Mental Health Case: Sandra Littlefield Documentation Assignments 1. Document your findings related to the focused assessment of Sandra Littlefield's coping strategies. Include her responses to your assessment. Document all patient teaching regarding coping strategies and cognitive restructuring techniques provided to Sandra Littlefield. Include her response to the teaching. Referring to your feedback log, document all nursing care provided and Sandra Littlefield's response to this care. Document all interventions associated with boundary and limit setting directed toward managing Sandra Littlefield's manipulative behavior. Document examples of Sandra Littlefield's statements that shows she views the world in a polarized, extreme way (i.e., individuals are either all good or all bad), and include interventions implemented to respond appropriately. 6. Document your handoff report in the SBAR format to communicate Sandra Littlefield's future needs. 2. 3. 4. 5.

Essentials Health Info Management Principles/Practices
4th Edition
ISBN:9780357191651
Author:Bowie
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Chapter7: Numbering & Filing Systems And Record Storage & Circulation
Section7.1: Numbering Systems
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m.thepoint.lww.com/titles/9781975198183/classes/687f62f6-68e7-4b65-aba0-460a00fb0baf/assignments
Location: Apartment in a retirement community (independent living)
ons
Time: 1400
x +
Report given by a nurse employed at the retirement community:
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 65 years, Anna, 3 years
ago. He was diagnosed with minor neurocognitive decline, likely Alzheimer's type, 6 months ago and was prescribed donepezil. He also has mild hypertension and is being
medicated for that as well. The patient was managing well until 2 months ago when Max, his 13-year-old golden retriever, died. Maggie, his daughter, recently contacted us and
asked for a visit because she is concerned that he seems to have become more forgetful and weaker, and she thinks his clothes look bigger, so he may have lost weight
recently.
Mental Health Assessment
Background: One of the nurses from your agency made a visit to George Palo 7 months ago at the request of his daughter, who was concerned at that time about his memory
Your agency nurse did a physical and cognitive assessment using the Confusion Assessment Method (CAM) and Mini-Cog tools. The CAM was negative for delirium, but some
impairment in executive functioning was evident. You can review the result of the Mini- Cog tool in the chart. The nurse suggested some memory aids and resources to help him
maintain independence and recommended that he see his physician, who later diagnosed him with Alzheimer's disease and prescribed donepezil Since then, he has been
managing very well with his new medication-that is, until Max died.
Assessment: George Palo's blood pressure has been well controlled these past few months. We have been visiting him on a weekly basis to check it. He had lab work drawn
last week, and the results were normal and are in his chart. Previously, we frequently saw him out walking with Max-daily or sometimes even more often. He worked as a
volunteer at the Humane Society. But since Max died, we rarely see him, and when we do, he looks sad and disheveled.
Alzheimer's Disease
Recommendation: I administered the Geriatric Depression Scale (GDS) assessment yesterday when I visited George Palo to take his blood pressure. His score was 10. I also
administered the Columbia-Suicide Severity Rating Scale (C-SSRS) and his score was 0. The results are in the health record for your review. In addition, I recommend that you
do a focused physical assessment to address his family's concerns about his physical condition. Please also reassess his cognition with the Mini-Cogo tool and compare with
the previous result. A family member will be there during your visit. Communicate your findings to me or one of the other retirement community resource nurses and to his
physician if you think he needs to be seen again before his next scheduled visit
A
Videbeck, S. (2023). Psychiatric-Mental Health Nursing, 9th Edition.
Content of the Assessment, Chapter 8, pp. 132-137
301
Videbeck, S. (2023). Psychiatric-Mental Health Nursing, 9th Edition.
Dementia, Chapter 24, pp. 458-471
Videbeck, S. (2023). Psychiatric-Mental Health Nursing, 9th Edition.
