[온라인실습] V-Sim documents, Andrew Davis-알코올금단증후군

소개글

vsim 실습 후 작성하는 'documents'에 대한 레포트입니다.
직접 하나하나 작성하였으며, 대상자의 정보도 간단 요약되어있습니다.

목차

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. Referring to your feedback log, document all nursing care provided and Mr. Davis’s response to this care.
4. Document all patient teaching regarding assessments and safety issues provided to Mr. Davis, and his response to the teaching.
5. Document your handoff report in the SBAR format to communicate Mr. Davis’s future needs.

본문내용

1. Document your findings related to the focused assessment of Mr. Davis’s alcohol withdrawal symptoms.
Include his responses to your assessment.
→ Davis의 알코올 금단 증상에 대한 집중적인 평가와 관련된 사항의 문서화(평가에 대한 Davis의 답변을 포함하여)

① Davis의 V/S
BP: 160/82, HR: 92회, SpO2: 99%, RR: 20회/분, BT: 37.2℃

② Davis의 답변
“왜 이렇게 시끄러워. 다 닥쳐!”
“불빛이 너무 밝아요. 머리가 아파요.”

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.

참고 자료

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