How to Evaluate the Health History and Medical Information for a Case Study: Mr. M (Solved)

How to Evaluate the Health History and Medical Information for a Case Study: Mr. M (Solved)

Prompt: Assessment Description
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.

You are required to submit this assignment to LopesWrite. A link to the LopesWrite technical support articles is located in Class Resources if you need assistance.


Clinical Manifestations

Mr. M is a known hypertensive patient. He presents with an unsteady gait and difficulty in motor activity, with impaired short-term memory. He is agitated, fearful when he gets aggressive. He also sleepwalks and is dependent on executing many activities of daily living. The possible primary diagnoses include known hypertension evidenced by hypertensive medication and stable blood pressure. He also has dementia evidenced by a lack of recall of names of his family members, his room number, or what he has just read. The secondary diagnoses are aggression and anxiety disorder, evidenced by his quick agitation, fearfulness when he’s aggressive.

Abnormalities found on nursing assessment

On assessing the patient’s overall appearance, he looks agitated. A cognitive ability assessment using the General Practitioner Assessment of Cognition tool reveals evidence of cognitive impairment. The findings are evidenced by impaired time orientation, inability to number and space appropriately, and a lack of recall of names of family members (Julayanont et al., 2017). The patient has a high risk of harm related to poor short-term memory, agitation, and aggressiveness. The patient has disturbed thought processes evidenced by mental deficits such as poor memory, unsteady gait, and impaired motor activity which hinders his performance of activities of daily living.

Physical, psychological, and emotional impacts of his health status

The physical, psychological, and emotional effects of Mr. M’s health status have a diverse impact on him and his family. First, his impaired motor activity and unsteady gait present problems related to activity intolerance. He cannot carry out activities of daily living due to difficulty in movement related to an unsteady gait. As a result, will need assistance to perform self-care activities and other activities of daily living. Additionally, he is at a high risk of falling due to impaired short-term memory and unsteady gait. A study by Allali et al.(2017) concurs with this as it states that cognitive impairment is an independent risk factor for falls. The study asserts that falls are highly prevalent among the elderly who have particular deficits in cognition and attention. The psychological effects of his health status are loss of short-term memory and sleepwalking. His frequent wandering at night and lack of recall pose a serious risk to himself and his caregivers. First, he could hurt himself though falls. Also, the resultant sleep disruption can lead to increased daytime sleepiness, and behavioral disorders. Additionally, the impaired short-term memory can lead him to social isolation, as holding a conversation becomes a challenge. Aggressiveness and agitation can further exacerbate social isolation by straining interpersonal relationships. Social isolation is significantly associated with depression. Reckless actions due to aggressiveness can also lead to physical injuries.

The effects on the family or caregivers are also diverse. They are tasked with helping the patient achieve his activities of daily living, including self-care. When the family cannot provide such help, they might pay for a caregiver or have him registered at an assisted living facility, which can be costly. Also, constant waking up at night and lack of recall can disrupt the family members’ sleep.


First, help the patient orient to the environment as necessary. Reality orientation strategies enhance patients’ self and environmental awareness. One can use calendars and television to do this. According to Weller and Budson (2018), it reassures patients in the early stages of dementia and is aware they are losing their short-term memory. Second, create a safe patient environment by reducing the sources of accidents in that environment. Maintaining a safe environment eliminates or minimizes the risk of injury, allowing the patient to exercise independence and autonomy (Weller & Budson, 2018). Third, have the patient wear an identification band when outside. It helps identify and safely return the patient to his residence when lost and unable to recall any identification information. Fourth, instruct the family members to be vigilant and lock up sharp objects, including knives, away from the patient to avoid self-injuries. Fifth, to manage a constantly interrupted sleep pattern, ensure a quiet and comfortable sleeping environment free from external stimuli. Provide formal procedures such as warm drinks and baths before sleeping as they enhance comfort. Provide relaxation techniques such as music and backrubs to ease anxiety and tension before sleeping. Lastly, assess for the need of and provide sleep apnea apparatus if needed as it enables the completion of all sleep stages. Social support through family is critical in managing mental illnesses as patients feel valued and accepted despite their conditions that force them to depend on others for basic needs.

Actual and potential problems

Given his current condition, the following are the actual problems Mr. M faces: he has a viral infection evidenced by elevated leukocytes (19.2 cells per 1,000/uL) and lymphocyte (6700 cells/uL) count. The normal range for leukocytes is 4.5 to 11 cells per 109/L, and lymphocytes are 1000 to 4800 cells per uL. The patient has stable hypertension, as evidenced by the antihypertensive drugs he is currently using. He is on Lisinopril 20mg per day. The patient has a potential problem of dementia evidenced by a lack of recall of simple activities and names of family members. Some of the early signs and symptoms of dementia include poor short-term memory, reduced concentration span, mood changes, and inability to accomplish activities of daily living (Livingston et al., 2017). The patient also has a potential anxiety disorder evidenced by frequent agitation and aggressiveness. Additionally, the drugs he is taking have the side effect of eliciting anxiety. The category of drugs with this side effect include benzodiazepines (Xanax), cholesterol-lowering drugs (Lipitor), and sedatives (Ambien) (Satoskar & Bhandarkar, 2020).


Allali, G., Launay, C. P., Blumen, H. M., Callisaya, M. L., De Cock, A. M., Kressig, R. W., … & Biomathics Consortium. (2017). Falls, cognitive impairment, and gait performance: results from the GOOD initiative. Journal of the American Medical Directors Association18(4), 335-340.

Julayanont, P., Phillips, N., Chertkow, H., & Nasreddine, Z. (2017). Cognitive screening instruments. A. J. Larner (Ed.). Cham: Springer.

Livingston, G., Sommerlad, A., Orgeta, V., Costafreda, S. G., Huntley, J., Ames, D., … & Mukadam, N. (2017). Dementia prevention, intervention, and care. The Lancet390(10113), 2673-2734.

Satoskar, R. S., & Bhandarkar, S. D. (2020). Pharmacology and pharmacotherapeutics. Elsevier India.

Weller, J., & Budson, A. (2018). Current understanding of Alzheimer’s disease diagnosis and treatment. F1000Research7.

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