Assessment TraitsRequires LopeswriteAssessment Description
It is necessary for an RN-BSN-prepared nurse to demonstrate an enhanced understanding of the pathophysiological processes of disease, the clinical manifestations and treatment protocols, and how they affect clients across the life span.
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
- 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 subjective and objective clinical manifestations present in Mr. M.
- 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.
- What abnormalities would you expect to find and why when performing your nursing assessment using the identified primary and secondary medical diagnoses.
- 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 a rationale for each.
You are required to submit this assignment to Lopes Write. A link to the Lopes Write technical support articles is located in Class Resources if you need assistance. 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.
Prepare this assignment according to the guidelines found in the APA Style Guide, located in the Student Success Center.
This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion very paper must have a title page to start out. Then you need an introduction with a solid thesis statement. When you jump right into the rubric list, the paper is rushed and not organized. For these case studies you should start something like this:
Cardiorespiratory health problems can be very debilitating for a patient. As a nurse, there are many interventions, education, and support that can be provided. In the following essay, a case study will be evaluated, and a plan of care will be determined to allow for optimal outcomes for the patient.
The thesis statement will be the last line of your introduction and is the purpose of your paper. Every paper moving forward needs this form.
You are required to submit this assignment to Lopes Write. A link to the Lopes Write technical support articles is located in Class Resources if you need 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. We will analyze his current situation, describe the subjective and objective clinical manifestations, propose primary and secondary medical diagnoses, discuss the possible abnormalities in nursing assessments, and examine the physical, psychological, and emotional effects on Mr. M. and his family. Additionally, we will explore interventions that can be implemented to support Mr. M. and his family and identify actual or potential problems he may face.
Answer to content:
1. Describe the subjective and objective clinical manifestations present in Mr. M.
Subjective clinical manifestations reported by Mr. M. include trouble recalling names, remembering his room number, and repeating information he has just read. He is becoming agitated, aggressive, afraid, and fearful. He has also been found wandering at night and getting lost, requiring assistance to return to his room.
Objective clinical manifestations include a temperature of 37.1 degrees C, blood pressure of 123/78 mmHg, heart rate of 93 bpm, respiratory rate of 22 breaths per minute, and oxygen saturation of 99%. Mr. M. denies pain, and his height is 69.5 inches with a weight of 87 kg. Laboratory results show a white blood cell count of 19.2 (1,000/uL), lymphocytes count of 6700 (cells/uL), a CT head scan with no changes since the previous scan, and a urinalysis positive for a cloudy and moderate amount of leukocytes. Additionally, the protein level is 7.1 g/dL, AST is 32 U/L, and ALT is 29 U/L.
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.
Primary medical diagnoses to consider for Mr. M. include dementia and urinary tract infection (UTI). The subjective manifestations of memory loss, confusion, agitation, aggression, and fearfulness in combination with the objective findings of leukocytes in the urine and cloudy urine support the consideration of a UTI. Dementia is supported by the subjective manifestations of cognitive decline, difficulty recalling information, and objective manifestations of behavioral changes and decline in activities of daily living (ADLs).
A nursing diagnosis that can be formulated based on these medical diagnoses is Disturbed Thought Processes related to dementia and UTI. The subjective manifestations of memory loss, confusion, and difficulty recalling information, along with the objective manifestations of behavioral changes, support this nursing diagnosis.
3. What abnormalities would you expect to find and why when performing your nursing assessment using the identified primary and secondary medical diagnoses.
When performing a nursing assessment using the identified primary and secondary medical diagnoses, we would expect to find abnormalities such as impaired cognitive function, disorientation, difficulty with memory recall, poor judgment, and altered behavior. These abnormalities are expected as a result of the dementia diagnosis. In the case of a UTI, we may find symptoms such as urinary urgency, frequency, dysuria, and cloudy urine. The presence of leukocytes in the urine suggests a localized inflammatory response in the urinary system.
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.
Mr. M.’s current health status can have significant physical, psychological, and emotional effects on him. Physically, he may experience a decline in functional abilities, such as difficulties with ambulation and unsteady gait. He may become increasingly dependent on others for ADLs, affecting his overall independence and sense of control over his own well-being.
Psychologically, Mr. M. may experience frustration, confusion, and a loss of self-identity due to the cognitive decline associated with dementia. He may feel anxious, agitated, and fearful as his ability to comprehend and interact with his surroundings diminishes. These psychological effects can be distressing and lead to further behavioral changes.
Emotionally, Mr. M. may feel isolated, depressed, and experience a sense of loss as he struggles to remember his family members and maintain social connections. He may also feel a loss of dignity and autonomy as he becomes more reliant on others for support.
This health status can have a significant impact on Mr. M.’s family. They may feel overwhelmed, stressed, and emotionally drained as they witness their loved one’s decline. Caregiver burden may increase as they navigate the challenges of providing care and support for Mr. M. The family may also experience grief and a sense of loss as they witness the changes in Mr. M. and anticipate the progression of his condition.
5. Discuss what interventions can be put into place to support Mr. M. and his family.
To support Mr. M. and his family, various interventions can be implemented.
For Mr. M., interventions may include medication management to address the symptoms of dementia and UTI. Non-pharmacological interventions such as cognitive stimulation therapy, reminiscence therapy, and reality orientation can be beneficial in promoting cognitive functioning and preserving autonomy to some extent. Ensuring a safe and comfortable physical environment can reduce risks and improve overall well-being. Engaging in regular physical activity or physiotherapy can enhance physical mobility and prevent further decline. Social support and activities can help maintain social connections and reduce isolation. Education and counseling can also be provided to Mr. M. and his family to promote understanding of the condition and coping strategies.
For the family, interventions may include providing education and support to help them understand the progression of dementia and the challenges they may face. Providing respite care services and connecting them with support groups can offer opportunities for self-care and reduce caregiver burden. Counseling and emotional support can assist in addressing their feelings of grief, loss, and stress associated with caregiving.
6. Given Mr. M.’s current condition, discuss at least four actual or potential problems he faces. Provide a rationale for each.
Four actual or potential problems that Mr. M. faces include:
1. Impaired cognition: Mr. M.’s cognitive decline and memory loss impact his ability to participate in daily activities and maintain independence. This poses a problem for his overall functioning and quality of life.
2. Safety risks: Mr. M.’s wandering behavior and disorientation increase the risk of falls, getting lost, and potential harm to himself. This poses a problem for his physical well-being.
3. Communication difficulties: Mr. M.’s difficulty recalling names and information, combined with behavioral changes, may lead to challenges in effective communication with healthcare providers, caregivers, and family members. This poses a problem for his ability to express needs and preferences.
4. Emotional distress: Mr. M.’s fearfulness, agitation, and aggressive behaviors can cause emotional distress for both himself and those around him. This poses a problem for his emotional well-being and may adversely affect his relationships and social interactions.
Rationale: These problems arise from the underlying medical diagnoses of dementia and UTI, as well as the associated cognitive decline, behavioral changes, and physical limitations experienced by Mr. M. It is important to address these problems to optimize his care, promote his well-being, and provide support to him and his family.
