Introduction
Mr. M.’s subjective data includes his statements that he has trouble remembering names, cannot find his room number and becomes agitated and aggressive very quickly. When he acts aggressively, he also seems scared and nervous. Mr. M.’s CT head scan is unaltered from the prior scan, and his laboratory results show a WBC of 19.2 (1,000/uL) and lymphocytes of 6700 (cells/uL). His AST and ALT levels are high, and his urinalysis shows a moderate number of leukocytes and cloudy protein.
Mr. M’s Primary and Secondary Diagnosis
When evaluating Mr. M.’s health, Alzheimer’s disease should be considered first and foremost. A neurodegenerative disease that impairs one’s ability to remember, reason, and make choices, Alzheimer’s disease is a devastating condition for any family to endure. The accumulation of plaques and tangles in the brain is a hallmark of the disease, resulting in the death of neurons and a decline in mental capacity (Papadakis, 2020). Memory loss, inability to complete complex tasks, and alterations in mood and behavior are all early symptoms of Alzheimer’s disease. In addition, delusions, hallucinations, and difficulties swallowing and communicating are all symptoms that may appear as the disease progresses. Unfortunately, Alzheimer’s disease cannot be cured, and there is no medical treatment that can slow its progression.
Dementia should be Mr. M.’s secondary medical diagnosis. Alzheimer’s and dementia are both neurodegenerative diseases that rob victims of their cognitive and linguistic abilities. Dementia manifests itself in various ways, the most common being memory loss, communication issues, a diminished ability to solve problems, and shifts in temperament (Navarro, 2018). When brain tissue is damaged, the result is dementia, which is a progressive disease because it worsens over time. Although dementia currently has no cure, it can be treated to alleviate its symptoms.
Mr. M’s nursing diagnosis
Cognitive Impairment, specifically dementia, is Mr. M’s official medical diagnosis. A decline in cognitive abilities due to illness or injury is referred to as dementia. Since Mr. M.’s health has rapidly deteriorated over the past few months, he cannot perform basic self-care tasks like dressing, bathing, and feeding himself (American Medical Association, 2019). In addition, he is becoming increasingly agitated and hostile and has begun wandering the streets at night. An infection could cause a slightly elevated white blood cell count and protein level found in the lab results. However, a CT scan of his brain shows no abnormalities, ruling out structural changes as a possible cause of his mental decline. Possible nursing diagnoses for Mr. M. are:
- Memory Loss from Alzheimer’s Disease
- Cognitive Impairment and Agitation Lead to Dangerous Wandering
- Due to cognitive Impairment and impaired communication, there is an increased risk of infection.
Due to Mr. M.’s rapid decline in mental abilities and his difficulty with ADLs, the case data supports the cognitive impairment diagnosis. The data shows that his nighttime wandering poses a risk for injury diagnosis. Increased white blood cell count and protein level in the laboratory data support the possibility of an infection diagnosis (Vlad & Roman, 2022). Based on the available data, including laboratory results, symptoms of infection and inflammation would be anticipated. Furthermore, given the patient’s history, one would anticipate hypertension and hypercholesterolemia symptoms.
Support Needs for Patients and Family
Mr. M. and his family need to be supported in many ways. First, a trained medical professional, such as a geriatrician, neurologist, or psychiatrist is needed to conduct a comprehensive cognitive and functional assessment. This evaluation will help pinpoint the cause of Mr. M.’s cognitive decline and identify the specific form of dementia he suffers from before commencing treatment (Pape-Haugaard, 2020). A treatment plan, which may consist of medication, therapy, and support services, can be formulated based on the assessment results. Some patients with dementia may benefit from using cholinesterase inhibitors and memantine. Moreover, cognitive stimulation therapy and reminiscence therapy are examples of potentially helpful therapies that may be suggested to enhance cognitive performance and quality of life. Respite care, which gives caregivers a break, and day programs, which engage people with dementia in social and recreational activities, are two examples of support services that may be suggested.
Conclusion
Mr. M.’s current health situation may seriously affect his body, mind, and soul. The rapid decline in his mental faculties may cause him to become disoriented and confused, a state that can be quite terrifying (American Medical Association, 2019). The anxiety and helplessness he is experiencing may cause him to lose his temper and act violently. Mr. M’s deteriorating health may compel him to rely on others for help with even the simplest of tasks, which can be both annoying and humiliating. Additionally, Mr. M. has a high risk of falling because of his mobility issues and shaky gait. Additional harm, such as a hip fracture, may result from this. The incontinence and inability to self-feed can also lead to dehydration. A more rapid decline or even death may result from this. Due to his UTI, Mr. M. is at risk for sepsis. There is a risk of organ failure and eventual death if this continues. Because of his swallowing difficulties, Mr. M. is also at risk for developing aspiration pneumonia. As a result, the victim may experience respiratory failure and eventually die.
References
American Medical Association. (2019). CPT 2020 professional edition. American Medical Association.
Navarro, V. (2018). Imperialism, health and medicine. Routledge.
Papadakis, M. A. (2020). Current medical diagnosis and treatment 2021. McGraw Hill.
Pape-Haugaard, L. B. (2020). Digital personalized health and medicine : proceedings of MIE 2020. Ios Press.
Vlad, S., & Roman, N. M. (2022). 7th International Conference on Advancements of Medicine and Health Care through Technology : proceedings of MEDITECH-2020, 13-15 October 2020. Springer