VSIM ANDREW DAVIS MENTAL HEALTH CASE DOCUMENTATION 2023

VSIM ANDREW DAVIS MENTAL HEALTH CASE DOCUMENTATION 2023 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 yesterday but left because he says he “is not like those people” and felt as if he would not benefit from the meeting. Background: Mr. Davis is a 58 year old man who voluntarily admitted himself yesterday. He is currently in the acute detoxification unit and has been here for approximately 16 hours. He is a member of the school board and a pastor at a church. Yesterday he was removed from a school board meeting by security guards after becoming angry and directing slurs towards those attending the meeting Assessment: PT labs have already been drawn and the results are available in his chart. He is currently AOx3. His CIWA-AR score was 1 on admission. At 0400 it increased to 7. His latest vitals are: BP: 160.82. Respirations: 20 breaths/min. HR 100. Temp 99.0°. His CIWA score at the end of this shift is 26. I administered 10 mg Diazepam. Education has been provided. Recommendation: PT is due for reassessment of CIWA. He is supposed to go to an AA meeting later today and will then be evaluated by a psychiatrist .