Andrew Davis Documentation assignment.docx - Mental Health...

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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. Apon assessessment of Mr. Davis’s alcohol withdrawl symptoms his vitals include temp. 99.0F, HR 94 bpm, RR 20 breaths/min, BP 154/90 mmHg, and O2 at 98%. Pt c/o headache stating, “Why are you asking me so many questions? You are making my headache worse.” PT denied feeling sick to his stomach stating, “Not really sick to my stomach. I just don’t want to eat”. PT complains of HA and stated, “It just wont go away.” Pt c/o discomfort to sounds and asked, “Why is everyone so loud?” Pt complains of sensitivity to light and stated, “The lights in here are too bright they; they are hurting my head.” 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 assessment was completed. Upon observation, Mr. Davis had a moderate tremor with his arms extended. Pt had obvious beads of sweat on his forehead. Pt was moderately anxious as evidence by him stating, “I don’t know what to do with my hands.” It was found that Pt was moderately figety and restless. Pt

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