M
8
0
X
0
8:30 PM
12/17/2023
C
Ques
CENTAUS
Parve 1
Test
REPA
Transcribed Image Text:Search nts Sim Standalone m.thepoint.lww.com/titles/9781975198183/classes/687f62f6-68e7-4b65-aba0-460a00fb0baf/assignments Location: Apartment in a retirement community (independent living) ons Time: 1400 x + Report given by a nurse employed at the retirement community: 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 65 years, Anna, 3 years ago. He was diagnosed with minor neurocognitive decline, likely Alzheimer's type, 6 months ago and was prescribed donepezil. He also has mild hypertension and is being medicated for that as well. The patient was managing well until 2 months ago when Max, his 13-year-old golden retriever, died. Maggie, his daughter, recently contacted us and asked for a visit because she is concerned that he seems to have become more forgetful and weaker, and she thinks his clothes look bigger, so he may have lost weight recently. Mental Health Assessment Background: One of the nurses from your agency made a visit to George Palo 7 months ago at the request of his daughter, who was concerned at that time about his memory Your agency nurse did a physical and cognitive assessment using the Confusion Assessment Method (CAM) and Mini-Cog tools. The CAM was negative for delirium, but some impairment in executive functioning was evident. You can review the result of the Mini- Cog tool in the chart. The nurse suggested some memory aids and resources to help him maintain independence and recommended that he see his physician, who later diagnosed him with Alzheimer's disease and prescribed donepezil Since then, he has been managing very well with his new medication-that is, until Max died. Assessment: George Palo's blood pressure has been well controlled these past few months. We have been visiting him on a weekly basis to check it. He had lab work drawn last week, and the results were normal and are in his chart. Previously, we frequently saw him out walking with Max-daily or sometimes even more often. He worked as a volunteer at the Humane Society. But since Max died, we rarely see him, and when we do, he looks sad and disheveled. Alzheimer's Disease Recommendation: I administered the Geriatric Depression Scale (GDS) assessment yesterday when I visited George Palo to take his blood pressure. His score was 10. I also administered the Columbia-Suicide Severity Rating Scale (C-SSRS) and his score was 0. The results are in the health record for your review. In addition, I recommend that you do a focused physical assessment to address his family's concerns about his physical condition. Please also reassess his cognition with the Mini-Cogo tool and compare with the previous result. A family member will be there during your visit. Communicate your findings to me or one of the other retirement community resource nurses and to his physician if you think he needs to be seen again before his next scheduled visit A Videbeck, S. (2023). Psychiatric-Mental Health Nursing, 9th Edition. Content of the Assessment, Chapter 8, pp. 132-137 301 Videbeck, S. (2023). Psychiatric-Mental Health Nursing, 9th Edition. Dementia, Chapter 24, pp. 458-471 Videbeck, S. (2023). Psychiatric-Mental Health Nursing, 9th Edition. M 8 0 X 0 8:30 PM 12/17/2023 C Ques CENTAUS Parve 1 Test REPA
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Mental Health Case: Sandra Littlefield
Documentation Assignments
1. Document your findings related to the focused assessment of Sandra Littlefield's coping strategies. Include her
responses to your assessment.
2. Document all patient teaching regarding coping strategies and cognitive restructuring techniques provided to Sandra
Littlefield. Include her response to the teaching.
3. Referring to your feedback log, document all nursing care provided and Sandra Littlefield's response to this care.
Document all interventions associated with boundary and limit setting directed toward managing Sandra Littlefield's
manipulative behavior.
4.
5. Document examples of Sandra Littlefield's statements that shows she views the world in a polarized, extreme way
(i.e., individuals are either all good or all bad), and include interventions implemented to respond appropriately.
6. Document your handoff report in the SBAR format to communicate Sandra Littlefield's future needs.
L
Q Search
Transcribed Image Text:-) Protected View - Saved V W View Help you need to edit, it's safer to stay in Protected View. Enable Editing e disabled. Reactivate Search Mental Health Case: Sandra Littlefield Documentation Assignments 1. Document your findings related to the focused assessment of Sandra Littlefield's coping strategies. Include her responses to your assessment. 2. Document all patient teaching regarding coping strategies and cognitive restructuring techniques provided to Sandra Littlefield. Include her response to the teaching. 3. Referring to your feedback log, document all nursing care provided and Sandra Littlefield's response to this care. Document all interventions associated with boundary and limit setting directed toward managing Sandra Littlefield's manipulative behavior. 4. 5. Document examples of Sandra Littlefield's statements that shows she views the world in a polarized, extreme way (i.e., individuals are either all good or all bad), and include interventions implemented to respond appropriately. 6. Document your handoff report in the SBAR format to communicate Sandra Littlefield's future needs. L Q Search
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