Mental Health Case: Andrew Davis
Documentation Assignments
Document your findings related to the focused assessment of Mr. Davis’s alcohol withdrawal symptoms.Include his
responses to your assessment.
Mr. Davis is AOx3. BP: 160.82. Respirations: 20 breaths/min. HR 100. Temp 99.0°F . Mood is anxious, restless and
he is irritated with questions. Reports headache and states pain is 4 on a 0-10 pain scale. Reports sensitivity to
lights. Perspiration on forehead and is warm to touch. Mr. Davis had a tremor in his hands. Reports no
nausea/vomiting. States no auditory or visual hallucinations.
1. 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.
Mr. Davis is moderately restless and is fidgeting. He did not have any tactile disturbances, and had moderate
sensitivity to visual disturbances. Extending his arms revealed moderate hand tremors. Visible perspiration
forehead. He had anxiety, stating “I don’t know what to do with my hands”. Denied unusual sensations,
numbness or tingling. Denied hallucinations. CIWA score 26.
2. Referring to your feedback log, document all nursing care provided and Mr. Davis’s response to this care.
CIWA performed. Asked patient general mental status examination questions. Patient reported headache and
stated “the lights are too bright”. Dimmed lights in room to relieve visual discomfort. Patient scored 26 on CIWA
assessment. Hands tremors observed when arms were fully extended. Patient reported anxiety, stating “I’m not
sure what to do with my hands”. 10 mg Diazepam given for withdrawal.
3. Document all patient teaching regarding assessments and safety issues provided to Mr. Davis, and his
response to the teaching.
Educated Mr. Davis on purpose for CIWA and informed him that the assessment will need to be performed every
hour because he is showing symptoms of withdrawal. Patient started feelings of irritation, stating “how often will
I have to answer all of these questions.” Provided education on prescription of 10 mg of Diazepam for
withdrawal. I advised Mr. Davis that he might feel dizzy and drowsy and to remember sitting up slowly from a
seated position. PT was educated on symptoms of alcohol withdrawal (tremors, irritability, sweating, light
sensitivity, and fever).
4. Document your handoff report in the SBAR format to communicate Mr. Davis’s future needs.
Situation: PT admitted himself to the unit after his wife asked him to move out of their home. He reports he
drinks around 1 pint of vodka per day. He denies any other substance use. He did attend a 12 step meeting
Documentation Assignments
Document your findings related to the focused assessment of Mr. Davis’s alcohol withdrawal symptoms.Include his
responses to your assessment.
Mr. Davis is AOx3. BP: 160.82. Respirations: 20 breaths/min. HR 100. Temp 99.0°F . Mood is anxious, restless and
he is irritated with questions. Reports headache and states pain is 4 on a 0-10 pain scale. Reports sensitivity to
lights. Perspiration on forehead and is warm to touch. Mr. Davis had a tremor in his hands. Reports no
nausea/vomiting. States no auditory or visual hallucinations.
1. 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.
Mr. Davis is moderately restless and is fidgeting. He did not have any tactile disturbances, and had moderate
sensitivity to visual disturbances. Extending his arms revealed moderate hand tremors. Visible perspiration
forehead. He had anxiety, stating “I don’t know what to do with my hands”. Denied unusual sensations,
numbness or tingling. Denied hallucinations. CIWA score 26.
2. Referring to your feedback log, document all nursing care provided and Mr. Davis’s response to this care.
CIWA performed. Asked patient general mental status examination questions. Patient reported headache and
stated “the lights are too bright”. Dimmed lights in room to relieve visual discomfort. Patient scored 26 on CIWA
assessment. Hands tremors observed when arms were fully extended. Patient reported anxiety, stating “I’m not
sure what to do with my hands”. 10 mg Diazepam given for withdrawal.
3. Document all patient teaching regarding assessments and safety issues provided to Mr. Davis, and his
response to the teaching.
Educated Mr. Davis on purpose for CIWA and informed him that the assessment will need to be performed every
hour because he is showing symptoms of withdrawal. Patient started feelings of irritation, stating “how often will
I have to answer all of these questions.” Provided education on prescription of 10 mg of Diazepam for
withdrawal. I advised Mr. Davis that he might feel dizzy and drowsy and to remember sitting up slowly from a
seated position. PT was educated on symptoms of alcohol withdrawal (tremors, irritability, sweating, light
sensitivity, and fever).
4. Document your handoff report in the SBAR format to communicate Mr. Davis’s future needs.
Situation: PT admitted himself to the unit after his wife asked him to move out of their home. He reports he
drinks around 1 pint of vodka per day. He denies any other substance use. He did attend a 12 step meeting
