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
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 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.
ANSWER
Based on the symptoms as well as the past history that Mr. M has had, there are many clinical manifestations that can be linked to his condition. For instance, he can be said to be having signs of Alzheimer. Some of the symptoms that can be linked to this condition include having a loss in memory that has apparently disrupted normal daily operations such as inability to remember his name, what he has read and the room number. Another clinical manifestation is arthritis, which has been shown by the instability and difficulty in walking. This symptom can also be linked to tendonitis. Besides this clinical manifestation, this very symptom can also be linked to possible tibial fractures. The fact that he is under lisinopril medication, chances are that he could be suffering from stage four hypertension. The last clinical manifestation is dementia that is associated …
Medical Conditions to Be Considered
Based on the blood pressure of 123/78 HR 93 RR 22 Pox 99%, the patient could be suffering from prehypertension and hence has to be subjected to stroke and heart attack as the primary diagnosis (Mymedicalscore 2019). Another primary diagnosis will be to undertake a urinary tract infection test as it is linked to leukocytes whose elevated amount may imply swelling of the urinary tract as well as the kidney. This diagnosis is also important owing to the side effects of the drugs that he is currently taking. A secondary diagnosis that will be important to …
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