Please see rubric attached.
Samples: https://www.google.com/search?q=nursing+ipr+sample&source=lnms&tbm=isch&sa=X&ved=2ahUKEwjRptG9iebzAhWYITQIHRQZAI0Q_AUoAXoECAEQAw&biw=1077&bih=875&dpr=1&safe=active&ssui=on
Background: Patient IntroductionLocation: Apartment in a retirement community (independent living)
Time: 14:00
Report given by one of the nurses employed at the retirement community to the community health nurse who is making the visit:
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. George was diagnosed with minor neurocognitive decline, Alzheimer’s type, 6 months ago and prescribed galantamine. He also has mild hypertension and is being medicated for that, as well. George 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 George seems to have become more forgetful and weaker, and she thinks his clothes look 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 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. Your 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 galantamine. Since then he has been managing very well with his new medication—that is, until Max died.
Assessment: George’s blood pressure has been well controlled these past few months. We have been visiting him on a weekly basis to check it. 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.
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 to address his daughter’s concerns about his physical condition. Please also reassess his cognition with the Mini-Cog tool and compare with the previous result. Maggie 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.
No sources except for Lippincott
