Health History and Medical Information: Dementia and Urinary Tract Infection (UTI)
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 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 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
6. Critical Thinking Essay
In 750-1,000 words, critically evaluate Mr. M.'s situation. Include the following:
1. Describe the subjective and objective clinical manifestations present in Mr. M.
2. 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.
3. What abnormalities would you expect to find and why when performing your nursing assessment using the identified primary and secondary medical diagnoses.
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 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.
Health History and Medical Information
Name of the Student
Institution Affiliation
Course Name
Professor’s Name
Date
Health History and Medical Information
Subjective and Objective Clinical Manifestations
Subjective manifestations
A 70-year-old assisted living resident named Mr. M. has shown a decline in cognitive and functional abilities over the past two months. He's never smoked or drunk and has no allergies. His unsteady gait and mobility issues limit his physical activity. He has hypertension controlled with ACE inhibitors, hypercholesterolemia, an appendectomy, and a tibial fracture repaired without complications. Mr. M. takes Lisinopril 20mg daily for hypertension, Lipitor 40mg for hypercholesterolemia, Ambien 10mg for sleep, Xanax 0.5mg for anxiety, and ibuprofen 400mg for pain. His memory deficits, agitation, aggression, fearfulness, nighttime wandering, and increased ADL dependency have prompted the assisted living facility to conduct further diagnostic testing to determine the cause of his rapid deterioration.
Objective data
Mr. M.'s objective data shows a temperature of 37.1°C, blood pressure of 123/78, heart rate of 93 beats per minute, respiratory rate of 22 breaths per minute, and oxygen saturation of 99%. He claims no pain. He weighs 87 kilograms and is 69.5 inches tall. These objective vital signs indicate no significant medical issues. However, Mr. M's rapid cognitive deterioration, agitation, hostility, nightly wandering, and growing ADL reliance require further evaluation and diagnostic testing to discover the cause of his deteriorating condition.
Primary and Secondary Medical Diagnoses
Primary Diagnosis: Dementia
Dementia, a neurodegenerative disease that impairs cognition, is Mr. M.'s number one prognosis. His cognitive impairments include remembering names, room numbers, and recent information. He also exhibits dementia-related agitation, aggression, and fearfulness. His nighttime wandering is typical of the condition. The rapid cognitive decline over two months strongly suggests neurodegenerative disease: brain cell deterioration
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