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Report from charge nurse:

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

Background: Mr. Davis is a member of the school board and the pastor of a large church. Yesterday he was removed from a school board meeting by security guards after becoming angry and directing racial and ethnic slurs at students and their family members. His wife afterward asked him to move out of their home, and this led to the admission. He has three children: a son who is 25 years old, and two daughters, aged 21 and 17 years. His daughters will not speak to him. His son accompanied him to the rehabilitation facility. Mr. Davis had an open reduction internal fixation surgery to repair a humerus fracture 2 years ago, but otherwise, he has no significant medical history and no known allergies. He reports that his alcohol intake is approximately 1 pint of vodka per day and his last drink was prior to the school board meeting. He denies using recreational drugs and tested negative for opiates and marijuana. He does not smoke.

Assessment: He is currently oriented ×3 and is embarrassed about his behavior at the school board meeting. He went to a 12-step meeting yesterday but left early, saying that he was “not like those people” and felt he wouldn’t benefit from the meeting. He was restless last night and did not sleep much. Morning laboratory tests were also drawn at 06:00, when he woke up. Their results are available in the chart, together with the laboratory results from yesterday afternoon. His behavior is appropriate, and he engages appropriately with staff, although his affect is constricted. His CIWA-Ar score was 1 on admission. At 04:00, it had increased to 7. His last set of vital signs included the following: temperature, 37.2°C (99.0°F); heart rate, 94 beats/min; respiratory rate, 20 breaths/min; blood pressure, 154/90 mmHg; and blood oxygen saturation, 98%.

Recommendation: He is due for reassessment of the CIWA score in our treatment room. He has an order for as-needed diazepam for a CIWA score of 8 or greater, so he may need that soon. He is supposed to go to group therapy today and to an Alcoholics Anonymous meeting. He is going to be evaluated by a psychiatrist later today.

Mental Health Case: Andrew Davis

Documentation Assignments

questions

1. Document your findings related to the focused assessment of Mr. Davis’s alcohol withdrawal symptoms. Include his responses to your assessment.

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.

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

4. Document your report in the focus charting format to.

SCIENCE
HEALTH SCIENCE
NURSING

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