Doc Assignment (A. Davis).docx - Mental Health Case Andrew Davis Documentation Assignments 1 Document your findings related to the focused assessment of

Doc Assignment (A. Davis).docx - Mental Health Case Andrew...

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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. Upon assessment A.D was disheveled, clothing was appropriate to the environment, he was easily engaged in conversation along with well maintained eye contact. A.D was able to focus in the conversation w/o difficulty. Patient was restless and pacing. Patient’s speech was fluid, normoactive, and with appropriate volume. A.D’s thought process was linear and goal oriented. He had minimal sweat on foreheard. Upon patient extended arms and opening of fingers, he showed signs of a tremor. VS: BP: 160/94, TEMP 37.2*, SPO2: 99%, HR 20 breaths/min, RR: 100/min. HR and rhythm were regular w/o murmurs. Lungs were clear and equal bilaterally. He c/o 4/10 pain due to a headache. 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.

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