Case Study: Mr. M
In the case under analysis, Mr. M, a 70-year-old male, is a patient whose condition continues deteriorating quickly during the last two months. He is a resident of an assisted living facility, who takes medications like Lisinopril and Lipitor to control his hypertension and hypercholesterolemia. The analysis of current symptoms, chief complaints, and physical/psychological effects will help identify primary and secondary diagnoses and choose the interventions to support Mr. M.
Clinical Manifestations
In this case, specific objective and subjective information are present. Mr. M has problems recalling the names of his relatives or his room number. He is not able to repeat the material he has just read or reach the place he needs. As a result, he becomes aggressive, agitated, and fearful of his emotions. It is necessary to provide him with help in doing his activities of daily living (ADLs). Regarding his hypertension, his blood pressure 123/93 is not a serious problem. However, the levels of white blood cells (WBC), 19.2, and lymphocytes, 6700, are high. Urinary analysis proves the presence of leukocytes, and computer tomography (CT) debuts head traumas or brain changes.
Primary Diagnoses and Secondary Diagnoses
Primary diagnoses are based on his mental health and physiological changes. Alzheimer’s disease is characterized by multiple cognitive changes and progressive decline in memory, behavior, and personality (Weller & Budson, 2018). In this case, Mr. M shows difficulties in names’ recalling and showing his room’s number. The patient cannot get to his room without additional help and loses his way. In addition, he remains dependent on nurses in many ADLs. Finally, his behavioral and personality changes call aggression, agitation, and fears. Another diagnosis that has to be taken into consideration is urinary tract infection (UTI). According to Wojszel and Toczyńska-Silkiewicz (2018), high body mass index (overweight or obesity), lymphocytes, and WBC are the signs of UTI in the geriatric population. The patient’s presenting symptoms include a high level of WBC (19.2, when normal ratings are 4.5-11) and a high level of lymphocytes (6700, when a normal range is between 1000-4800). The labs of urinalysis also show that urine is cloudy. Such signs as a urination urge and a burning sensation are absent, but the lack of this information could be explained by the development of mental health problems (Alzheimer’s).
Secondary diagnoses may be a stroke because of uncontrolled high blood pressure. His systolic pressure at the moment of assessment is higher than normal (123). In addition, such risk factors as old age, overweight, and sleeping problems (the patient takes Ambien to treat his insomnia) cannot be ignored. Muscle paralysis, difficulties in talking, poor self-care, and memory loss are the possible complication of a stroke. A high lymphocyte ratio may also be associated with autoimmune diseases, and multiple sclerosis is one of them (Hasselbalch et al., 2018). The elderly and postoperative patients are at risk of this diagnosis because of the development of infections (lab results prove its presence) and the lack of vitamins. In this case, the patient takes Ibuprofen, and his denial of pain could be explained by this medication.
Abnormalities During Nursing Assessment
Certain risks to Mr. M’s health exist, and a nurse should be attentive while performing an assessment. For example, the change of vital signs could fasten due to the progress of the infection in the body. El Chakhtoura et al. (2017) state that fever elevation usually occurs in older adults due to such conditions as endocarditis, intraabdominal infection, or tuberculosis. Although these diseases are neither reported by the patient nor mentioned in his medical history, internal infections cannot be neglected because of past appendectomy and tibia fracture status. His hypertension history is a sign to worry about the elevation of blood pressure. The combination of Alzheimer’s and stroke may result in impaired functions (speaking, reasoning, and orientation) (Duong et al., 2017). Therefore, it is important to check the patient’s speech and the way of how he understands what is happening to him at the moment of the assessment.
Health Status Effects
Mr. M’s current health status includes hypertension history, appendectomy, a postsurgical repair of a tibia fracture, insomnia, and challenges in memorizing things and doing his regular daily activities. The psychological effects of insomnia in the elderly are depression and anxiety (Suzuki et al., 2017). Although surgery helped remove complications because of a tibia fracture, such physical changes as unsteady gait and difficulty ambulating require the patient to address for professional help. The reasons for memory challenges remain unclear, but the use of medication and the possibility of Alzheimer’s could provoke memory loss and aggression because of the inability to control his life events. His hypertension status proves the necessity to take medications, but his memory works poorly, and psychosis or emotional changes may be observed. Finally, his family has to be ready for new obligations and tasks because the patient has become dependent while completing his ADLs. It is expected from relatives and healthcare providers to help him dress, bathe, and even feed. When Mr. M cannot remember something, he becomes aggressive, and his emotions are hard to control. Increased heart beating and confusion influence his emotions and behaviors.
