Mr. Ms Case
Subjective and Objective Clinical Manifestations
Mr. M.'s subjective manifestations include difficulty recalling names of family members and remembering his room number. He has trouble repeating what he just read. He experiences rapid mood swings. He is agitated and aggressive and also appears to be fearful. He has shown an increased tendency to wander at night and frequently gets lost. He also is dependent on assistance for many Activities of Daily Living (ADLs), including dressing, bathing, and feeding.
The objective manifestations include a WBC count of 19.2 (1,000/uL), which is elevated, and urinalysis results positive for a moderate amount of leukocytes and cloudy. His vital signs are within normal range, and his physical parameters are unremarkable. The CT scan of the head shows no changes from the previous scan.
Medical and Nursing Diagnoses
The primary medical diagnosis to consider is a urinary tract infection (UTI), suggested by the elevated leukocytes in the urine, which may also contribute to the elevated WBC count (Czajkowski et al., 2021). The cloudy urine is also indicative of a possible UTI. UTIs in older adults can often present with atypical symptoms, including changes in cognitive function, which could be contributing to Mr. M.'s confusion, aggression, and changes in ADL abilities (Godbole et al., 2020).
The secondary medical diagnosis is cognitive impairment, possibly due to dementia or Alzheimer's disease. This is indicated by his difficulty with memory, agitated and aggressive behavior, getting lost, and needing help with ADLs.
The nursing diagnosis would be "Risk for injury related to unsteady gait and cognitive impairment" due to Mr. M.'s unsteady gait and frequent wandering, particularly at night. Another nursing diagnosis is "Impaired memory related to cognitive changes as evidenced by difficulty recalling names, room numbers, and recent reading."
Abnormalities in Nursing Assessment
Abnormalities would likely include cognitive impairments, such as memory loss, difficulty with speech and language, confusion about time and place, and changes in mood or personality. A physical exam may also reveal signs of a UTI,...
…of falling. Falls in older adults can result in severe injuries that can undermine their overall health status (Vaishya & Vaish, 2020).Another significant concern is the management of his chronic conditions, particularly hypertension and hypercholesterolemia. Mr. M.'s cognitive decline could impair his ability to manage these conditions effectively. Inadequate treatment of these conditions could lead to potential exacerbations or complications. Similarly, uncontrolled hypercholesterolemia can lead to atherosclerosis and increase the risk of heart attack or stroke.
The agitation and aggressive behavior exhibited by Mr. M. are another set of problems. These behaviors pose a risk to Mr. M. and those around him. They also make caregiving more challenging.
Finally, the rapid cognitive decline experienced by Mr. M. is a problem. If his cognitive symptoms continue to worsen rapidly, Mr. M. could soon become fully dependent on caregivers for all activities of daily living. This would cause a significant shift in his care needs and potentially necessitate a transition to a higher level of care, such…
References
Czajkowski, K., Bro?-Konopielko, M., & Teliga-Czajkowska, J. (2021). Urinary tract infectionin women. Menopause Review/Przegl?d Menopauzalny, 20(1), 40-47.
Godbole, G. P., Cerruto, N., & Chavada, R. (2020). Principles of assessment and management ofurinary tract infections in older adults. Journal of Pharmacy Practice and Research, 50(3), 276-283.
Vaishya, R., & Vaish, A. (2020). Falls in older adults are serious. Indian journal oforthopaedics, 54, 69-74.
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