Evaluation of the Health History and Medical Information Essay Assignment Paper
Evaluation of the Health History and Medical Information Essay Assignment Paper
Case Study Mr. M
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Case Study Mr. M
Mr. M, who is seventy years old, resides in an assisted living center. His health has worsened in the past two months. The healthcare team is worried, and testing has been requested. Mr. M’s physical results, as well as the emotional and psychological impacts of his health on him and his family, will be discussed in this paper. Interventions for the issues he experiences will be addressed.
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Clinical Manifestations
Mr. M has hypercholesterolemia and takes Lipitor 40 mg every day for it. His hypertension is managed with lisinopril 20 mg. Ambulation is a challenging task. He has an unsteady gait, limiting his ability to move about. He takes Ibuprofen 400 mg every other day for pain, Xanax 0.5 mg every other day for anxiety, and Ambien 10 mg every other day for sleep. Mr. M has trouble remembering people’s names and his room number. He has a habit of repeating himself. He seems agitated and aggressive, as well as frightened and apprehensive. He’s started wandering at night and getting lost. Bathing, dressing, and eating were previously independent activities. He is now completely reliant on others.
Primary and Secondary Diagnoses
Evaluation of the Health History and Medical Information
The primary diagnoses would be Alzheimer’s disease and urinary tract infection (UTI). Surgical tibial fracture repair, appendectomy, hypercholesterolemia, and hypertension are the secondary diagnoses.
Alzheimer’s disease is the most prevalent kind of dementia. Loss of memory, personality and mood changes, withdrawal from social and work events, complexity making decisions, misplacing items, trouble finding the right words, vision loss, and so on are all the clinical manifestations of early-onset Alzheimer’s disease (Bature et al., 2017). The brain tends to forget how to operate effectively in the latter stages of Alzheimer’s disease. Mr. M has been experiencing memory problems. It is tough for him to recall people, his room number. He also keeps repeating things. Distress and aggressiveness have been signs of mood shifts. It’s also tough to do routine chores. He is incapable of conducting his own daily activities such as bathing, dressing, and eating. When all of these factors are combined, Alzheimer’s disease is diagnosed. The urinalysis findings and increased WBC confirm the diagnosis of a Urinary tract infection. When a UTI is prevalent, elderly individuals may suffer disorientation and be incapable of communicating their feelings. Mr. M, sadly, has Alzheimer’s disease as well as a urinary tract infection. Confusion may be a sign of either disease.
Evaluation of the Health History and Medical Information
Expected Abnormalities
The objective information provided has abnormalities for an individual with a urinary tract infection. WBC levels range from 4,500 to 11,000 in a healthy person. He had a WBC of 19.2. This indicates the presence of infection or inflammation. The typical lymphocyte count is between 1,000 and 4,800. He had a high count of 6,700.
This is most likely linked to his body’s natural reaction to his UTI. The presence of a significant number of leukocytes in unusually murky urine indicates a UTI. It’s tough to evaluate cognitive decline in elderly people. Many various problems may induce cognitive abnormalities, such as metabolic diseases, endocrine difficulties, delirium following a disease, depression, or drug side effects (Tavares-Júnior et al., 2019). A clinical examination of a person with dementia may be done using a variety of scales. Dementia’s most serious problem is cognitive impairment. Various diagnostic criteria are used to establish whether or not an individual has Alzheimer’s disease. The existence of cognitive decline, behavioral abnormalities, decreased functionality, and general complexity of health problems are the factors.
Physical, Psychological, and Emotional Effects
Alzheimer’s disease is incurable. However, certain things may be done to alleviate the emotional and psychological effects. The mission is to improve people’s life quality. Loss of bodily function would be one of the physical attributes. Incontinence may result from a lack of muscular function of the bladder and bowel. This occurs when the brain’s impulses to certain muscles cease to function. This typically happens when the illness is in its middle phases. Patients with Alzheimer’s disease lose their capacity to conduct daily activities and interact with their surroundings as the disease progresses. Rage, dread, worry, and isolation plague such individuals. Care providers should be sympathetic to their emotional and psychological requirements. When caring for such individuals, it is critical to have an enthusiastic mindset. This may have a significant impact on long-term results.
It is critical to understand Alzheimer’s medicines and their interactions with other drugs. Family members may dismiss the condition as the result of the individual’s advancing years. Relatives must be informed and comprehend the disease’s progression. This is a difficult period for the family, and they must establish support networks and use coping strategies to get over it. When communicating with a loved one, patience is key. Questions and remarks may get tedious after a while. They should know how to refocus the patient’s attention.
Interventions for Support
To enhance mental skills, medicines may be utilized. They will only help with symptoms and delay the condition’s advancement. The patient might gain from cognitive training to execute particular tasks in a specific manner in the initial stages. It’s also possible to employ behavioral therapy. Healthy behavior is rewarded, while unpleasant behavior is ignored. Support network resources may be beneficial.
Actual or Potential Problems
Increased fluid intake and medications are used to treat UTI. If left untreated, renal damage or sepsis may occur. This may put one’s life in jeopardy. A patient with Alzheimer’s disease may have swallowing difficulties, which may result in severe dehydration or delirium. They are also prone to forgetting to feed. Irritability, disorientation, fatigue, fast heart rate or breathing, dizziness, dry skin, reduced urination or concentrated darker urine are all signs of severe dehydration.
This may have an impact on their nutritional condition as well. Hallucinations, Restlessness, mood swings, and anxiety are the signs of delirium. Typically, this results in a reluctance to comply with the treatment regimen. It may also manifest as lethargy or reduced motor function, tiredness, drowsiness, or a daze-like state. Delirium may be alleviated with the use of certain medicines.
References
Bature, F., Guinn, B. A., Pang, D., & Pappas, Y. (2017). Signs and symptoms preceding the diagnosis of Alzheimer’s disease: a systematic scoping review of literature from 1937 to 2016. BMJ open, 7(8).
Tavares-Júnior, J. W. L., De Souza, A. C. C., Alves, G. S., Bonfadini, J. D. C., Siqueira-Neto, J. I., & Braga-Neto, P. (2019). Cognitive assessment tools for screening older adults with low levels of education: a critical review. Frontiers in psychiatry, 10, 878.
Question
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.
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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