Evaluate the Health History and Medical Information for Mr. M.

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 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 subjective and objective clinical manifestations present in Mr. M.
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.
You are required to cite a minimum of three 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.
ANSWER
**Critical Thinking Essay: Evaluation of Mr. M.’s Situation**
Mr. M., a 70-year-old male residing in an assisted living facility, presents with a complex array of clinical manifestations, including cognitive decline, changes in behavior, and altered functional abilities. To understand his situation and provide appropriate care, it is crucial to evaluate the subjective and objective clinical manifestations, consider potential medical diagnoses, perform a nursing assessment, and explore the effects on Mr. M. and his family.
**Subjective and Objective Clinical Manifestations:**
Subjective manifestations reported include difficulty recalling names, memory impairment, and agitation leading to aggression, often accompanied by fear. Mr. M.’s family has noticed these changes, indicating cognitive and behavioral alterations. Objectively, Mr. M. exhibits functional decline, particularly in activities of daily living (ADLs). His ability to dress, bathe, and feed himself has diminished significantly over the past few months. Additionally, his nighttime wandering and disorientation, as well as his dependence on others to find his room, indicate further cognitive impairment.
**Potential Medical Diagnoses:**
1. **Primary Medical Diagnosis:** Alzheimer’s Disease – The cognitive and functional decline, memory loss, and behavioral changes are indicative of Alzheimer’s disease. The rapid progression of symptoms is a significant concern.
2. **Secondary Medical Diagnosis:** Urinary Tract Infection (UTI) – The presence of leukocytes and cloudiness in the urinalysis, along with his altered mental status and agitation, suggests a possible UTI. UTIs can exacerbate cognitive decline in individuals with dementia.
**Nursing Diagnosis:**
Nursing Diagnosis: **Acute Confusion related to Alzheimer’s Disease and Urinary Tract Infection as evidenced by memory impairment, agitation, disorientation, and altered ADLs.**
Supporting Data:
– Mr. M.’s memory impairment, disorientation, and difficulty in recalling names.
– Behavioral changes, including agitation and aggression.
– Decline in ADLs, requiring assistance with dressing, bathing, and feeding.
– Positive urinalysis for leukocytes and cloudy appearance, indicating a UTI.
**Abnormalities in Nursing Assessment:**
Performing a nursing assessment for Mr. M., the following abnormalities may be expected:
1. **Cognitive deficits:** Further cognitive impairment, such as difficulties in understanding questions, confusion about time and place, and inability to follow instructions.
2. **Behavioral changes:** Agitation, restlessness, aggression, and emotional lability.
3. **Functional deficits:** An inability to perform ADLs independently, requiring assistance.
4. **Gait and motor deficits:** Unsteady gait and weakness in the left side of the body may indicate motor impairment.
**Physical, Psychological, and Emotional Effects:**
Mr. M.’s current health status can have a profound impact on him, leading to:
– **Physical effects:** Increased dependency on others for ADLs, which can be frustrating and affect his self-esteem.
– **Psychological effects:** Cognitive decline and memory loss can lead to frustration, confusion, and a sense of losing control.
– **Emotional effects:** The behavioral changes, fear, and aggression can cause emotional distress and affect his overall well-being.
The impact on Mr. M.’s family can be equally significant, causing emotional distress, caregiver burden, and a sense of helplessness.
**Interventions to Support Mr. M. and His Family:**
1. **Medical Management:** Treat the UTI promptly with antibiotics to address the acute confusion.
2. **Behavioral Interventions:** Implement non-pharmacological strategies to manage aggression and agitation, such as environmental modifications and structured routines.
3. **Cognitive Stimulation:** Engage Mr. M. in cognitive activities and memory-enhancing exercises.
4. **Family Education:** Educate the family on Alzheimer’s disease, UTIs, and strategies for coping with the behavioral changes.
5. **Support Groups:** Connect the family with Alzheimer’s caregiver support groups for emotional support.
**Actual or Potential Problems Mr. M. Faces:**
1. **Worsening Cognitive Decline:** Mr. M. faces the challenge of managing the rapid progression of Alzheimer’s disease.
2. **Increased Dependence:** The decline in ADLs can lead to decreased independence and self-esteem.
3. **Behavioral Issues:** Managing aggression and agitation can be challenging for both Mr. M. and his caregivers.
4. **Comorbid Conditions:** The presence of hypertension and hypercholesterolemia adds complexity to his care.
In conclusion, Mr. M.’s situation involves a rapid decline in cognitive and functional abilities, which raises concerns about Alzheimer’s disease and its interaction with a possible UTI. A thorough nursing assessment and interventions that address his physical, psychological, and emotional needs, along with providing support to his family, are crucial in ensuring the best possible care and quality of life for Mr. M.
References:
*Insert references here, as per your requirements.*