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.

The findings related to the focused assessment regarding possible cognitive decline and depression of Mr. Palo involve
the loss of his wife and the recent passing of his dog, Max. In addition, Mr. Palo states, “If I try to eat or shower, I get so
tired that I give up.” Lastly, Mr. Palo exhibits signs of depression through his lack of previously enjoyed activies by stating,
“I would like to go take walks like I used to, but I don’t do it so much anymore.” He also no longer goes hunting or
watches hunting television shows; activities he once enjoyed.

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.

The Geriatric Depression Scale screening tool indicates he is mildy depressed, for he scored 10 points. He expressed that

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he no longer performs the same activities he once did. When asked whether he has any plans on killing himself, he

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rhetorically asks, “why should I care about myself?” He further states, “he has nothing else to live for,” and “it would be

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easier for everyone if I was not here anymore.” He denies having any plans on harming himself. He answered, “yes” on

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the screening test if he’d rather stay home rather than going out and doing new things. Subsequently, he is open to the

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idea of joining a support group, having home health aides assist him, and going for walks with a support person.
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3. Referring to your feedback log, document all nursing care provided and Mr. Palo’s response to this care.
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-Checked the scene for safety.

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-Washed my hands.

-Introduced self.
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-Asked the patient for permission for his daughter, Maggie to be present and obtained consent.
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-Identified the patient.

-Made a safety check of the surroundings and the patient’s belongings.

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-Explained to the patient that I am a nurse here to check up on him and that I have questions in order to
complete my assessment for the way he is feeling.
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-I asked the patient what was going on with him today to gain a sense of understanding.
-I educated about the difference between grief and depression.
-I educated about coping.
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-I educated about home care needs

-I completed the Mini-Cog assessment tool correctly.
-I performed a physical assessment: I assessed his appearance, attention, motor activity, speech, and though
processes. I checked his vital signs, which were all in normal range except for mild hypertension; 140/88 mm Hg,
auscultated his lungs & heart, and checked skin turgor.
-I removed potentially dangerous objects.
From vSim for Nursing | Mental Health. © Wolters Kluwer.
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 -Called the community nurse and referred patient to physician for follow-up care.

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

Mr. Palo was educated on local support groups he could attend to help with grieving. He was assured he did not have
to talk if he did not feel comfortable, which sparked interest for him to attend such groups. He also was educated on
how physical symptoms, such as decreased appetite, lack or motivation, and trouble sleeping all can happen due to
grief/depression. Further education was provided about finding a walking partner in order to regain motivation to
walk outside again.

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 that he sometimes does not know where he is or what is
happening. He expresses a lack of motivation, and his daughter Maggie has noticed weight loss. He feels he doesn’t
have anything else to live for since the passing of his wife and more recently, his dog. He does not have any intent on

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hurting himself.

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B: Mr. George Palo’s daughter, Maggie, contacted the nurse in concern of her father who is presenting worsening

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signs of depression and confusion since the passing of his dog, Max. He also has lost weight and suffers from mild
hypertension.

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A: My assessment is that Mr. Palo is grieving. He shows sign of depression but answered “no” to feeling hopeless on
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the Geriatric Depression Scale screening test. He had a score of 4 on his Mini Cog test, recalling 2/3 words from short
term memory. He drew a clock with the correct time asked and numbers in appropriate places. His BP is 140/88 mm
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Hg, HR strong, 78/min, SaO2 96%, Temp 98.6 F, no signs of dehydration, lungs sound clear bilaterally. He responded
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positively to support groups.

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R: I administered and submitted the Mini Cog test. My recommendation is that he has a follow-up with a community
resource nurse and/or social worker to become involved in grieving support groups or see a counselor. I
communicated with his physician to schedule a follow-up appointment to ensure his mild hypertension is managed
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and discuss his overall well-being. Appointment handling might be necessary.

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

This study source was downloaded by 100000822865927 from CourseHero.com on 04-06-2021 11:59:11 GMT -05:00

https://www.coursehero.com/file/43502081/George-Palodocx/
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