Case Study: Ms. M.

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.

RUBRIC:
Clinical Manifestations of Mr. M.
10.0
Clinical 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 Diagnoses
10.0
A 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 Assessment
15.0
A 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 Family
15.0
The 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 Support
15.0
Interventions 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 Condition
15.0
Fewer 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 Format
20.0

Thesis Development and Purpose
5.0
Paper 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 Construction
5.0
Statement 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)
5.0
Surface 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)
2.0
Template 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)
3.0
Sources 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.