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
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
Critical Thinking Essay
1. Describe the clinical manifestations present in Mr. M.
1. 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.
2. When performing your nursing assessment, discuss what abnormalities would you expect to find and why.
3. 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.
4. Discuss what interventions can be put into place to support Mr. M. and his family.
5. 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.
Prepare this assignment according to the guidelines found in the APA Style Guide, located in the Student Success Center. An abstract is not required.
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Case Study 2
In the current essay the case study of Mr. M is discussed who has been suffering from rapid denigration of his mental health. Early Identification of the symptoms and the underlying cause forms the basis of the effective management and a good prognosis. The steps involving diagnosis and the analysis of the potential clinical manifestations that may lead to acute conditions are discussed to demonstrate the understanding of the pathophysiology of the disease
Medical Diagnoses
Mr. M showed a slight elevation in the body temperature 37.1o C indicating a low-grade fever. His medical history reveals the existing health complications such as hypercholesteremia currently regulated by the usage of Lipitor. Mr. M also has hypertension however, the blood pressure reading obtained showed a value of 123/78 within the normal range. This is achieved by a ACE inhibitor Lisinopril. Primary diagnosis includes the analysis of the deteriorating condition of the patient which in this case is the lack of mind-body coordination, poor memory retention, in addition to that agitated attitude towards self and other surrounding him. A CT-scan and an MRI scan would reveal any abnormalities in the functionality of the brain. Markers for the inflammation in the brain and speech capacity, spatial orientation should be assessed. Any physical injury that was unreported should be checked for. This aids in the understanding the sudden onset of the poor memory (dementia) and uncoordinated behavior of Mr.M
As a part of secondary diagnosis, the temperature elevation should be supported with the estim
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