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. Health History and Medical Information
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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
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.
1. 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.
2. When performing your nursing assessment, discuss what abnormalities would you expect to find and why.
3. 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.
4. Discuss what interventions can be put into place to support Mr. M. and his family.
5. Given Mr. M.’s current condition, discuss at least four actual or potential problems he faces. Provide rationale for each. Health History and Medical Information
RUBRICS:
Subjective and objective clinical manifestations are detailed. The clinical manifestations are accurate and clearly report the observed and perceived signs and symptoms.
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.
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.
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.
All relevant interventions that can be put into place to support Mr. M. and his family are thoroughly discussed.
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 Health History and Medical Information
