GCU Health History & Medical Information Mr M Case Study Critical Thinking Essay

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

  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

In 750-1,000 words, critically evaluate Mr. M.’s situation. Include the following:

  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. 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 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. 

This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion. 

You are required to submit this assignment to LopesWrite. Refer to the LopesWrite Technical Support articles for assistance. 

Expert Solution Preview

Introduction:

In this critical thinking essay, we will evaluate the health history and medical information of Mr. M., a 70-year-old male living in an assisted living facility. Mr. M. is experiencing a rapid decline in his cognitive and physical abilities, and the facility has ordered testing to determine the cause of his deterioration. We will describe the clinical manifestations present in Mr. M., discuss possible medical diagnoses, nursing assessments, and the physical, psychological, and emotional effects of his current health status on him and his family. We will also suggest interventions that can support Mr. M. and his family and present four actual or potential problems he faces based on his condition.

1. Describe the clinical manifestations present in Mr. M.

Mr. M. is experiencing cognitive decline shown by his trouble recalling the names of his family members, room number, and repeating what he has just read in the past two months. He also shows signs of aggression, fear, agitation, and difficulty sleeping. Mr. M. has lost his ability to perform activities of daily living (ADLs), which he was fully able to do before.

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.

Primary medical diagnoses for Mr. M. may include Alzheimer’s disease, dementia, or mild cognitive impairment. The symptoms Mr. M is experiencing suggest memory loss, confusion, decreased ability to perform daily tasks, and impaired judgment. Secondary medical diagnoses may include urinary tract infection (UTI) due to positive urinalysis for moderate leukocytes and being cloudy. UTI commonly causes cognitive changes, particularly in the elderly population. It can also cause agitation and aggression. The laboratory results revealed elevated WBC, lymphocyte count, and protein, which may indicate an infection.

3. When performing your nursing assessment, discuss what abnormalities would you expect to find and why.

During nursing assessment, we would expect to find abnormalities such as changes in behavior, mood, and cognitive processes, as shown by Mr. M’s rapid cognitive decline. We would also expect to find decreased physical ability, which would translate into difficulty performing ADLs. Mr. M’s lab results indicate a UTI; therefore, we would expect to find physical symptoms of UTI such as painful urination, increased urinary frequency, and cloudy urine.

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.

The physical effects of Mr. M’s current health condition include decreased mobility, decreased ability to perform ADLs, and increased vulnerability to infections. The psychological and emotional effects include confusion, anxiety, depression, and agitation. Mr. M’s family may also experience emotional and psychological distress due to the sudden changes in his condition, increased care needs, and financial burden of providing additional care.

5. Discuss what interventions can be put into place to support Mr. M. and his family.

Interventions to support Mr. M. may include appropriate medication to manage symptoms of cognitive decline, infection, and agitation. A physical therapy program can be implemented to prevent further decline in physical abilities. Providing a safe and secure environment can also help reduce Mr. M.’s anxiety and agitation. Interventions for family members may include providing information about the disease and proper care techniques, counseling, respite care, and financial support.

6. Given Mr. M.’s current condition, discuss at least four actual or potential problems he faces. Provide rationale for each.

Actual or potential problems that Mr. M. faces include:
– Risk of falls due to decreased physical ability and unsteady gait
– Increased risk of infections, including pneumonia, due to decreased mobility
– Malnutrition and dehydration due to decreased appetite, decreased ability to prepare meals, and cognitive decline
– Difficulty managing finances, medication administration, and other aspects of daily living

Conclusion:

Mr. M. is a 70-year-old male experiencing cognitive decline, physical weakness, and rapid deterioration of his health status. Possible primary and secondary medical diagnoses that should be considered for him include Alzheimer’s disease, dementia, mild cognitive impairment, and UTI. Nursing assessment would include monitoring any changes in behavior, mood, and cognitive processes while being aware of physical symptoms of an infection. Mr. M.’s physical, psychological, and emotional health could have negative impacts on him and his family. Interventions that can be put into place to support Mr. M. and his family include medication management, physical therapy, and providing a safe and secure environment. Mr. M. faces potential problems, such as falls, infections, malnutrition, dehydration, and managing finances and medication.

