Evaluate the Health History and Medical Information for Mr. M.
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 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 Instruction
Must have: Thesis is comprehensive and contains the essence of the paper. Thesis statement makes the purpose of the paper clear.
In 750-1,000 words, critically evaluate Mr. M.’s situation. Include the following:
Describe the clinical manifestations present in Mr. M.
Rubric criteria:
Subjective and objective clinical manifestations are detailed. The clinical manifestations are accurate and clearly report the observed and perceived signs and symptoms.
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.
Rubric criteria:
A detailed discussion on what primary and secondary medical diagnoses should be considered for Mr. M. is presented. Strong rationale and reliable data are used to explain why the diagnoses are relevant and should be considered.
When performing your nursing assessment, discuss what abnormalities would you expect to find and why.
Rubric criteria:
A thorough discussion of abnormalities a nurse would expect to find during a nursing assessment is presented. Strong rationale and evidence are provided for support.
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.
Rubric criteria:
A thorough discussion of the effects of the health status on the physical, psychological, and emotional aspects of the patient, and the impact the health status has on the family, is presented. Strong support for the discussion is provided.
Discuss what interventions can be put into place to support Mr. M. and his family.
Rubric criteria:
All relevant interventions that can be put into place to support Mr. M. and his family are thoroughly discussed.
Given Mr. M.’s current condition, discuss at least four actual or potential problems he faces. Provide rationale for each.
Rubric criteria:
Four or more actual or potential problems faced by the patient are thoroughly discussed. The posed problems are clearly related to his condition. Strong rationale is provided and supports the discussion.
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.
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Answer preview to evaluate the Health History and Medical Information for Mr. M.
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