Evaluate the Health History and Medical Information for Mr. M., presented below.
Based on this information, formulate a conclusion based on your Assessment, 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 Helped living facility where you work. He has no known 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 Helped living facility is concerned with his rapid decline and has decided to order testing.
Objective Data
Temperature: 37.1 degrees C
BP 123/78 HR 93 RR 22 Pox 99%
Denies pain
Height: 69.5 inches; Weight 87 kg
Laboratory Results
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 subjective and objective clinical manifestations present in Mr. M.
Based on the information presented in the case scenario, state what primary and secondary medical diagnoses should be considered for Mr. M. Formulate a nursing diagnosis from the medical diagnosis and explain why these should be considered and what data is provided for support.
What abnormalities would you expect to find and why when performing your nursing assessment using the identified primary and secondary medical diagnoses.
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 a rationale for each.
You are required to cite a minimum of three 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.
—
Subjective and Objective Clinical Manifestations present in Mr. M.
Subjective: Mr. M. is experiencing difficulty recalling the names of his family members, remembering his room number, and repeating what he has just read. He is becoming agitated and aggressive quickly, and appears to be afraid and fearful when he gets aggressive. He has become dependent on many activities of daily living (ADLs), such as dressing, bathing, and feeding himself.
Objective: Mr. M. has a temperature of 37.1 degrees C, blood pressure of 123/78, heart rate of 93, respiratory rate of 22, and oxygen saturation of 99%. He denies pain, and has a height of 69.5 inches and weight of 87 kg. Laboratory results show a white blood cell count of 19.2 (1,000/uL), lymphocytes of 6700 (cells/uL), and a urinalysis positive for moderate amount of leukocytes and cloudy. Protein levels are 7.1 g/dL, AST is 32 U/L, and ALT is 29 U/L. A CT head scan shows no changes since previous scan.
Primary and Secondary Medical Diagnoses for Mr. M.
Primary: Dementia (possible Alzheimer’s disease)
Secondary: Urinary tract infection
Nursing Diagn from Medical Diagnoses
Dementia related to age and possible Alzheimer’s disease as evidenced by difficulty in recall, memory loss, and dependency on ADLs.
Urinary tract infection as evidenced by moderate leukocytes and cloudy urine in urinalysis.
Abnormalities to Expect in Nursing Assessment
Memory and cognitive impairment
Difficulty with ADLs
Agitation and aggression
Fear and anxiety
Changes in urinary output and frequency
Changes in vital signs (e.g. fever)
Physical, Psychological, and Emotional Effects on Mr. M. and Family
Mr. M. may experience physical decline, including a decline in mobility and independence.
He may also experience psychological and emotional effects, such as confusion, anxiety, depression, and agitation.
Family members may experience emotional stress and strain as they witness their loved one’s decline and may have to take on additional caregiving responsibilities.
Interventions to Support Mr. M. and Family
Implementing a care plan that addresses Mr. M.’s cognitive impairment and memory loss, including reality orientation and memory aids.
Assessing and addressing Mr. M’s psychological and emotional needs
Providing education to the family about the condition and how to support their loved one.
Implementing infection control measures to prevent the spread of UTI
Regular monitoring of vital signs and lab results to track the progress and any changes in Mr. M’s condition.
Actual or Potential Problems Mr. M. Faces
Increased risk of falls and injuries due to difficulty ambulating and unsteady gait.
Increased risk of infection due to immobility and limited ability to care for self.
Increased risk of emotional and psychological distress due to cognitive impairment and memory loss.
Increased caregiving burden on family members which can lead to caregiver burnout and emotional stress.
Sources:
“Alzheimer’s Disease Fact Sheet.” National Institute on Aging, U.S. Department of Health and Human Services, www.nia.nih.gov/health/alzheimers-disease-fact-sheet.
“Urinary tract infection in older people.” National Institute for Health and Care Excellence, www.nice.org.uk/guidance/ng106
