Case Study: Mr. M.

Case Study
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Case Study: Mr. M. 

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.

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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

  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.
  2. 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.
  3. When performing your nursing assessment, discuss what abnormalities would you expect to find and why.
  4. 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.
  5. Discuss what interventions can be put into place to support Mr. M. and his family.
  6. 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. Refer to the LopesWrite Technical Support articles for assistance. 

RUBRIC

Attempt Start Date: 23-Sep-2019 at 12:00:00 AM

Due Date: 29-Sep-2019 at 11:59:59 PM

Maximum Points: 120.0

Case Study: Mr. M.

No of Criteria: 11 Achievement Levels: 5CriteriaAchievement LevelsDescriptionPercentageUnsatisfactory0.00 %Less Than Satisfactory75.00 %Satisfactory79.00 %Good89.00 %Excellent100.00 %Content80.0     Clinical Manifestations of Mr. M.10.0Clinical manifestations are omitted.Clinical manifestations are partially presented. There are major omissions and inaccuracies.Clinical manifestations are summarized. An overview of the general symptoms is presented. Some findings are incomplete.Subjective and objective clinical manifestations are described. Overall, the clinical manifestations are accurate and reflect observed and perceived signs and symptoms.Subjective and objective clinical manifestations are detailed. The clinical manifestations are accurate and clearly report the observed and perceived signs and symptoms.Diagnoses and Secondary Diagnoses10.0A discussion on what primary and secondary medical diagnoses should be considered for Mr. M. is omitted; or, medical diagnoses presented are inaccurate.A partial discussion on what primary and secondary medical diagnoses should be considered for Mr. M. is presented. There are major inaccuracies. Rationale and evidence for the diagnoses are lacking.A general discussion on what primary and secondary medical diagnoses should be considered for Mr. M. is presented. There are some inaccuracies. A summary provides some rationale and evidence to explain why the diagnoses are relevant.A discussion on what primary and secondary medical diagnoses should be considered for Mr. M. is presented. General rationale and relevant data are used to explain why the diagnoses should be considered. There are minor inaccuracies.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.Explanation of Expected Abnormalities During Nursing Assessment15.0A discussion of what abnormalities a nurse would expect to find during a nursing assessment is omitted; or, the expected findings are not relevant for the patient or his health status.An incomplete summary of some abnormalities a nurse would expect to find during a nursing assessment is presented. There are inaccuracies. No rationale or evidence is provided for support.A general discussion on the abnormalities a nurse would expect to find during a nursing assessment is presented. There are minor inaccuracies. Some rationale or evidence is provided for support.A discussion of abnormalities a nurse would expect to find during a nursing assessment is presented. General rationale and evidence are provided for support.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.Effects of Health Status on Physical, Psychological, and Emotional Aspects of Patient and Family15.0The effects of the health status on the physical, psychological, and emotional aspects of the patent, and the impact the health status has on the family, are omitted.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, are partially summarized. The effects presented are questionable, and support for the discussion is not provided.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, are summarized. Overall, the described effects on the patient and impact to the family are relevant. Some support for the discussion is provided.A 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. Support for the discussion is provided.