Andrew_Davis - 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. 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.

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