Alcohol Abuse Documentation .docx - Mental Health Case...

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Mental Health Case: Andrew Davis 1. Document your findings related to the focused assessment of Mr. Davis’s alcohol withdrawal symptoms. Include his responses to your assessment. a. Mr. Davis continuously had a headache as a symptom from alcohol withdrawal. When asked if he was sensitive to noise, he responded with “everyone is so loud.” Mr. Davis also displayed sweating from his forehead, restlessness, and tremors when his hands were out. Mr. Davis’s heart rate was 100 bpm while resting which is also a symptom of alcohol withdrawal. 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 . a. Mr. Davis denied any sickness in stomach, however he did not have an appetite and did not eat. He stated that he wished to not answer so many questions due to his headache. He denied any vomiting and stated that he was anxious. Moreover, Mr. Davis denied any itching, but reported having more awareness to sound and the sounds were harsh. 3. Referring to your feedback log, document all nursing care provided and Mr. Davis’s response to this care. a. I dimmed the lights, as he was sensitive to them. After asking general questions, I performed a CIWA of alcohol scale and a mental status exam. I assessed his appearance, mood, affect, and insight. He

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