George Palo Clinical Worksheet

Clinical Worksheet Date: Initials: GP Age: 90 Sex: M Code status: Full Code Name: Diagnosis: HTN, AD Adjustment disorder with depressed mood Vsim: George Palo HCP: None listed Isolation: None IV Type: N/A Consults: Community nurse, physician, Fall Risk: No fall risk Location: Transfer: N/A Critical Labs: N/A Other Services: N/A Fluid: Consults needed: Rate: Physician Length of stay: 3 yrs in independe nt living Community Nurse Allergies: Penicillin Why is the patient in the hospital? The patient has been in the independent living community since the death of his wife 3 years ago. We are seeing him today because his daughter reports he has been having worsening problems with his memory, apparent weight loss, a decrease in activity, and a reduced ability to care for himself. Health history and comorbidities that relate to this hospitalization: The patient was diagnosed with Alzheimer’s 6 months ago. He also has high blood pressure that is managed with medications. Shift goals/ patient education 1. Assess for suicidal intent 2. Ensure patient safety 3. Education regarding coping with loss 4. Education regarding coping with grief and depression 5. Education regarding staying active Path to discharge: Contacting the physician for further assessment for depression, if the physician prescribes antidepressants assess the efficacy of the selected antidepressant for this patient, make sure the patient can contract for safety and does not have access to firearms or dangerous means at home, make sure the patient can perform ADLs and care for himself. Contact the community health nurse to coordinate a walking group to keep the patient active. This nurse will also help Mr. Palo to join a support group for coping with loss. Volunteer services will help to provide transport to a local animal shelter where George Palo will be able to volunteer to help animals. This will help him through having contact with animals but will also help him to feel more purposeful within his community. Path to death or injury: No further assessment for depression and not removing dangers from the patient’s environment. Without further assessment or intervention regarding the patient’s depression it’s possible it could become worse and progress to self harm or the development of a plan for suicide. If the patient has access to firearms or dangerous means he could act on suicidal thoughts and cause himself serious death or injury. Signs and symptoms to be on alert for 1. Stockpiling medications, obtaining/hiding hazardous items like razors, belts etc 2. Increase in reported hopeless feelings, reporting passive or active suicidal ideations 3. Further decrease in appetite leading to malnutrition, dehydration, or further weight loss 4. Increased memory problems, anomia, agnosia, forgetting people who are close to him How will these signs and symptoms be identified (assessment) 1. Safety checks of his environment and removal of hazards 2. Assessment and periodic reassessment of the patient’s risk for depression using the geriatric depression tool and reporting abnormal findings to the healthcare provider 3. Daily weights performed by the patient will help the healthcare provider to assess the patient’s nutritional status 4. Using the mini cog assessment to assess the patient’s cognitive abilities and cognitive changes over time Complications that may occur related to discharge, procedure, comorbidities 1. Increased suicidal thoughts, self harm 2. Further loss of cognitive function, worsening memory problems 3. Increase in blood pressure/ blood pressure is no longer responsive to the patient’s medications Nursing or medical interventions that may prevent the above alert or complications 1. Removing all hazardous items from his home 2. Assessing whether or not the patient can contract for safety 3. Assessing the patient’s current cognitive abilities his ability to care for himself, perform ADLs 4. Taking the patient’s vitals signs, especially blood pressure, every visit to make sure they are within expected ranges What needs to be done for this patient today 1. Ensure environmental safety 2. Assess for suicidal intent (Geriatric depression tool) 3. 4. 5. 6. 7. Mini cog Patient education for coping with loss Patient education for grief and depression Patient education on staying active Contacting the community health nurse and the physician for follow up Priorities for managing the patient’s care today 1. Performing a safety check of the patient’s environment 2. Assess the patient for suicidal ideations using the geriatric depression tool 3. reassess the patient’s cognitive abilities using the mini cog tool What aspects of care can be delegated and to who? Vital signs and safety checks could be delegated to a CNA, LPN, or a trained tech if one were available. 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’s mini cog score 7 months ago was a 4. Today he had the same mini cog score which indicates that his alzheimer’s disease has not significantly progressed in the past 7 months. He reports that his medications are worthless and they all look the same which could indicate that he has problems remembering his medications. He reports decreased energy, motivation, appetite, and problems sleeping. He reports confusion related to the place and situation he is in and this brings him significant distress. 