Health History and Medical Information Essay.

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Health History and Medical Information Essay.

 

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.Health History and Medical Information Essay.

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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 Essay.

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.Health History and Medical Information Essay.

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.Health History and Medical Information Essay.

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.Health History and Medical Information Essay.
  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. Health History and Medical Information Essay.

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

Clinical Manifestations in Mr. M

The patient is a 70-year-old called Mr. M living in an assisted facility and has a UTI and AD. Neither does he drink alcohol nor smokes but has limited physical activity resulting from an unsteady gait and difficulty ambulating. His overall health status seemed to be declining with trouble recalling his room number, names of his loved ones, and repeating what he has just read. Mr. M quickly becomes aggressive and agitated and appears to be fearful during the episodes of aggression. At night, Mr. M wanders and frequently gets lost requiring assisting to find his room and is unable to perform ADLs. The objective data reveals that Mr. M has a blood pressure of 123/78mmHg, a normal temperature of 37.10c, pulse rate of 93(elevated), pulse oximetry of 99 %( room air), respiratory rate of 22(slightly elevated). Laboratory findings reveal a WBC of 19.2 (1,000/uL), Lymphocytes 6700 (cells/uL), A CT scan with no changes from the previous one and a positive urinalysis for moderate leukocytes and cloudy, a protein 7.1 g/dL, AST 32 U/L, and ALT 29 U/L.Health History and Medical Information Essay.

Primary and Secondary Medical Diagnoses to Consider

Mr. M’s primary medical diagnosis is UTI and Alzheimer’s disease (AD). Secondary diagnoses are; hypertension and hypercholesterolemia.

  • Alzheimer’s disease-in older adults, AD is the commonest form of dementia in patients presenting with difficulties in completing familiar tasks, memory loss, loss of vision, frequently misplacing items, making decisions, mood and personality changes, and becoming socially withdrawn from people, work and activities.Health History and Medical Information Essay. In two months, Mr. M has had a gradual decline in cognitive function, presenting with trouble recalling his room number, names of his loved ones, and repeating what he has just read. Mr. M quickly becomes aggressive and agitated and appears to be fearful during the episodes of aggression. At night, Mr. M wanders and frequently gets lost requiring assisting to find his room and is unable to perform ADLs
  • Urinary Tract Infection- supported by the laboratory findings of a WBC of 19.2 (1,000/uL), Lymphocytes 6700 (cells/uL), and a positive urinalysis for moderate leukocytes and cloudy. Besides, UTIs can cause sudden delirium in patients with AD as observed in Mr. M with a sudden change in behavior, withdrawal, confusion, and agitation/aggression (Tan & Chlebicki, 2016).
  • Hypertension- the patient is currently on ACE inhibitors for hypertension management. For long term good outcomes, the patient needs education about close monitoring of blood pressure and the need to observe dietary recommendations for hypertensive patients (Gabb et al., 2016).Health History and Medical Information Essay.
  • Hypercholesterolemia- the laboratory findings of a protein 7.1 g/dL, AST 32 U/L, and ALT 29 U/L suggest that Mr. M has high cholesterol levels in the blood. Since Mr. M is hypertensive, high cholesterol levels place him at high risk of cardiovascular complications (Kraft et al., 2017).Health History and Medical Information Essay.

Abnormalities from the Nursing Assessment

Abnormalities for a UTI is present in the patient’s objective data. Normally, the range of lymphocytes in male adults is between 1000-4800. However, Mr. M’s lymphocytes were significantly high (6700 (cells/uL). Lymphocytes are part of the body’s immune cells. Lymphocytes are found in lymph and blood and are made in the bone marrow.  They have an integral role in the mechanism of the body’s immune response. Mr. M’s lymphocytes are likely elevated as a normal response of the body to the UTI (Tan & Chlebicki, 2016).Health History and Medical Information Essay.

Additionally, Mr. M’s WBC of 19.2 is elevated since the normal WBC range is 4500-11,000. The slight elevation suggests an inflammatory process due to an underlying infection. Mr. M also had a positive urinalysis for a moderate amount of leukocytes and cloudy, suggesting a correlation with a UTI diagnosis (Tan & Chlebicki, 2016).Health History and Medical Information Essay.

Older adults presenting with multiple comorbid conditions must be assessed for cognitive impairment, which may be due to; depression, the side effects of drugs, dementia, endocrine derangements, and delirium caused by a current illness (Weller & Budson, 2018). There are numerous scales to use for assessing older adults with AD. In routine clinical practice, cognitive status is the primary measure for the diagnostic criteria of dementia and may be evidenced by impaired functioning, cognitive impairment, and depression (Weller & Budson, 2018).Health History and Medical Information Essay.

Physical, Psychological and Emotional Effects of Health Status on Family

The physical effects of AD are that it impairs physical and physiological functioning. This includes limiting the patient’s ability to perform activities of daily life (ADLs) and in the advanced form, muscle loss results in the inability to withhold bowel movements and urine (Weller & Budson, 2018). The emotional and psychological effects of AD on patients are numerous. However, the most common effects on the patent are that it results in feelings of loneliness, depression, anger, fear and anxiety, aggression, and apathy (Weller & Budson, 2018). For family members, the most common effects are associated with caregiver burden, which may trigger feelings of sadness, anger frustration, and fear. Family members may also have to make decisions on finances, treatment, end-of-life care, and living arrangements, which may result in family conflicts(Weller & Budson, 2018).Health History and Medical Information Essay.

Interventions for Support

There are pharmacological drugs to use in the management of dementia to promote a patient’s mental abilities. Although the medications do not stop the disease or reverse the already existent brain damage, they slow disease progression and reduce the severity of symptoms, influencing marked improvement in a patient’s quality of life and a decrease in the caregiver burden (Weller & Budson, 2018). Apart from pharmacological support, cognitive behavioral therapy (CBT) has shown efficacy in managing the behavioral and cognitive problems that can change the trajectory of Alzheimer’s disease. CBT influences a patient to perform tasks in a specific way, help patients to identify trigger symptoms, and manage them (Weller & Budson, 2018). It would also be necessary to link Mr. M to a community support group for people with Alzheimer’s disease. Support groups provide patients with a platform to share advice, frustrations, and victories, and to grieve with other people. Health History and Medical Information Essay.

Potential Problems for Mr. M

The first problem is a UTI. When a UTI goes untreated, it may complicate to cause sepsis or renal impairment, which are both life-threatening conditions. Sepsis can further result in acute kidney injury and cause a decline in kidney function (Tan & Chlebicki, 2016). Another problem is Alzheimer’s disease as it causes dysphagia for both liquids and solids. Ultimately, this can result in either delirium or dehydration.  Severe dehydration may lead to speech difficulties, confusion, and increased heart rate and generalized weakness. In patients with Alzheimer’s disease, delirium causes easy distraction, sudden behavior change, hallucinations, and a decrease in energy levels(Weller & Budson, 2018). Health History and Medical Information Essay.