Mr. George Palo’s daughter contacted the nurse in concern of her father who seems to be more depressed, lose weight and lack motivation since the recent passing away of his nurse two months ago. Mr. Palo stated what is the point of give up .His vital signs was stable. They are as follow. BP: 140/88 mmHg. RR: 16 with equal movement bilaterally. Pulse (radial): 78 bpm’ strong and regular. Temperature: 98.6 oF. Sao2: 96%. Skin turgor: Normal elasticity of the skin color normal and no diaphoresis. Lung sound: clear and equal bilaterally. Heart sound: rate and rhythm regular with no murmurs.
I suggest a follow up appointment before his next scheduled appointment with pcp for further evaluation. I also recommend support group for grief, finding walking partners within communities, and returning to volunteering work at the animal shelter.
Mr. Polo should be encouraged to participate in some form of grief therapy. He should also be encouraged to volunteering activities, walking or socializing in the community. He should be encouraged to start eating and performing ADL, and also take his medications as prescribed. He will not harm himself. A follow up appointment was made to discuss his overall well being and management of his depression and hypertension. He needs to be continued to monitored for depression and hypertension
0:00 You checked scene safety. It was correct to check scene safety in order to maintain your own safety.
0:35 You washed your hands.
0:40 You identified the patient.
You should have asked the patient for his consent for letting his daughter be a part of the interview.
2:12 The patient said: The medicine is worthless; these pills all look the same. You answered: Let’s take a look at these pills and go over your medications together. You used the therapeutic technique of suggesting collaboration.
2:15 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.
2:48 The patient said: Sometimes I’m not sure where I am or what is happening. It scares me. You answered: What seems to lead up to those feelings? You used the therapeutic technique of placing the event in time or sequence.
2:55 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.
3:33 You asked the patient: Do you have any pain? The patient said: No, I don’t have any pain.
3:57 You asked the patient: Have you had any changes in your appetite over the past month?
4:25 The patient said: If I try to eat or shower, I get so tired that I give up. You answered: Physical symptoms are often related to grief. You must miss your wife and Max very much. You used the therapeutic technique of giving information.
4:59 The patient said: I’m not hungry and I’m tired all the time. You answered: That’s not uncommon when you are grieving. You used the non therapeutic technique of denial.
5:04 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.
5:36 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.
6:57 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.
8:08 The patient said: Why are you asking me so many questions? There is nothing wrong with me. You answered: I am the nurse here to check up on you. I have to ask you these questions to complete my assessment. You used the therapeutic technique of giving information.
8:27 The patient said: The best times of my life are past. You answered: Are you suggesting that you feel hopeless? You used the therapeutic technique of translating to feelings.
9:18 The patient said: Anna was my entire life. You answered: Tell me how you felt after her death. You used the non therapeutic technique of probing.
11:13 The patient said: It would be easier for everyone if I was not here anymore. You answered: Mr. Palo, are you considering hurting yourself? You used the therapeutic technique of seeking information.
11:48 The patient said: You should mind your own business! You answered: Are you saying that you are feeling frustrated? You used the therapeutic technique of verbalizing the implied.
12:34 The patient said: I’m not going to a nursing home, not now and not ever! You answered: Mr. Palo, my purpose for being here is to complete your assessment. You used the therapeutic technique of giving information.
12:40 You asked the patient: Are you frightened of anything? The patient said: No, not really.
12:48 You supported the patient about loss of dog.
13:02 You supported the patient about loss of wife.
14:19 You educated about coping.
14:53 You educated about getting active.
16:05 You educated about the difference between grief and depression.
16:34 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.
18:13 You assessed the respiration.
18:24 You checked the pulse oximetry.
18:41 You checked the radial pulse.
18:55 You measured the blood pressure.
19:12 You measured the temperature.
19:28 You auscultated the lung sounds.
19:54 You checked the patient’s skin.
21:58 You completed the Mini-Cog© assessment tool. The tool is correctly completed.
23:37 You removed potentially dangerous objects.
You should have made a safety check of the surroundings and the patient’s belongings before removing them.
24:38 You called the community nurse.
24:53 You referred the patient to a physician.