to 5 and continue to add 7 to the results until I say stop? The patient said: “OK. Math problems too? ...12...19...26...umm...33..” Pt scored a 27 in which diazepam 10mg was administered orally as per Dr. order. 3. Referring to your feedback log, document all nursing care provided and Mr. Davis’s response to this care. @0800 Checked scene safety, introduced self, washed my hands, and identified the patient. Asked if the patient had any known allergies and performed medication reconciliation.

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