Mental Health George Palo documentation assignment PDF

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Mental Health Case: George Palo Documentation Assignments 1. Document your findings related to the focused assessment regarding Mr. Palo’s possible cognitive decline and depression. Include his responses to your assessment. Mr. Palo scored a 4 on the Mini-Cog assessment tool. He recalled 2 of the three words he was asked to remember. He stated that he “sometimes does not know what is happening” and is scared. Mr. Palo indicated he is experiencing depression – he stated that if he “tries to eat or shower, he gets tired and just gives up.” Mr. Palo also stated that he has difficulty falling asleep. He stated “I have a hard time falling asleep. Sometimes I lay in bedfor quite some time staring at the clock…and then I wake up a few times during the night.” Mr. Palo recently lost his dog and his wife. He made several statements detailing how those losses has affected his ability to perform ADLs at the level he used to.

2. Document your findings related to the assessment of Mr. Palo associated with the Geriatric Depression Scale screening tool. Include his responses to your assessment. Mr. Palo was unable to recall the three words given that were banana, sunrise, and chair. Only was able to remember two of the words. Was able to draw a clock and put the hands of the clock at 11:10

3. Referring to your feedback log, document all nursing care provided and Mr. Palo’s response to this care. 0:00

You checked scene safety. It was correct to check scene safety in order to maintain your own safety.

0:07

You introduced yourself.

0:38

You washed your hands.

0:45

You identified the patient.

1:07

You asked if the patient had any known allergies.

1:26 You asked the patient: Is it OK for your daughter to be here, while we talk? The patient said: Yes. It was correct to let the patient give his consent for letting his daughter be a part of the interview. 1:33

You made a safety check of the surroundings and the patient's belongings.

1:54

You performed medication reconciliation.

2:14

You assessed the respiration.

2:25

You checked the pulse oximetry.

2:47

You checked the radial pulse. From vSim for Nursing | Mental Health. © Wolters Kluwer.

3:02

You measured the blood pressure.

3:21

You measured the temperature.

3:39

You auscultated the lung sounds.

4:01

You checked the patient's skin.

4:43

You removed potentially dangerous objects.

5:23 pain.

You asked the patient: How would you rate your pain, on a scale of 0 to 10? The patient said: I don't have any

5:35

You asked the patient: Do you have chest pain? The patient said: No, I don't.

5:40

You asked the patient: Do you have any pain? The patient said: No, I don't have any pain.

5:57 You asked the patient: Can you tell me a little bit more about what's going on with you today? It was appropriate to ask the patient what was going on with him to get an understanding of this. 6:30 The patient said: Sometimes I'm not sure where I am or what is happening. It scares me.\nYou answered: What seems to lead up to those feelings? \nYou used the therapeutic technique of placing the event in time or sequence. 6:41 You asked the patient: Over the past year, when did you feel your best? It was appropriate to ask the patient about when he felt his best. 7:03 The patient said: Max gave me a reason to live and now he's gone too.\nYou answered: Are you saying you feel hopeless? \nYou used the therapeutic technique of translating to feelings. 7:30

You asked the patient: Have you had any changes in your appetite over the past month?

7:55 The patient said: If I try to eat or shower, I get so tired that I give up.\nYou answered: Physical symptoms are often related to grief. You must miss your wife and Max very much. \nYou used the therapeutic technique of giving information. 8:06 You asked the patient: Have you lost or gained weight over the past month? The patient said: I think I have lost weight, but I don't really weigh myself. 8:32 You asked the patient: Tell me about any changes you have had in your sleep over the past few weeks? The patient said: I have a hard time falling asleep. Sometimes I lay in bed for quite some time staring at the clock before I go to sleep, and then I wake up a few times during the night. 8:57 You asked the patient: Do you have energy to do the normal activities necessary to get through the day? The patient said: No, it is not as good as it was, and now I don't have Max to nudge me along, so I find myself sitting on that sofa most of the day. 9:29

You educated about coping.

10:15 You educated about getting active. From vSim for Nursing | Mental Health. © Wolters Kluwer.

10:51 You educated about home care needs. 11:24 You educated about the difference between grief and depression. 12:14 You supported the patient about loss of dog. 12:27 You supported the patient about loss of wife. 12:51 You supported the patient's daughter about seeing dad ill. 13:27 You said: I would like to ask you a few questions and for you to draw a specific thing, which will help me to better assess you. May I ask you these questions? The patient said: Yes. 13:40 You said: Please listen carefully. I am going to say three words that I want you to repeat back to me now and try to remember. The words are banana, sunrise, chair. Please say them for me now. The patient said: Banana, sunrise, chair. 14:00 You said: I want you to draw a clock for me. First, put in all of the numbers where they go. Then, set the hands to ten past eleven. The patient said: Ok. 14:23 You said: What are the three words I asked you to remember? The patient said: Banana...chair.... I don't know. 14:54 You completed the Mini-Cog© assessment tool. The tool is correctly completed. 15:13 You called the community nurse. 15:47 You referred the patient to a physician

4. Document all patient teaching regarding assessments and safety issues provided to Mr. Palo, and his response to the teaching. In regards to safty issues, I removed the hunting gun from his home and gave it to his daughter and informed Mr. Palo to ask for it form his daught hen he wants to go hunting. He wsn’t too happy about that. We talked about ways that Mr. Palo can get active again, talked about community resources. Mr. Palo verbalized understanding.

5. Document your handoff report in the SBAR format to communicate Mr. Palo’s future needs. S- Mr. George Palo is a 90-year-old male who reports no pain or difficulty breathing has sad demeanor, weight loss and lack of motivation to continue usual activities within the past two months. B- Mr. George Palo’s daughter contacted the nurse in concern of her father who seems to become more depressed, lost weight and lacks motivation since the recent passing of his dog 2 months ago. Mr. Palo has stated “what’s the point of and gives up”. On 10/2/18 at 1400 vital signs were stable. They are as follows BP: 140/88mmHg, RR: 16 w/ equal movement bilaterally, Pulse: (radial) 78bpm strong and regular, Temp: 98.6 F, Sa02: 96%, Skin Turgor: normal elasticity skin color normal and no diaphoresis, Lung Sounds: clear and equal bilaterally, Heart Sounds: rate and rhythm regular w/o murmurs. From vSim for Nursing | Mental Health. © Wolters Kluwer.

A-Believed that this is an extreme difficult time for Mr. Palo as he has given up on personal hygiene and eating at most times, and activity has drastically declined. R- I suggest a follow up appointment before his next scheduled appoint with PCP for further evaluation. Also recommended support groups for grief, finding walking partner within community, and returning to volunteer work at the animal shelter.

From vSim for Nursing | Mental Health. © Wolters Kluwer....