Assignment:Case Study: Mr. M

Assignment:Case Study: Mr. M

Assignment:Case Study: Mr. M

In the given case study, Mr. M, a 70-year-old patient, is shown to have become worse during the previous two months. The patient’s memory loss is growing worse since he sometimes forgets to return to his room after being outdoors. His aggression and agitation are rising swiftly. When he becomes aggressive, he conveys dread and apprehension. Due to his inability to continue independent living, he needs assistance with the majority of his daily tasks. The purpose of this paper is to evaluate the patient’s clinical symptoms under other circumstances, establish the main and secondary diagnoses, and provide a suitable solution.

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Clinical Manifestations Present In Mr. M.

 There might be several reasons for the patient’s declining health. The patient is unable to carry out daily life tasks on his own. He periodically forgets where he is, which is another sign of his deteriorating memory loss. As a result, he has trouble recalling information he has read. These signs may indicate that the patient is having cognitive issues (Filshtein et al., 2019). Additionally, he exhibits shifts in hostility and irritability, both of which are indicators of emotional issues. The patient seems to be disoriented and then wanders off, which is a sign of behavioral issues. For the best course of action, the patient must undergo a comprehensive medical examination.

Primary and Secondary Diagnosis

 The most appropriate main diagnosis for Mr. M is dementia or Alzheimer’s disease based on the facts presented. In addition to deteriorating memory loss, the patient also exhibits increased anger and bewilderment. According to Ansai et al. (2019), the early stages of Alzheimer’s disease are often marked by changes in the patient’s mood, confusion about time or place, language issues, attention problems, challenges with everyday chores, memory impairment, and retreat from social involvement.

For the majority of these symptoms, the patient tests positive. The patient seems to have a secondary diagnosis of urinary tract infection based on the results of the lab tests. His leukocyte and white blood cell counts are increased. As a consequence, traces of leukocytes were detected in the urine findings. Additionally, research indicates that UTIs are frequent among people with cognitive decline, which makes them more confused (Hardy et al., 2022). For instance, sleepiness, agitation, incontinence, impaired mobility, and falls are a few of the non-classic symptoms of UTI.

Abnormalities Expected To Be Found

  It is anticipated that the patient’s sense of time, place, and person would be impaired upon further evaluation of his health, signaling a loss in cognitive function. Additionally, the patient can be dehydrated and malnourished. The patient may have mild to severe discomfort while peeing as a result of the UTI diagnosis. The patient’s vital signs may also exhibit aberrant results, such as raised blood pressure and respiration rates, depending on his main and secondary diagnoses (Wang et al., 2020). Even though the aberrant results do not fulfill the criteria for a nursing diagnosis, they should be taken into account to prevent consequences.

Physical, Psychological, And Emotional Effects

 Physically, the patient has a greater chance of falling, having less-than-stellar skin, and being undernourished. The patient is at significant risk of falling and suffering bodily harm as a consequence of this because of their impaired cognitive function and unstable stride. Due to the patient’s memory loss, he may forget when it’s time to eat or drink, which might lead to malnutrition and dehydration (Andrews et al., 2019). As a result, the patient may develop bowel and urine incontinence, which might cause irritation or skin breakdown. The patient has shown psychological symptoms of increasing agitation, disorientation, and anxiety. Alzheimer’s disease patients often have a deteriorating cognitive function, which includes increasing confusion and gradual memory loss. The patient seems emotionally unhappy since he can’t go about his everyday routines. The patient may have anxiety at his inability to recall the names of his family members, which might increase his risk of mood disorders including depression. Therefore, it is essential to think about the patient’s emotional support to prevent related issues.


 Before treating the patient’s major diagnosis, it will be vital to think about treating the patient’s underlying illnesses to boost their health. It is necessary to start the appropriate antibiotic medication based on the recognized etiological microorganism as soon as the findings are positive and indicate the existence of an infection. Clinicians will need to perform further assessments on patients with Alzheimer’s to identify all of the patient’s daily life activities that need help and make sure he receives all the care he needs (Filshtein et al., 2019). To prevent the patient from forgetting to eat, the nurse should assist him in setting an alarm and wearing name tags with the patient’s room information. The patient’s family members should also get training on how to encourage the patient’s memory rather than annoy him. The patient’s mental health must also be supported emotionally.

Actual or Potential Problems He Faces

 The patient is at a greater risk of falling because of his Alzheimer’s disease, as was already indicated. The fall may have caused him to endure bodily damage. Sepsis from the infection, which is clear from the test results, is the other issue the patient could have. If antibiotic treatment is delayed, the patient’s illness might worsen and turn into sepsis (Hardy et al., 2022). Dehydration, weight loss, and malnutrition may also result from the patient neglecting to eat and drink water. The patient also runs the chance of passing away. According to studies, the majority of Alzheimer’s sufferers pass away in the disease’s advanced stages.


  The case study presented shows a patient whose health is failing as a result of Alzheimer’s disease. The patient’s blood results also show that an infection is present. The nurse must do a risk assessment owing to the patient’s diminishing cognitive abilities given the likelihood of falls. Antibiotic therapy for the underlying illnesses and assistance for the parent’s memory loss and cognitive decline is, therefore, necessary to promote the patient’s health.


Andrews, J. S., Desai, U., Kirson, N. Y., Zichlin, M. L., Ball, D. E., & Matthews, B. R. (2019). Disease severity and minimal clinically important differences in clinical outcome assessments for Alzheimer’s disease clinical trials. Alzheimer’s & Dementia: Translational Research & Clinical Interventions, 5(1), 354–363.

Ansai, J. H., Andrade, L. P. de, Masse, F. A. A., Gonçalves, J., Takahashi, A. C. de M., Vale, F. A. C., & Rebelatto, J. R. (2019). Risk Factors for Falls in Older Adults With Mild Cognitive Impairment and Mild Alzheimer Disease. Journal of Geriatric Physical Therapy, 42(3), E116–E121.‌

Filshtein, T. J., Brenowitz, W. D., Mayeda, E. R., Hohman, T. J., Walter, S., Jones, R. N., Elahi, F. M., & Glymour, M. M. (2019). Reserve and Alzheimer’s disease genetic risk: Effects on hospitalization and mortality. Alzheimer’s & Dementia, 15(7), 907–916.

Hardy, C. C., Ramasamy, R., Rosenberg, D. A., Kuchel, G. A., Yan, R., Hu, X., & Smith, P. P. (2022). Alzheimer’s disease amyloidogenesis is linked to altered lower urinary tract physiology. Neurourology and Urodynamics, 41(6), 1344–1354.

Wang, X., Huang, W., Su, L., Xing, Y., Jessen, F., Sun, Y., Shu, N., & Han, Y. (2020). Neuroimaging advances regarding subjective cognitive decline in preclinical Alzheimer’s disease. Molecular Neurodegeneration, 15(1).


Assessment Description

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

Mr. M., a 70-year-old male, has been living at the assisted living facility where you work. He has no known 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 subjective and objective clinical manifestations present in Mr. M.

Based on the information presented in the case scenario, state what primary and secondary medical diagnoses should be considered for Mr. M. Formulate a nursing diagnosis from the medical diagnosis and explain why these should be considered and what data is provided for support.

What abnormalities would you expect to find and why when performing your nursing assessment using the identified primary and secondary medical diagnoses.

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 a rationale for each.

You are required to cite a minimum of three 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.

This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion.

You are required to submit this assignment to LopesWrite. A link to the LopesWrite technical support articles is located in Class Resources if you need assistance.

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