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3 pages/≈825 words
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APA
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Health, Medicine, Nursing
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English (U.S.)
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Topic:

Evaluate the Health History and Medical Information for Mr. M

Essay Instructions:

It is necessary for an RN-BSN-prepared nurse to demonstrate an enhanced understanding of the pathophysiological processes of disease, the clinical manifestations and treatment protocols, and how they affect clients across the life span.
Evaluate the Health History and Medical Information for Mr. M., presented below.
Based on this information, formulate a conclusion based on your evaluation, and complete the Critical Thinking Essay assignment, as instructed below.
Health History and Medical Information
Health History
Mr. M., a 70-year-old male, has been living at the assisted living facility where you work. He has no know allergies. He is a nonsmoker and does not use alcohol. Limited physical activity related to difficulty ambulating and unsteady gait. Medical history includes hypertension controlled with ACE inhibitors, hypercholesterolemia, status post appendectomy, and tibial fracture status postsurgical repair with no obvious signs of complications. Current medications include Lisinopril 20mg daily, Lipitor 40mg daily, Ambien 10mg PRN, Xanax 0.5 mg PRN, and ibuprofen 400mg PRN.
Case Scenario
Over the past 2 months, Mr. M. seems to be deteriorating quickly. He is having trouble recalling the names of his family members, remembering his room number, and even repeating what he has just read. He is becoming agitated and aggressive quickly. He appears to be afraid and fearful when he gets aggressive. He has been found wandering at night and will frequently become lost, needing help to get back to his room. Mr. M has become dependent with many ADLs, whereas a few months ago he was fully able to dress, bathe, and feed himself. The assisted living facility is concerned with his rapid decline and has decided to order testing.
Objective Data
1. Temperature: 37.1 degrees C
2. BP 123/78 HR 93 RR 22 Pox 99%
3. Denies pain
4. Height: 69.5 inches; Weight 87 kg
Laboratory Results
1. WBC: 19.2 (1,000/uL)
2. Lymphocytes 6700 (cells/uL)
3. CT Head shows no changes since previous scan
4. Urinalysis positive for moderate amount of leukocytes and cloudy
5. Protein: 7.1 g/dL; AST: 32 U/L; ALT 29 U/L
Critical Thinking Essay
In 750-1,000 words, critically evaluate Mr. M.'s situation. Include the following:
1. Describe the clinical manifestations present in Mr. M.
1. Based on the information presented in the case scenario, discuss what primary and secondary medical diagnoses should be considered for Mr. M. Explain why these should be considered and what data is provided for support.
2. When performing your nursing assessment, discuss what abnormalities would you expect to find and why.
3. Describe the physical, psychological, and emotional effects Mr. M.'s current health status may have on him. Discuss the impact it can have on his family.
4. Discuss what interventions can be put into place to support Mr. M. and his family.
5. Given Mr. M.'s current condition, discuss at least four actual or potential problems he faces. Provide rationale for each.
You are required to cite to a minimum of two sources to complete this assignment. Sources must be published within the last 5 years and appropriate for the assignment criteria and relevant to nursing practice.
Prepare this assignment according to the guidelines found in the APA Style Guide, located in the Student Success Center. An abstract is not required.
This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion.

Essay Sample Content Preview:

Case Study: Mr. M.
Student Name
Institutional Affiliation
Case Study: Mr. M
This report delineates the clinical manifestations, secondary and primary medical diagnoses, anticipated abnormalities, psychological, physical, and emotional ramifications, and initiatives geared towards supporting Alzheimer’s patients and their families.
Mr. M’s Clinical Manifestations
Deriving from Mr. M’s test results, most of his outcomes seem normal, thus ruling out potential underlying conditions. The objective information provided in the case scenario that Mr. M’s blood pressure is average as evidenced in his hypertensive condition. The client also has healthy body temperature and Body Mass Index (BMI). In addition, Mr. M is physically fit as there is no evidence that he is in pain or suffering. His urinalysis and blood results turned negative on various conditions that could be impacting him. The client’s clinical manifestations include memory loss characterized by difficulties remembering distinct rooms, his relatives, and is finding it challenging making rationale and recalling written text. In addition, Mr. M shows aggressive tendencies and is increasingly restless. In certain occasions, the client roams within the facilities compound and gets lost. He is also having difficulties performing activities of daily living (ADLs) such as feeding, bathing, and dressing. In that vein, it can be deduced that Mr. M suffers from a particular mental degeneration condition. More specifically, the clinical manifestations indicate that Mr. M suffers from Alzheimer’s disease (Weller & Budson, 2018).
Mr. M’s Primary and Secondary Medical Diagnoses
Primary diagnoses to be taken into account for Mr. M includes assessing the reports from medical center professionals of where the patient is admitted, coupled with inquiring from Mr. M to share his condition. In order to evaluate Alzheimer’s disease, a test would be administered to assess the patient’s memory and thinking capabilities (Bondi, Edmonds, & Salmon, 2017). It is also increasingly essential to conduct neurological and physical examinations evaluate Mr. M’s hearing and sight abilities, reflexes, coordination capacities, body balance, as well as muscle tone and strength. Such tests are ideal for evaluating Mr. M’s overall neurological wellbeing.
Secondary health diagnoses would be taken into account due to Mr. M’s clinical manifestations, including neuropsychological and mental status testing, brain imaging, and laboratory tests. Neuropsychological tests and psychological status assessments would assist in determining patient’s cognitive functioning compared to individuals of similar age and education levels. Brain imaging, including CT and MRI scans, would be conducted to determine Mr. M’s brain abnormalities, which could be linked to conditions including strokes, tumors, trauma, and that could lead to cognitive alterations. Laboratory examinations such as urinalysis and blood tests enable the physician to rule out other potential rationales for memory loss as well as confusion, including thyroid conditions and other medical insufficiencies. The seclusion of these abnormalities would confirm that...
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