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3 pages/β‰ˆ825 words
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Style:
APA
Subject:
Health, Medicine, Nursing
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Research Paper
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English (U.S.)
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Topic:

Evaluating The Patient Health History and Medical Information

Research Paper 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.
2.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.
3.When performing your nursing assessment, discuss what abnormalities would you expect to find and why.
4.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.
5.Discuss what interventions can be put into place to support Mr. M. and his family.
6.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.

Research Paper Sample Content Preview:

Evaluating The Health History and Medical Information
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Evaluating The Health History and Medical Information
Clinical Manifestations
Mr. M's clinical manifestations indicate that he is suffering from Alzheimer's disease. In this case, the signs and symptoms he presents show an individual who might have dementia. For example, he is unable to recall the names of his relatives, which shows that he has a problem with his memory. The patient also shows signs of agitation and aggressiveness. Fear is the main cause of his aggression, which is common for patients with Alzheimer's when dementia begins to affect them. Besides, the patient has developed an unusual habit of wandering at night and forgets his room, causing him to get lost in the hospital. It has also become difficult for Mr. M to carry out his activities of daily living, a situation that has recently emerged, which shows the rapid progression of his condition. Such incidences indicate that Mr. M's condition is worse, and an assessment is needed to determine if he will experience further deterioration of his memory.
Medical Diagnoses
The diagnosis of dementia follows a standard primary and secondary diagnostic process. First, an assessment of Mr. M’s memory will be conducted in order to determine the patient’s mental status. In addition, the patient’s family will also be interviewed to determine the patient’s normal behavior. A brain image test will also be helpful to ensure that Mr. M’s disease is not caused by traumatic brain injuries, which can result in the memory problems that he is experiencing. Further biological tests will also be conducted to eliminate the chances of other diseases being the cause of the patient’s problem. For instance, according to Brenowitz, Han, Kukull, and Nelson (2018), hypothyroidism and lack of vitamin B12 are some conditions that are also accompanied by memory loss. The patient’s blood protein is low at 7.1 g/dL; AST: 32 U/L; ALT 29 U/L. In addition, Mr. M’s white blood cell (WBC) count is low at 1,000/uL, because it is normally supposed to be between 4,000/uL and 10,000/uL. The patients’ lymphocytes level of 6700 cells/uL indicates that he does not have thyroid problems. Nevertheless, testing is needed to ascertain that Alzheimer’s disease is the cause of the patient’s dementia.
Abnormalities
Considering Mr. M's laboratory results, various abnormalities might arise during the assessment. For example, the patient's low WBC count is a sign of both Alzheimer's and Thyroid problems. As such, the nurse will need to collect further evidence in order to determine the condition that is affecting the patient correctly. In addition, there are high chances of misinterpreting the results due to the prevailing abnormalities, which can result in misdiagnosis, which would affect the quality of care and safety of treatment.
Physical, Psychol...
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