CASE STUDY MRS. M

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.
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.
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.
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.   
RUBRIC
1. Clinical Manifestations of Mr. M.
Subjective and objective clinical manifestations are detailed. The clinical manifestations are accurate and clearly report the observed and perceived signs and symptoms. 10pts
2. Diagnoses and Secondary Diagnosis
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.  10pts
3. Explanation of Expected Abnormalities During Assessment
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. 15pts
4.  Effects of Health Status on Physical, Psychological, and Emotional Aspects of Patient and Family 
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. 15pts
5. Intervention for Support
All relevant interventions that can be put into place to support Mr. M. and his family are thoroughly discussed.  15pts
6. Actual and Potential Problems Based on the Condition
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. 15pts
7. Theses Development and Purpose
Thesis is comprehensive and contains the essence of the paper. Thesis statement makes the purpose of the paper clear.  5pts
8. Argument Logic and Construction
Clear and convincing argument presents a persuasive claim in a distinctive and compelling manner. All sources are authoritative  5pts
9. Mechanics of Writing (includes spelling, punctuation, grammar, language use)  5pts
Writer is clearly in command of standard, written, academic English.  5pts
10.  Paper Format (use of appropriate style for the major and assignment) 
All format element are correct 2pts
11.  Documentation of Sources (citations, footnotes, references, bibliography, etc., as appropriate to assignment and style)
Sources are completely and correctly documented, as appropriate to assignment and style, and format is free of error 3pts
TOTAL MARKS 100%