section name header

Skill

Mental Health: Abuse and Withdrawal

Prerequisite Skills

Concepts of Communication

Critical Element Criteria

Students must meet criteria of Critical Elements to safely perform the skill based on evidence-based practice. Score can be pass/fail, letter grade, or point assignment. Only acceptable score for Critical Elements is 100%

Critical Elements

  • Understanding of the importance and variations that can occur with an abuse and/or withdrawal assessment.
  • Create appropriate physical environment.
  • Provide privacy.
  • Explain procedure.

Procedure

EXPAND

Abuse Assessment

EXPAND

Withdrawal Assessment

Prior to Treatment: (Critical Thinking)

  • Gather appropriate assessment equipment (chair).
  • Parent or legal guardian when appropriate.

Prior to Treatment: (Critical Thinking)

  • Gather appropriate assessment equipment (chair).
  • Parent or legal guardian when appropriate.

Patient Interaction: (Safety)

  • Patient identifiers.
  • Create appropriate physical environment.
  • Provide privacy.
  • Explain procedure.

Patient Interaction: (Safety)

  • Patient identifiers.
  • Create appropriate physical environment.
  • Provide privacy.
  • Explain procedure.

Alcohol Use Disorders Identification Test (AUDIT): (Patient Centered Care)

  1. How often do you have a drink containing alcohol?
  2. How many drinks containing alcohol do you have on a typical day when you are drinking?
  3. How often do you have 6 or more drinks on one occasion?
  4. How often during the last year have you found that you were not able to stop drinking once you started?
  5. How often during the last year have you failed to do what was normally expected from you because of drinking?
  6. How often during the last year have you been unable to remember what happened the night before because you had been drinking?
  7. How often during the last year have you needed an alcoholic drink first thing in the morning to get yourself going after a night of heavy drinking?
  8. How often during the last year have you had a feeling of guilt or remorse after drinking?
  9. Have you or someone else been injured as a result of your drinking?
  10. Has a relative, friend, doctor, or another health professional expressed concern about your drinking or suggested that you cut down?

Clinical Institute Withdrawal Assessment (CIWA): (Patient Centered Care)

  1. Agitation
  2. Anxiety
  3. Auditory Disturbances
  4. Clouding of Sensorium
  5. Headache
  6. Nausea/Vomiting
  7. Paroxysmal Sweats
  8. Tactile Disturbances
  9. Tremor
  10. Visual Disturbances

After Procedure (Patient Centered Care, Safety)

  • Provide appropriate nursing management for abnormal findings.
  • Consider collaborative care for abnormal findings.

After Procedure (Patient Centered Care, Safety)

  • Provide appropriate nursing management for abnormal findings.
  • Consider collaborative care for abnormal findings.

Documentation (Informatics, Communication)

  • Outcome of assessment.
  • Interventions used for nursing management of care.
  • Interventions used for collaborative management of care.
  • Patient"s response to interventions.

Documentation (Informatics, Communication)

  • Outcome of assessment.
  • Interventions used for nursing management of care.
  • Interventions used for collaborative management of care.
  • Patient"s response to interventions.