Health History and Medical Information

Health History and Medical Information

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