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.Interventions for Support15.0Interventions that can be put into place to support Mr. M. and his family are omitted.Some interventions that can be put into place to support Mr. M. and his family are partially presented. More information is required.Some interventions that can be put into place to support Mr. M. and his family are summarized. There are minor inaccuracies.Key interventions that can be put into place to support Mr. M. and his family are discussed. Some detail is needed for clarity.All relevant interventions that can be put into place to support Mr. M. and his family are thoroughly discussed.Actual or Potential Problems Based on Condition15.0Fewer than three actual or potential problems faced by the patient are presented. The problems posed are not relevant to his condition.Three actual or potential problems faced by the patient are partially presented. It is unclear how some of the posed problems are relevant to his condition. There are inaccuracies.At least four actual or potential problems faced by the patient are summarized. The posed problems are generally relevant to his condition. There are minor inaccuracies. Some information or rationale is needed.Four or more actual or potential problems faced by the patient are discussed. The posed problems are relevant to his condition. Rationale provided generally supports the discussion.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 the discussion.Organization, Effectiveness, and Format20.0     Thesis Development and Purpose5.0Paper lacks any discernible overall purpose or organizing claim.Thesis is insufficiently developed or vague. Purpose is not clear.Thesis is apparent and appropriate to purpose.Thesis is clear and forecasts the development of the paper. Thesis is descriptive and reflective of the arguments and appropriate to the purpose.Thesis is comprehensive and contains the essence of the paper. Thesis statement makes the purpose of the paper clear.Argument Logic and Construction5.0Statement of purpose is not justified by the conclusion. The conclusion does not support the claim made. Argument is incoherent and uses noncredible sources.Sufficient justification of claims is lacking. Argument lacks consistent unity. There are obvious flaws in the logic. Some sources have questionable credibility.Argument is orderly but may have a few inconsistencies. The argument presents minimal justification of claims. Argument logically, but not thoroughly, supports the purpose. Sources used are credible. Introduction and conclusion bracket the thesis.Argument shows logical progression. Techniques of argumentation are evident. There is a smooth progression of claims from introduction to conclusion. Most sources are authoritative.Clear and convincing argument presents a persuasive claim in a distinctive and compelling manner. All sources are authoritative.Mechanics of Writing (includes spelling, punctuation, grammar, language use)5.0Surface errors are pervasive enough that they impede communication of meaning. Inappropriate word choice or sentence construction is used.Frequent and repetitive mechanical errors distract the reader. Inconsistencies in language choice (register), sentence structure, or word choice are present.Some mechanical errors or typos are present, but they are not overly distracting to the reader. Correct sentence structure and audience-appropriate language are used.Prose is largely free of mechanical errors, although a few may be present. A variety of sentence structures and effective figures of speech are used.Writer is clearly in command of standard, written, academic English.Paper Format (use of appropriate style for the major and assignment)2.0Template is not used appropriately, or documentation format is rarely followed correctly.Appropriate template is used, but some elements are missing or mistaken. A lack of control with formatting is apparent.Appropriate template is used. Formatting is correct, although some minor errors may be present.Appropriate template is fully used. There are virtually no errors in formatting style.All format elements are correct.Documentation of Sources (citations, footnotes, references, bibliography, etc., as appropriate to assignment and style)3.0Sources are not documented.Documentation of sources is inconsistent or incorrect, as appropriate to assignment and style, with numerous formatting errors.Sources are documented, as appropriate to assignment and style, although some formatting errors may be present.Sources are documented, as appropriate to assignment and style, and format is mostly correct.Sources are completely and correctly documented, as appropriate to assignment and style, and format is free of error.Total Percentage  100