Interventions
There are several intentions with the help of which Mr. M could stabilize his behavior, and his family may be adjusted to his psychological or emotional changes. First, cognitive training aims at improving the patient’s cognition and memory (Duong et al., 2017). Simple exercises should help take some actions regularly and train his memory, and this intervention can be implemented by a specially trained nurse or a family member who is aware of some personal facts that are interesting and meaningful to Mr. M.
Another strategy is focused on the client’s emotional and psychological problems because of poor sleep in old age. To reduce the number of medications, such steps as stimulus control and cognitive behavioral therapy are recommended (Suzuki et al., 2017). Communication with Mr. M is an opportunity to identify his positive beliefs and thoughts and use them to calm him down and reduce aggressive behaviors. The creation of a quiet bedroom environment, regular meals, and the lack of caffeine will have a favorable impact on the patient.
Being either in an assisted living facility or at home with his family, Mr. M needs one person nearby. It is possible to hire a nurse or a private practitioner who could share his emotions, knowledge, and information regularly. Instead of bothering the man with a number of new people, it is better to limit the communication circle. Sometimes, cooperation with people who have similar problems positively influences patients and enhances their activities and interests (Duong et al., 2017). The task is to create a list of constant and obligatory affairs and follow it every day.
Actual and Potential Problems
Taking into consideration the current status of the patient, his complaints, and his style of life, several potential, and actual problems have to be recognized and managed. Firstly, Mr. M has high blood pressure that needs to be controlled and monitored regularly. Because older adults have high blood pressure variability and isolated systolic hypertension, Anker et al. (2018) underline the importance of close monitoring. It helps to predict stroke and other heart- or vessel-related problems. Secondly, it is also obvious that Mr. M is developing dementia or Alzheimer’s, and the number of behavioral and cognitive changes can be dramatically increased, including a progressive decline in visuospatial function, personality, and language (Weller & Budson, 2018). Regular observations and communication should help to report on recent changes. Thirdly, the presence of UTIs in geriatric patients provokes new medical problems, based on different characteristics (Wojszel & Toczyńska-Silkiewicz, 2018). Recurrent infections and kidney damage must be prevented by taking antibiotics. Finally, even if there are no complications after surgery, such outcomes as hemorrhage, pulmonary embolism, and vein thrombosis may be recognized with time. Mr. M has to be regularly checked, and laboratory work is obligatory.
Conclusion
In general, the case under analysis introduces a complex situation when an old patient has to deal with several medical problems at once. In addition to the impossibility to continue doing his ADLs, his memory is challenged, and it is hard for the man to memorize all the necessary facts. His lab results are not good, and the reasons for increased WBC and lymphocyte levels must be investigated. His family or other caregivers should understand the worth of their cooperation with the patient to predict his emotional and psychological complications.
References
Anker, D., Santos-Eggimann, B., Santschi, V., Del Giovane, C., Wolfson, C., Streit, S., Rodondi, N., & Chiolero, A. (2018). Screening and treatment of hypertension in older adults: Less is more? Public Health Reviews, 39(1). Web.
Duong, S., Patel, T., Chang, F. (2017). Dementia: What pharmacists need to know. Canadian Pharmacists Journal, 150(2), 118-129. Web.
El Chakhtoura, N. G., Bonomo, R. A., & Jump, R. L. (2017). Influence of aging and environment on presentation of infection in older adults. Infectious Disease Clinics, 31(4), 593-608. Web.
Hasselbalch, I. C., Søndergaard, H. B., Koch-Henriksen, N., Olsson, A., Ullum, H., Sellebjerg, F., & Oturai, A. B. (2018). The neutrophil-to-lymphocyte ratio is associated with multiple sclerosis. Multiple Sclerosis Journal–Experimental, Translational and Clinical, 4(4). Web.
Suzuki, K., Miyamoto, M., & Hirata, K. (2017). Sleep disorders in the elderly: Diagnosis and management. Journal of General and Family Medicine, 18(2), 61-71. Web.
Weller, J., & Budson, A. (2018). Current understanding of Alzheimer’s disease diagnosis and treatment. F1000 Research, 7. Web.
Wojszel, Z. B., & Toczyńska-Silkiewicz, M. (2018). Urinary tract infections in a geriatric sub-acute ward-health correlates and atypical presentations. European Geriatric Medicine, 9(5), 659-667. Web.