Expert Solution Preview

Introduction: In this critical thinking essay, we will evaluate the health history and medical information of Mr. M., a 70-year-old male living in an assisted living facility. Mr. M. is experiencing a rapid decline in his cognitive and physical abilities, and the facility has ordered testing to determine the cause of his deterioration. We will describe the clinical manifestations present in Mr. M., discuss possible medical diagnoses, nursing assessments, and the physical, psychological, and emotional effects of his current health status on him and his family. We will also suggest interventions that can support Mr. M. and his family and present four actual or potential problems he faces based on his condition.

1. Describe the clinical manifestations present in Mr. M.

Mr. M. is experiencing cognitive decline shown by his trouble recalling the names of his family members, room number, and repeating what he has just read in the past two months. He also shows signs of aggression, fear, agitation, and difficulty sleeping. Mr. M. has lost his ability to perform activities of daily living (ADLs), which he was fully able to do before.

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.

Primary medical diagnoses for Mr. M. may include Alzheimer’s disease, dementia, or mild cognitive impairment. The symptoms Mr. M is experiencing suggest memory loss, confusion, decreased ability to perform daily tasks, and impaired judgment. Secondary medical diagnoses may include urinary tract infection (UTI) due to positive urinalysis for moderate leukocytes and being cloudy. UTI commonly causes cognitive changes, particularly in the elderly population. It can also cause agitation and aggression. The laboratory results revealed elevated WBC, lymphocyte count, and protein, which may indicate an infection.

3. When performing your nursing assessment, discuss what abnormalities would you expect to find and why.

During nursing assessment, we would expect to find abnormalities such as changes in behavior, mood, and cognitive processes, as shown by Mr. M’s rapid cognitive decline. We would also expect to find decreased physical ability, which would translate into difficulty performing ADLs. Mr. M’s lab results indicate a UTI; therefore, we would expect to find physical symptoms of UTI such as painful urination, increased urinary frequency, and cloudy urine.

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.

The physical effects of Mr. M.’s current health condition include decreased mobility, decreased ability to perform ADLs, and increased vulnerability to infections. The psychological and emotional effects include confusion, anxiety, depression, and agitation. Mr. M.’s family may also experience emotional and psychological distress due to the sudden changes in his condition, increased care needs, and financial burden of providing additional care.

5. Discuss what interventions can be put into place to support Mr. M. and his family.

Interventions to support Mr. M. may include appropriate medication to manage symptoms of cognitive decline, infection, and agitation. A physical therapy program can be implemented to prevent further decline in physical abilities. Providing a safe and secure environment can also help reduce Mr. M.’s anxiety and agitation. Interventions for family members may include providing information about the disease and proper care techniques, counseling, respite care, and financial support.

6. Given Mr. M.’s current condition, discuss at least four actual or potential problems he faces. Provide rationale for each.

Actual or potential problems that Mr. M. faces include:
– Risk of falls due to decreased physical ability and unsteady gait
– Increased risk of infections, including pneumonia, due to decreased mobility
– Malnutrition and dehydration due to decreased appetite, decreased ability to prepare meals, and cognitive decline
– Difficulty managing finances, medication administration, and other aspects of daily living

Conclusion: Mr. M. is a 70-year-old male experiencing cognitive decline, physical weakness, and rapid deterioration of his health status. Possible primary and secondary medical diagnoses that should be considered for him include Alzheimer’s disease, dementia, mild cognitive impairment, and UTI. Nursing assessment would include monitoring any changes in behavior, mood, and cognitive processes while being aware of physical symptoms of an infection. Mr. M.’s physical, psychological, and emotional health could have negative impacts on him and his family. Interventions that can be put into place to support Mr. M. and his family include medication management, physical therapy, and providing a safe and secure environment. Mr. M. faces potential problems, such as falls, infections, malnutrition, dehydration, and managing finances and medication.

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