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Essay Available:
Pages:
3 pages/≈825 words
Sources:
2 Sources
Style:
APA
Subject:
Health, Medicine, Nursing
Type:
Essay
Language:
English (U.S.)
Document:
MS Word
Date:
Total cost:
$ 12.96
Topic:

Health History and Medical Information of Mr. M

Essay Instructions:

Case Study: Mr. M.
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
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.
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.

Essay Sample Content Preview:
            Case Study       Student Name Instructor Name Institutional Affiliation Course Number and Name Due Date           Case Study Clinical Manifestations Mr. M presents with an uneven walk that exposes him to ambulation issues. He claims that he remains awake most of the nighttime and uses Ambien to assist him in sleep. Physical observation indicates he appears exhausted as a result of his lack of sleep. He cannot execute routine tasks on his own and hence, requires assistance with clothing, eating, and bathing. According to reports, he began losing his memory in the last two months, as he repeats himself when speaking and forgets his room code and the names of certain family members. Primary and Secondary Diagnoses Primary diagnosis indicates Alzheimer’s disease, namely Creutzfeldt-Jakob (CJD) condition. Trends indicate that its symptoms emerge at 60 years, with approximately 70% of victims dying within a year (Qi et al., 2020). Individuals with Alzheimer’s disease may suffer memory loss, behavioral abnormalities, lack of coordination, and visual impairments in the early stages. As the illness advances, mental degeneration becomes more acute, and involuntary movements, blindness, extremity weakness, and coma may ensue. In this context, Mr. M exhibits the signs of this disorder, including memory loss, anxiety, unsteady walking, depression, stiffness and eyesight issues, and a quickly deteriorating state (Qi et al., 2020). Since he takes Ambien to fall asleep faster, Qi (2020) recommends that the doctor discuss the drug’s adverse effects, including memory loss, weariness, irritability, moods swings, and disorientation. Urinary tract infection is a secondary diagnosis that relates to Mr. M’s evident symptoms (UTI). He has a relatively high number of lymphocytes (6700) and a WCBC of 19.2, higher than the recommended range (Antinori & Pezzani, 2017). Antinori and Pezzani (2017) report that lymphocytes beyond the usual scope of 3000 demonstrate that the patient is experiencing inflammation, consistent with a UTI. Moreover, leukocytes’ presence in the urine supports the diagnosis of UTI. A combination of these findings informs the conclusions of the healthcare provider. Abnormalities in Assessment Expected The vital signs, orientation, and degree of awareness were the significant factors that assisted the health practitioner in determining the severity of acute sickness. Mr. M’s vital signs would only be considered stable if his blood pressure was within normal limits. Despite depending on memory loss and confusion, more testing would be necessary to confirm the diagnosis of Alzheimer’s disease (Qi et al., 2020). Other tests to establish a UTI diagnosis include his urine excretion frequency and whether he has discomfort or a burning sensation during urination. Physical, psychological, and emotional effects Sitammagari and Masood (2021) indicate that the physical effects of CJD comprise difficulties in walking due to loss of balance and coordination, slurred speech, numbness of the body, frequent di...
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