Case Study: Mr. M. Nonsmoker And Does Not Use Alcohol (Essay Sample)
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
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.
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.
Temperature: 37.1 degrees C
BP 123/78 HR 93 RR 22 Pox 99%
Height: 69.5 inches; Weight 87 kg
WBC: 19.2 (1,000/uL)
Lymphocytes 6700 (cells/uL)
CT Head shows no changes since previous scan
Urinalysis positive for moderate amount of leukocytes and cloudy
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:
Describe the clinical manifestations present in Mr. M.
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.
When performing your nursing assessment, discuss what abnormalities would you expect to find and why.
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.
Discuss what interventions can be put into place to support Mr. M. and his family.
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.
According to Mr.M’s description of the health conditions that he is in, there are several medical manifestations that Mr. M has. Firstly, he may be having a condition called Alzheimer. Alzheimer refers to a condition that develops at the later stages of memory loss and confusion. When a person has this condition, he tends to forget familiar people, places that one has ever visited, and things around. At the early stages of the disease, a person experiences memory loss and confusion (Hales, Carroll, Fryar, & Ogden, 2017). This condition and the changes that may be taking place in their bodies frustrate people.
Some of the changes that occur during the process include difficulty-remembering events that may have taken place, challenges in making decisions and hardships in processing information received from others. At the later stages of the disease, the condition gets worse and people not only forget places, but even their family members. Victims find it hard to remember relationships, call the names of their family members, forget the location of their houses, and do not even recognize the passage of time. From the description of Mr. M that stated that he had problems remembering the names of his family members, remembering his room number, and even repeating what he had just read, this 3was an indication that it was Alzheimer condition.
Additionally, the description that Mr. M gets afraid and fearful when he gets agitated shows that he has the Alzheimer’s disease. Agitation refers to a where a person gets worried and restless for no reason (Hales, Carroll, Fryar, & Ogden, 2017). Agitation can make one unable to settle down, lack of sleep to the patient, and aggressive where one tries to hurt the people around with no reason. Additionally, according to Mr. M’s heart condition where he has a blood pressure of 123/78, which is an indication that he has high blood pressure. Normally, two parts or numbers show blood pressure and those are the systolic and diastolic. When the blood pressure is 123/78, it’s an indication that the systolic pressure is 123 and the diastolic pressure is 78.
The systolic pressure is the pressure of the arteries when the heart is beating, and the diastolic pressure is the pressure of the arteries between heartbeats. According to research, the normal systolic blood pressure should be less than 120. Any number above 120 is taken to be high blood pressure. Additionally, for the diastolic blood pressure, it should be less than 80, and any number above 80 is hypertension. For Mr. M’s blood pressure to be normal and in good condition, both numbers should fit in the range of being normal. Anything out of the range is high blood pressure. Since the systolic pressure is 123, it is above the normal range by 3, therefore it is hypertension. Although 78 is within the normal range, Mr. M’s blood pressure is high and medical actions should be taken.
Additionally, according to the objective data that was gathered, deduction show that the client had a high respiratory rate, 22. A respiratory rate refers to the number of breaths that individuals takes in one minute, while resting. Measurements taken about respiratory rates can indicate serious medical conditions. The number of breaths than an individual takes show how the brain
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