Health History and Medical Information

Health History and Medical Information

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 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. Health History and Medical Information

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 Health History and Medical Information
  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. Health History and Medical Information

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.

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. Health History and Medical Information

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. Health History and Medical Information

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

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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. Health History and Medical Information

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. Health History and Medical Information


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 Health History and Medical Information.

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