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.
Some of the
...
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.
Some of the alcohol withdrawal symptoms that Mr. Davis showed was headache, sensitivity to light, sensitivity to
noise, moderate tremors when patient’s arms are extended, anxiety and slight agitation, fidgety and diaphoresis on
forehead.
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.
No nausea/vomiting, no tactile disturbances, no auditory disturbances, moderate tremor with patient’s arms
extended, mild light sensitivity, beads of sweat obvious on forehead, moderate severe headache, moderately anxious
and guarded, moderately fidgety and restless, oriented and can do serial additions.
3. Referring to your feedback log, document all nursing care provided and Mr. Davis’s response to this care.
Introduced self to the patient, obtained patient’s vital signs, used therapeutic communication to speak with patient,
assessed his pain conducted a CIWA alcohol scale to figure out withdrawal level of the patient, administered diazepam
10 mg to patient, educated him on withdrawing from alcohol, CIWA results, substance abuse, medications and plans
post discharge. I also supported the patient about having a difficult time, his decision to get help, his responsibilities
and his supportive son.
4. Document all patient teaching regarding assessments and safety issues provided to Mr. Davis, and his response
to the teaching
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