Case Study: Mr. M

Case Study: Mr. M.

Clinical presentation of Mr. M

Mr. M. is a 70-year-old male patient. Mr. M denies any allergies. Mar M has an unsteady gain and experiences challenges in ambulating. Mr. M experiences memory lapses since he finds it difficult to remember the names of family members, the number of his room or repeating the words he has uttered. Mr. M shows fear and shows aggressiveness. Mr. M cannot bathe dress or feed without being assisted. Mr. M looks pale and tired due to lack of adequate rest and relies on Zolpidem to manage his sleep disorder. From the objective data collected from the lab tests, Mr. M has a normal body temperature hence no signs of fever. Mr. M has blood pressure of C BP 123/78 HR 93 RR 22 Pox 99%, which signifies prehypertension, which is usually asymptomatic. Mr. M shows no sign of being in any pain and denies feeling any pain. Mr. M is overweight after calculating his Body Mass Index Height: 69.5 inches; Weight 87 kg, which translates to a BMI of 28.4. Mr. M has a WBC count of 19.2 (1,000/uL) and lymphocyte count of 6700 (cells/uL).  The results from a CT scan of the head shows no alteration since the preceding scan. Mr. M Urinalysis read positive for a substantial amount of leukocytes and appeared cloudy. Mr. M protein analysis stood at 7.1 g/dL; AST: 32 U/L; ALT 29 U/L.

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Primary and Secondary diagnosis

Primary diagnosis of Mr. M would include stroke, or a heart attack since has a C BP 123/78 HR 93 RR 22 Pox 99% which signifies prehypertension. Any reading above 120 systolic pressure means prehypertension even when the diastolic pressure ranges from 60 to 79 (Mymedicalscore, 2019). The worse reading is used in the event diastolic, and systolic pressure fall into different ranges. Furthermore, people with prehypertension have increased chances of experiencing heart attacks compared to individuals with lower blood pressure (Mymedicalscore, 2019). The second primary diagnosis would be to test for urinary tract infections in Mr. M due to the presence of leukocytes in urine. An unusual elevated number of leukocytes in urine signifies swelling or infection in the urinary tract, most commonly in the bladder or kidney (Pol et al., 2017). The diagnosis is essential to Mr. M, who is undertaking medications such as Lipitor and Lisinopril, which has known side effects to the kidneys. Hence, the diagnosis of urinary tract infection is necessary.

A secondary diagnosis that needs to be carried out include liver damage due to the daily intake of Lisinopril and Lipitor, which have damaging effects on the liver (Emedicinehealth, 2019). The second diagnosis is that of the mental health condition of Mr. M. The reason is that Mr. M. experiences mental loss and cannot remember his rooms or the words he has spoken despite CT scan showing no changes (Pol et al., 2017). The other secondary diagnosis that would be necessary is to check for kidney stones since the elevated amount of leukocytes can at times, indicate the presence of kidney stones.

Expected abnormalities would you expect to find

The expected abnormalities a nurse would expect to see include changes in the vital signs of the patient. These include body temperature changes, changes in blood pressure, decreased increased respiratory rate, which may vary from time to time depending on the presence or absence of infection. Besides, Mr. M denies may pain; a nursing assessment on him would prove otherwise (Registered Nursing, 2018). The baselines of vital signs are recorded because they are vitally crucial for comparison during and after treatment. Vital signs are highly responsive to abnormalities and changes of a patient

Physical, psychological and Emotional aspects to the patient and family

Mr. M’s health condition has significantly impacted on him physically. Mr. M. experiences challenges in ambulating and does not have a steady gait. Also, Mr. M. has a tibial fracture status postsurgical repair. The condition has also lead to memory loss, and Mr. M finds it difficult even to remember his room number, names of family members, or words he had uttered.  Mr. M has also been affected psychologically and emotionally in that when he is aggressive and agitated easily. Mr. M’s unsteady mental state sees him wander at night and often get lost. The condition has also affected his family since Mr. M. has become dependent with many ADLs. Initially, Mr. M could bathe, dress, and feed on his own; however, right now, he depends on his family members to assist him doing ADLs. Besides, Mr. M becomes in approachable, especially when he is aggressive as he becomes fearful and afraid.

Interventions that can be put in place

Interventions to be implemented include mental assessment of Mr. M., and Mr. M. needs to be assigned to a therapist to help in the recovery process to minimize his aggressive behaviour. In addition, the family needs to hire a private practitioner or assistant to assist Mr. M. in his ADLs, thereby reducing the burden on the family members. Mr. M from the case study seems lonely, and that’s why he wonders alone and get lost, putting him up in a facility with other people of the same age or health conditions would undoubtedly help in his recuperation. Furthermore, he forgets the names of family members, occasional visits by family members would be helpful for bonding or otherwise arrange visits to the homes of family members away from the assisted living facility.

Potential problems faced by Mr. M. due to his condition.

Due to hypertension and hypercholesterolemia, Mr. M has a potential of developing stroke. A stroke occurs when a blood vessel transporting oxygen and nutrients in the brain is blocked or bursts. A stroke occurs when blood supply to the brain is reduced (Mayo Clinic Staff, 2019). The second potential problem Mr. M can face is the risk of cardiovascular failure. Hypertension can strain the heart leading to weakening of the heart muscles making the heart to work less efficiently, and with time, the heart gets overwhelmed and fails (Mayo Clinic Staff, 2019). Hypercholesterolemia can also increase the likelihood of Type 2 diabetes because diabetes can impact different cholesterol levels and increases the chances of developing atherosclerosis (Mayo Clinic Staff, 2019). Mr. M. is also at the verge of developing dementia. Dementia is a disease of the brain that leads to challenges of thinking, speaking vision, movement, and reasoning (Mayo Clinic Staff, 2019). There are several causes of dementia one being vascular dementia, that is caused by narrowing and blockage of arteries that supply blood to the brain.

References

Mayo Clinic Staff. (2019, January 09). How high blood pressure can affect your body. Retrieved from https://www.mayoclinic.org/diseases-conditions/high-blood-pressure/in-depth/high-blood-pressure/art-20045868

Pol, J. G., Levesque, S., Workenhe, S. T., Gujar, S., Le Boeuf, F., Clements, D. R., … & Fucikova, J. (2018). Trial Watch: Oncolytic viro-immunotherapy of hematologic and solid tumors. Oncoimmunology, 7(12), e1503032.

Mymedicalscore. (2019). 123/78 Blood Pressure – Good or Bad? – MyMedicalScore. Retrieved from https://mymedicalscore.com/blood-pressure/123-78/

Emedicnehealth. (2019). Lipitor (atorvastatin) Side Effects, Interactions, Uses & Drug Imprint. Retrieved from https://www.emedicinehealth.com/drug-atorvastatin/article_em.htm

RegisteredNursing.org. (2018, May 29). Changes and Abnormalities in Vital Signs: NCLEX-RN. Retrieved from https://www.registerednursing.org/nclex/changes-abnormalities-vital-signs/ Case Study: Mr. M