Andrew Davis.docx - Mairim Dominguez Mental Health Case...

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Mairim Dominguez 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. Pt. alert and oriented x3. Vital signs of BP 160/80, P 100, RR 20, Temp 99.0, SpO2 99%. Pt. skin is sweating and warm. Assessed pt. using CIWA. Denies nausea or vomiting. When asked if hearing things, pt. says “Oh , ofr god’s sake, I am not hearing things. It’s just too loud in here, if that’s what you mean”. Reported a headache. Rates pain 4/10. Easily engages with examiner with well-maintained contact. Restless and has been pacing. 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. Pt. alert and oriented x3 and can do serial additions. Denies nausea and vomiting. Moderate tremors, with pt’s. arms extedned. Beads of sweat observed on forehead. Mildly anxious and agitation is somewhat more than normal activity.

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