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Andrew Davis Documentation

Mr. Davis was assessed for alcohol withdrawal symptoms including visual and auditory disturbances, headaches, tremors, sweating, agitation, and anxiety. He scored a 4 on the CIWA scale for tremors, anxiety, and agitation, and a 3 for visual disturbances. Nursing care provided included assessments, education, and diazepam administration. Mr. Davis responded well to teaching about alcohol withdrawal and safety measures. In the SBAR handoff, it was noted that Mr. Davis was oriented but restless, had a recent CIWA score of 25 treated with diazepam, and would continue medication and participate in therapy.

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Aishat Awodele
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574 views2 pages

Andrew Davis Documentation

Mr. Davis was assessed for alcohol withdrawal symptoms including visual and auditory disturbances, headaches, tremors, sweating, agitation, and anxiety. He scored a 4 on the CIWA scale for tremors, anxiety, and agitation, and a 3 for visual disturbances. Nursing care provided included assessments, education, and diazepam administration. Mr. Davis responded well to teaching about alcohol withdrawal and safety measures. In the SBAR handoff, it was noted that Mr. Davis was oriented but restless, had a recent CIWA score of 25 treated with diazepam, and would continue medication and participate in therapy.

Uploaded by

Aishat Awodele
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as DOCX, PDF, TXT or read online on Scribd
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1. Document your findings related to the focused assessment of Mr.

Davis’s alcohol withdrawal


symptoms. Include his responses to your assessment. Mr. Davis reported visual and auditory
disturbances, a severe headache, tremors when holding his hands in front of him, diaphoresis,
agitation, and anxiety.
2. 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.
nausea/vomiting: 0 none
tremors: 4 moderate, with patient’s arms extended
anxiety: 4 moderately anxious or guarded, so anxiety is inferred
agitation: 4 moderately fidgety and restless
paroxysmal sweats: 4 beads of sweat obvious on forehead
orientation & clouding of sensorium: 0
tactile disturbances 0 none
auditory disturbances: 2 mild harshness or ability to startle
visual disturbances: 3 moderate sensitivities
headache: 4 moderately severe
3. Referring to your feedback log, document all nursing care provided and Mr. Davis’s response to
this care.
Nursing care for Mr. Davis included taking vitals, assessing pain, performing a CIWA assessment,
patient education on substance abuse, results of the CIWA assessment, medication, short term
goals, and diazepam medication administration.

4. Document all patient teaching regarding assessments and safety issues provided to Mr. Davis,
and his response to the teaching.

Patient teaching regarding the CIWA assessment included explaining the various protocols of the
CIWA (Clinical Institute Withdrawal Assessment), what was scored, and how it was scored. The
patient was educated on alcohol withdrawal symptoms and what safety measures needed to be put
in place when withdrawing from alcohol. Education was given in a nonjudgmental and supportive
manner. The patient responded well and was receptive to the teaching.

5. Document your handoff report in the SBAR format to communicate Mr. Davis’s future needs.

S: Mr. Davis, a 56-year-old man that voluntarily admitted himself to the alcohol rehabilitation
facility yesterday afternoon. He is currently in the acute detoxification unit. He has been on the unit
for about 16 hours.

B: Mr. Davis is a member of the school board and a pastor. Yesterday he was removed from a school
board meeting after becoming angry and screaming racial and ethnic slurs. He has three children,
two of whom do not speak to him. Other than a ORIF surgery 2 years ago to repair a humerus
fracture, he has no other significant medical history. He reports his alcohol intake is 1 pint of vodka /
day. His last drink was at the school board meeting. He does not smoke and tested negative for
opiates and marijuana.

A: He currently is oriented x3. He was restless and did not sleep much last night. His latest CIWA
score was 25 and was given 10 mg of diazepam. His last set of vitals were temperature 37.2 , heart
rate 94 beats/min, respiratory rate 20 ℃ breaths/min, blood pressure 154/90 mmHg, and blood
oxygen saturation 98%.

R: Reassess his CIWA score. Continue medication orders (PRN diazepam for a CIWA score of 8 or
greater). He will go to group therapy and an Alcoholics Anonymous meeting later today. He will also
be evaluated by a psychiatrist later today.

Jottings

The symptoms of alcohol withdrawal may worsen for 2 – 3 days and it may last long for 6-12 days.

1 drink is 8 ounces of alcohol……. Google this

Medications to stop alcohol consumption in patients: these medications give a side effect once they
take alcohol. Disulfiram (Antabuse): , naltrexone (Trexan), and acamprosate (Campral).
Antidepressant: Nefasodone and

AWS: Lorazepam, diazepam etc

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