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NRS-410V-0500 Pathophysiology and Nursing Management of Client’s Health, Topic 2 Case Study: Mr. M.

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NRS-410V-0500 Pathophysiology and Nursing Management of Client’s Health, Topic 2 Case Study: Mr. M. – Description

Case Study: Mr. M.

Assessment Description

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 activities of daily living, 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 (data that the nurse can measure)

Temperature: 37.1 degrees C

Blood Pressure 123/78 , Heart Rate 93,  Respiratory Rate 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. (subjective data are symptoms that patient says he feels while      objective is what the nurse can measure)

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.

Resources you can use:

https://eds-p-ebscohost-com.lopes.idm.oclc.org/eds/detail/detail?vid=0&sid=ebd0cd9f-3a96-4649-b589-674dec851df5%40redis&bdata=JnNpdGU9ZWRzLWxpdmUmc2NvcGU9c2l0ZQ%3d%3d#AN=2018-47217-001&db=pdh

https://www-sciencedirect-com.lopes.idm.oclc.org/science/article/pii/S0006322320300500

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