Submission Id: e37c0cb3-3174-4d8b-82f0-fb90776992db

31% SIMILARITY SCORE 7   CITATION ITEMS 12   GRAMMAR ISSUES 0   FEEDBACK COMMENT Internet Source   7% Inst itut ion   24%

Liliana Faura

Case StudyMrM.doc

Summary  744 Words  

Running Head: CASE STUDY: MR. M. 1

CASE STUDY 5

Case Study: Mr. M.

Liliana Faura

GCU

09/22/2019

Case Study

The case study is about Mr. M who is a 70 year old male in assisted living facility. He

has a history of hypertension, hypercholesterolemia. His hypertension is controlled by

ACE inhibitors and uses Lisinopril daily for the hypercholesterolemia, status post

appendectomy, and t ibial fracture status postsurgical repair and does not have any

sign of complicat ions. Mr. M does not have allergies and no history of smoking or use

of alcohol. His condit ion of hypertension and hypercholesterolemia is becoming

chronic and requires long term medical arrangement.

In the past two months, the medical team realized a decline in the cognit ive mental

memory of Mr. M. He is even struggling to remember the names of his family members

or even his residence room number. At the same t ime, he is experiencing behavioral

issues like repeating himself and mood issues that have made him become agitated

and aggressive. He is also experiencing fear, especially when he is agitated.

Addit ionally, he has become dependent on others for some key act ivit ies such as

feeding to dressing. From the presented symptoms, one can argue that he is

suffering from stroke. However, primary medical diagnosis should be done to confirm

whether or not he is suffering from stroke. Mr. M. can be asked to repeat speech

sentences, history or his family names. He can also be asked to repeat to raise his

arms one at a t ime and note any challenges in doing these. If he is experiencing

difficulty, the physician should look consider the history of the family. The diagnosis

will enable the doctor to administer appropriate treatment. Mr. can be directed to a

pediatric as a significant secondary intervention.

When doing the assessment, the physician should expect to detect symptoms of

struggling with the patient’s speech, patient misplacing objects, difficulty in handling

daily act ivit ies, poor judgment, confusion, and trouble planning or organizing his work.

Addit ionally, there may be inconsistency in aggressive nature of the patient and

changes in sleeping patterns. Hypertension is a condit ion that can be confirmed after

an increase in blood pressure (Huether & McCance, 2017).

Mr. M’s current health status is disturbing to him and the family as well. A feeling of

dependency and lack of privacy in his life is one thing that would start to worry about

his brain. Also, failing to recall his family member names could trigger a sense of

insecurity. Being agitated could also make him feel afraid of himself. Such experiences

diminish his thoughts on self-love and can start considering himself as a bother. Mr. M

will be struggling with basic self-care needs like bathing, hygiene, dressing himself,

eating, and even taking medications as scheduled. The emotional and psychological

effects may affect the personal life of an individual and even their loved ones as they

 Missing hyphens: 70 year old  70-year-old

 assist, assistance (help): assisted  help

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 Spelling mistake: hypercholesterolemia

 Passive voice: hypertension is controlled…

 Spelling mistake: Lisinopril  Eosinophil

 Spelling mistake: hypercholesterolemia

 Spelling mista…: postsurgical  post surgical

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 Possible wordiness: whether or not  whether

 Student: Submitted to Grand Canyon University 0…

 Student: Submitted to Grand Canyon University 0…

experience, anger, grief, disbelief, and loss. To the family, they must consider

changing the daily schedules that they may take care of their patient. Also, they may

feel alienated from Mr. M’s family since he cannot recall their names. They also need to

spend more cash in the assisted home, for the extra care the facility gives to Mr. M.

That means a drain from their accounts.

To support the family and Mr. M, the nurse can put different interventions. First of all,

the nurse should perform daily rehabilitat ion sessions to help improving the

functioning of the brain. The doctor can also use memory photos to help remind the

patient about his past and help him reconnect with the family members (Hammer &

McPhee, 2019). In this condit ion, the patient normally wants attention and someone

who will understand and attend to him. As a result , the nurse should train the family

about the best ways of handling the patient and support ing him.

Considering the condit ions of Mr. M, it is clear that he faces numerous problems such

as surviving at the mercy of others. They have to feed him, bath him and dress him as

well. Addit ionally, he is experiencing paralysis part icular when under stroke. Mr. M also

faces the challenge of poor motor coordination. He therefore cannot undertake some

of the daily act ivit ies of life. Difficulty in speech and communication is another

problem he faces because he cannot properly coordinate his muscles, lips, and

tongue.

References

Hammer, G. D., & McPhee, S. J. (2019). Pathophysiology of Disease: An introduction to

clinical medicine (8th Ed.). New York, NY: McGraw-Hill Education

Huether, S. E., & McCance, K. L. (2017). Understanding Pathophysiology (6th Ed.). St.

Louis, MO: Elsevier.

 Student: Submitted to Grand Canyon University 0…

 Student: Submitted to Grand Canyon University 0…

 Grammatical problem: improving

 Passive voice: it is clear that

 Redundant phrase: some of the  some

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