Evaluate the Health History and Medical Information for Mr. M., presented below.
\nBased on this information, formulate a conclusion based on your evaluation, and complete the Critical Thinking Essay assignment, as instructed below.
\nHealth History and Medical Information
\nHealth History
\nMr. M., a 70-year-old male, has been living at the assisted 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.
\nCase Assessment Help – – Scenario
\nOver 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.
\nObjective Data
\nTemperature: 37.1 degrees C
\nBP 123\/78 HR 93 RR 22 Pox 99%
\nDenies pain
\nHeight: 69.5 inches; Weight 87 kg
\nLaboratory Results
\nWBC: 19.2 (1,000\/uL)
\nLymphocytes 6700 (cells\/uL)
\nCT Head shows no changes since previous scan
\nUrinalysis positive for moderate amount of leukocytes and cloudy
\nProtein: 7.1 g\/dL; AST: 32 U\/L; ALT 29 U\/L
\nCritical Thinking Essay
\nIn 750-1,000 words, critically evaluate Mr. M.\u2019s situation. Include the following:
\nSuperior Essay Writers Describe the subjective and objective clinical manifestations present in Mr. M.
\nBased 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.
\nWhat abnormalities would you expect to find and why when performing your nursing assessment using the identified primary and secondary medical diagnoses.
\nSuperior Essay Writers Describe the physical, psychological, and emotional effects Mr. M.\u2019s current health status may have on him. Discuss the impact it can have on his family.
\nDiscuss what interventions can be put into place to support Mr. M. and his family.
\nGiven Mr. M.\u2019s current condition, discuss at least four actual or potential problems he faces. Provide a rationale for each.
\nYou 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.
\n—
\nSubjective and Objective Clinical Manifestations present in Mr. M.<\/p>\n
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.
\nObjective: 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.
\nPrimary and Secondary Medical Diagnoses for Mr. M.<\/p>\n
Primary: Dementia (possible Alzheimer’s disease)
\nSecondary: Urinary tract infection
\nNursing Diagn from Medical Diagnoses<\/p>\n
Dementia related to age and possible Alzheimer’s disease as evidenced by difficulty in recall, memory loss, and dependency on ADLs.
\nUrinary tract infection as evidenced by moderate leukocytes and cloudy urine in urinalysis.
\nAbnormalities to Expect in Nursing Assessment
\nMemory and cognitive impairment
\nDifficulty with ADLs
\nAgitation and aggression
\nFear and anxiety
\nChanges in urinary output and frequency
\nChanges in vital signs (e.g. fever)
\nPhysical, Psychological, and Emotional Effects on Mr. M. and Family
\nMr. M. may experience physical decline, including a decline in mobility and independence.
\nHe may also experience psychological and emotional effects, such as confusion, anxiety, depression, and agitation.
\nFamily members may experience emotional stress and strain as they witness their loved one’s decline and may have to take on additional caregiving responsibilities.
\nInterventions to Support Mr. M. and Family
\nImplementing a care plan that addresses Mr. M.’s cognitive impairment and memory loss, including reality orientation and memory aids.
\nAssessing and addressing Mr. M’s psychological and emotional needs
\nProviding education to the family about the condition and how to support their loved one.
\nImplementing infection control measures to prevent the spread of UTI
\nRegular monitoring of vital signs and lab results to track the progress and any changes in Mr. M’s condition.
\nActual or Potential Problems Mr. M. Faces
\nIncreased risk of falls and injuries due to difficulty ambulating and unsteady gait.
\nIncreased risk of infection due to immobility and limited ability to care for self.
\nIncreased risk of emotional and psychological distress due to cognitive impairment and memory loss.
\nIncreased caregiving burden on family members which can lead to caregiver burnout and emotional stress.
\nSources:
\n“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.
\n“Urinary tract infection in older people.” National Institute for Health and Care Excellence, www.nice.org.uk\/guidance\/ng106<\/p>\n","protected":false},"excerpt":{"rendered":"
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