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. Geriatric Depression Scale Choose the best answer for how you have felt over the past week: 1. Are you basically satisfied with your life? NO 2. Have you dropped many of your activities and interests? YES 3. Do you feel that your life is empty? YES 4. Do you often get bored? YES 5. Are you in good spirits most of the time? NO 6. Are you afraid that something bad is going to happen to you? NO 7. Do you feel happy most of the time? NO 8. Do you often feel helpless? NO 9. Do you prefer to stay at home, rather than going out and doing new things? YES 10. Do you feel you have more problems with memory than most? NO 11. Do you think it is wonderful to be alive now? NO 12. Do you feel pretty worthless the way you are now? NO 13. Do you feel full of energy? NO 14. Do you feel that your situation is hopeless? NO 15. Do you think that most people are better off than you are? YES / NO His score is 10 which is indicative of depression 3. Referring to your feedback log, document all nursing care provided and Mr. Palo’s response to this care. The first thing I did was check scene safety, I then introduced myself, I washed my hands, I identified the patient using his name and date of birth, I asked the patient if he has any allergies and he said penicillin, I asked the patient for his consent for his daughter to be in the room during the assessment and he said it was ok. I looked at his medications to make sure the prescriptions were complete and accurate, I then check the surroundings and his belongings for safety, there was a hunting gun in the room, I assessed his vital signs, I auscultated his lungs, I felt his radial pulse, I checked his skin, I removed objects in the room that were harmful to the patient, I assessed the patient’s pain, I asked the patient what was going on today, he replied he sometimes had confusion regarding where he was or what the situation is stating, “I’m not sure where I am or what is happening, It scares me,” I asked the patient when did he feel his best over the past year, he replied “Max gave me a reason to live and now he’s gone too,” I asked the patient if he had any changes in his appetite over the past month, he replied, “If I try to eat or shower, I get so tired that I give up,” When asked about weight changes the patient replied, “I think I have lost weight,” but also reported that he doesn't regularly weight himself. I asked if he had taken his medication and he replied that he felt the medication was worthless and that he could not differentiate between the pills. When asked about his sleeping habits the patient replied, “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.” I asked the patient if he had energy to perform his normal tasks throughout the day and he reported, “No, it is not as good as it was, and now I don’t have Max to nudge me along, so I find myself sitÝng on that sofa most of the day.” I provided patient education regarding grief and depression, coping, and getÝng active again. Before leaving I used therapeutic communication to support the patient regarding the loss of his dog and his wife. At the end of the encounter I contacted a community nurse to coordinate follow up care and I contacted the physician for a follow up appointment for further assessment of the patient. 4. Document all patient teaching regarding assessments and safety issues provided to Mr. Palo, and his response to the teaching. Today I provided patient education regarding coping and getÝng active. Regarding staying active I stated, “Mr. Palo, it’s important for both your physical and mental health that you continue to remain as active as possible. I would like to help you find a walking group or a walking buddy here at the retirement community. You can begin with short walks to get coffee or lunch.” To address patient education about coping I stated, “I understand you have had losses in your life recently. You may benefit from talking with others who have also experienced loss. I would like to arrange for you to attend a grief support group” I also educated the patient regarding the difference between depression and grief, stating, “While grief is a normal reaction to loss your physician will be performing an evaluation to determine if you are experiencing depression. Depression is more than a depressed mood: it is a cluster of symptoms lasting for an extended period of time that can include appetite changes, sleep disturbances, fatigue, feelings of worthlessness, reduced ability to concentrate, and the inability to experience pleasure.” 5. Document your handoff report in the SBAR format to communicate Mr. Palo’s future needs. ISBAR Introduction Your name, position, unit Maya Cho, RN, Independent retirement community nurse Situation Patient’s name, age, reason for visit George Palo is a 90 yo male. His daughter reports that he has been significantly more forgetful and displayed a loss of ability to care for himself. Background Patient’s primary diagnosis, date of admission, current orders for patient He was first diagnosed with alzheimer's 6 months ago. At that time he was prescribed glutamate. Two months ago his dog died and since then his daughter has reported he is more forgetful, weaker, seems to have lost weight, and has declined in his ability to care for himself. Assessment Current pertinent assessment data using head to toe approach, pertinent diagnostics, vital signs BP:140/88 HR:78 RR: 16 TEMP: 98.6F SPO2: 96 Height: 180cm Weight: 85kg Today I performed a focused physical assessment and a reassessment of the mini cog tool first performed 7 months ago (scored 4 pts then) to determine the progression of his alzheimer's disease. His new mini cog score is 4. He was able to draw a correct clock but only remembered 2 of 3 words. I found his blood pressure was elevated. He reported he feels his medications are worthless and he has trouble distinguishing them. He reports difficulty falling asleep and staying asleep. He reports anhedonia since the loss of his dog, Max. He reports a decrease in activity level, energy, and appetite. He reports feeling hopeless. Recommendation Any orders or recommendations you have for this patient I have contacted the community nurse and the physician for follow up appointments. Patient education regarding grief and depression, stating active, and coping were provided. I recommend that the community nurse connects the patient with resources to help him stay active. These include joining a walking group and contacting volunteer services to drive the patient to the animal shelter for him to volunteer. I also recommend the patient attend a support group for coping with his losses. These actions will keep the patient physically active and help to slow the progression of alzheimer’s.