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Patient Assessment Evaluation || Sample Nursing Assignment

QUESTION

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.

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.
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.

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

 

ANSWER

Abstract

Performing patient assessments and making inferences from the assessments is an essential process in every healthcare facility. It is through this process that the basic responsibility of quality healthcare provision can be achieved. In this discussion, an overview is given of an assessment that was done on Mr. M, a resident at a living facility where the nurse works from. The patient is a 70-year-old man whose condition had been relatively stable until recently.

Clinical Manifestation

Based on the observations there are various medical manifestations that can be inferred from Mr. M. To start with, the patient may be suffering from Alzheimer disease, a health condition that commonly occurs due to old age resulting in consistent memory lapses as well as confusion. People suffering from Alzheimer are known to forget basic things such as the names of familiar people, different places that one has been to and their basic environments. The fact that Mr. M forgets the things he has read a few moments prior is further indication of the disease. Further, the increased agitation and aggressiveness can also be considered a manifestation of Alzheimer’s disease. The occurrence of agitation and aggression can be attributed to various factors such as pain, stress, constipation or as is the case in Alzheimer patients, being required to do things or remember people in their forgetful states. Another crucial clinical manifestation that can be made from Mr. M is high blood pressure. The patient’s results indicated that he had a blood pressure of 123/78, a value that is commonly associated with pre-hypertension. This condition should be treated with caution considering that most studies reveal that individuals suffering from such conditions tend to have heart attacks or stroke later in their lives. Other clinical manifestations observed in Mr. M include a significantly high number of lymphocytes, a high WBC count and an abnormal respiration rate.

Primary Diagnoses and Secondary Diagnoses

From the manifestations presented above, the primary diagnosis that can be carried out on the patient is that of Alzheimer’s disease. Initially, Mr. M led a mostly independent life and had no history of the aggression or memory lapses. However, with time his medical condition drastically deteriorated and the fact that he occasionally forgets the names of relatives and his environment, coupled with increased unsettledness is a likely indicator of Alzheimer.

 

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