Evaluation of Health History and Medical Information
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
1. Describe the clinical manifestations present in Mr. M.
2.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.
3.When performing your nursing assessment, discuss what abnormalities would you expect to find and why.
4.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.
A clinical manifestation refers to the physical result of an infection or illness. In the case of Mr. M., these physical results include the inability to perform ADLs, wandering at night, getting lost, and needing help to get back into his room. He is also increasingly aggressive and easily irritable, with signs of being fearful and afraid. Furthermore, he cannot remember the names of his family members or room numbers and even repeats what he has just said. More importantly, the deteriorating ability to perform physical activities like ambulating, combined with their unsteady gait, provides a physical demonstration of his condition. Primary diagnosis is the condition chiefly responsible for the patient's admission for care. In the case of Mr. M, the primary diagnosis is the deteriorating ability to perform ADLs without assistance. The observation arises from his presence in an assisted living facility in the first place. He is admitted here because he is not physically capable of caring for himself. This could result from old age, status post appendectomy, and recovery from tibial fracture surgery. Secondary conditions, on the other hand, are those that develop subsequently or coexist at the time of admission. Therefore, secondary diagnosis outcomes must be addressed alongside the chief problem established in primary diagnosis. In the case of Mr. M, his condition (with primary diagnoses) was stable until two months ago, when he began to deteriorate rapidly. Thus, the manifestations that shape his secondary diagnosis include his increasing lapses in memory, aggressiveness, and irritability. According to the National Institute on Aging (NIA, 2022), wandering, agitation, problems recognizing family & friends, shortened attention span, and increased memory loss are some of the symptoms of Alzheimer's disease (AD). With 75% (AA, 2022) of Am...