Mental Health Case: George Palo Documentation Assignments 1. Document your findings related to the focused assessment regarding George Palo's possible cognitive decline and depression. Include his responses to your assessment. 2. Document your findings related to the assessment of George Palo associated with the Geriatric Depression Scale screening tool. Include his responses to your assessment. 3. Referring to your feedback log, document all nursing care provided and George Palo's response to this care. 4. Document all patient teaching provided to George Palo regarding assessments and safety issues, and his response to the teaching. 5. Document your handoff report in the SBAR format to communicate George Palo's future needs.

Document your findings related to the focused string Mr. Pald's possible cognitive decline and depression. Include his responses to your assessment. Mc Pale was able to state his name and DOB when asked in his Famas in the middle of the das he was pretty frustrated and confused. The daar want to answer all of the questions asked but he did. He said his medication is worthless and all the pits look the teed to eat or war.Document your findings related to the assessment of Mt. Pale associated with the Genatric Depression Scale screening tool including his responses to your assessment, Patitn said he has low wery He hasn't felt good since N's wife died and it has declined since ha Gulden ratLever .Referring to your feedback log, document all nursing care provided and Mr. Pala's response to this can. Handling hygiene, identifying patients, removing belongings that may be of concern, assessing vital signs, performing Cognitive test, offering self to patients and caregivers. Document all patient teaching regarding assessments and safety issues provided to Mr. Palo, and his response to theteaching. Patient teaching regarding physical activity, depressions, regarding being alone, and about communityresources5. Document your handoff report in the SBAR format to communicate Mr. Palo’s future needs. Situation: George Palo is a 90-year-old male who has been living independently in one of our apartments since shortly after the death of his wife of 65years, Anna, 3 years ago. George was diagnosed with minor neurocognitive decline, Alzheimer’s type, 6 months ago andprescribed galantamine. He also has mild hypertension and is being medicated for that, as well. George was managing welluntil 2 months ago, when Max, his 13-year-old golden retriever, died. Maggie, his daughter, recently contacted us and askedfor a visit because she is concerned that George seems to have become more forgetful and weaker, and she thinks his clotheslook bigger, so he may have lost weight recently.Background: One of the nurses from your agency made a visit to George 7 months ago at the request of his daughter, who wasconcerned at that time about his memory. Your agency nurse did a physical and cognitive assessment using the ConfusionAssessment Method (CAM) and Mini-Cog tools. The CAM was negative for delirium, but some impairment in executivefunctioning was evident. You can review the result of the Mini-Cog tool in the chart. Your nurse suggested some memory aidsand resources to help him maintain independence and recommended that he see his physician, who later diagnosed him withAlzheimer’s disease and prescribed galantamine. Since then he has been managing very well with his new medication—that is,until Max died.Assessment: I did a physical assessment to address his daughters concerns. He is losing weight and has a decline is appetite.He is depressed and has scored a 12/15 on the depression scale. He also scored a 2 on the mini-cognitive scale.Recommendation: I administered the Geriatric Depression Scale yesterday when I visited George to take his blood pressure.The result is in the health record for your review. In addition, I recommend that you do a focused physical assessment toaddress his daughter’s concerns about his physical condition. Please also reassess his accuracy with the Mini-Cog tool andcompare with the previous result. Maggie will be there during your visit. Communicate your findings to me or one of the otherretirement community resource nurses and to his physician next visit.Mental Health Case: George PaloDocumentation Assignments1. Document your findings related to the focused assessment regarding Mr. Palo’s possible cognitive decline anddepression. Include his responses to your assessment. Mr. Palo was able to state his name and DOB when asked. H wasin his Pajamas in the middle of the day. He was pretty frustrated and confused. He didn’t want to answer all of thequestions asked but he did. He saids his medication is worthless and all the pills look the same. The patient said he is tootired to eat or shower.2. Document your findings related to the assessment of Mr. Palo associated with the Geriatric Depression Scale screeningtool. Include his responses to your assessment. Patitn said he has low eery. He hasn’t felt good since his wife died and ithas declined since his goldrn retriever died.3. Referring to your feedback log, document all nursing care provided and Mr. Palo’s response to this care. Ahdn hygiene,identifying patient, removing belongings that may be of dander, assessed vital signs, performed Cognitive test, offeredself to patients and caregiver.4. Document all patient teaching regarding assessments and safety issues provided to Mr. Palo, and his response to theteaching. Patient teaching regarding physical t.George Palo SBAR Situation: George Palo is a 90 yo male with Alzheimer’s and mild hypertension. Mr. Palo has been living independently in a retirement community but recently has been more forgetful, weaker, and looks to have lost weight as his clothes look bigger. He lost his wife, Anna, 3 years ago and 2 months ago his dog, Max, when these issues came to light by his daughter, Maggie, expressing concern. Background: Upon completion of the CAM and a physical by one of our agency nurses 7 months ago the pt was negative for delirium, but some impairment in executive functioning was evident. Memory aids were suggested along with a follow up with a physician where pt was dx with Alzheimers. Pt was adhering to medication regimen with galantamine until Max died and has presenting with s/s of depression.Assessment: VSS. AxOx2-3. Gun was present in pt home, was removed along with other items that could be dangerous to the pt. Pt stated it was okay for his daughter, Maggie, to be there upon my assessment. Completion of the Geriatric Depression Scale showed that pt is depressed is at risk for suicide. Upon reassessment using the Mini-Cog tool the assessment showed the same result as the one completed 7 months ago. Pt is unable to adequately complete ADLS.Recommendation: HHA could be beneﬁcial to pt so he has company and ensures that ADLs are completed and that he adheres to medication regimen. Going to group activities that are hosted by the retirement community so pt socializes would be beneﬁcial. Frequent visits by daughter will continue. Potentially give pt ensure to increase nutritional intake.