Health History and Medical Information

This essay discusses the different primary and secondary medical diagnoses, abnormalities detected during nursing assessment, physical, psychological and emotional effects, interventions, as well as the actual and potential issues of the Mr. M’s current health status.

Running Head: HEALTH HISTORY AND MEDICAL INFORMATION
Health History and Medical Information (Case study)
Student Name
University Name
Student Notes

1HEALTH HISTORY AND MEDICAL INFORMATION
Introduction
Considering the case study mentioned, the 70 year old subject, who already has a medical history
of high blood pressure, and high cholesterol, has been showing symptoms like sudden agitation
and aggressiveness. He has been observed to have difficulty remembering obvious details, and
performing his ADL’s (Toot et al., 2017). Considering his symptoms of memory loss,
behavioral issues and cognitive impairment, it might be considered that he is suffering from
dementia, which is common given his age. The blood tests ordered by the assisted care facility,
detected the increase in the white blood cell count indicating infection in the body. The urinalysis
test came positive by appearing cloudy and highlighting the presence of leukocytes, indicating
urine infection. The following essay will discuss the different primary and secondary medical
diagnoses, abnormalities detected during nursing assessment, physical, psychological and
emotional effects, interventions, as well as the actual and potential issues of the Mr. M’s current
health status.
Diagnosis
Primary medical diagnosis:
The significant loss of memory and the increased dependence of Mr. M for the execution of his
ADL’s due to the observable cognitive impairment, it can be associated with different
neurodegenerative diseases, sepsis, urinary tract infection associated delirium and more.
Considering the sudden onset of the symptoms and the increased incidence of agitated and
aggravated behavior on Mr. M’s end, this situation needs more priority rather than the other
observed symptoms in the blood and urine tests conducted. The increased white blood cell count

2HEALTH HISTORY AND MEDICAL INFORMATION
detected in the blood tests can lead to delirium including symptoms like temporary state of
confusion and agitation, or the increased white blood cell count can also indicate the contraction
of UTI, which was confirmed in the urinalysis.
Secondary medical diagnosis:
Mr. M had been observed to have difficulty in efficiently executing his ADL’s. This matter of his
increased dependency on others requires medical attention. Physiotherapy sessions need to be
conducted for Mr. M, to help increase his limited physical activity, which might reduce his
dependency on others for executing his ADL’s (Toot et al., 2017).
Abnormalities detected during nursing assessment
During the nursing assessment of Mr. M, a nurse would be expected to deal with his agitated and
aggressive behavior. Due to his impaired cognitive status, he might be expected to have
difficulty understanding the simple medical procedures that are to be conducted on him. He
might be very uncooperative and might appear to be fearful of his surroundings. This can be due
to the incidence of infection induced delirium, or the sudden onset of dementia (Steis et al.,
2015). During the assessment, evaluating the blood and urine tests would help in understanding
that he contracted a urinary tract infection, which would need to be treated accordingly.

3HEALTH HISTORY AND MEDICAL INFORMATION
Physical, psychological, and emotional effects
Physical effect:
Mr. M has been observed to have become increasingly dependent on efficiently executing his
ADL’s. Considering the sudden onset of the symptoms, it can further limit the mobility of the
patient and result in balance and sight problems. Problems regarding balance can be usually
associated with psychosis and delirium.
Psychological effect:
Mr. M has been exhibiting these symptoms along with sleeping problems, agitation, aggression,
sleep disturbance, psychosis and delirium further increasing his social inappropriateness (Kales,
Gitlin & Lyketsos, 2015). The most significant of psychological effects is the significant and
sudden loss of memory, leading to limited recollection of basic information like name of family
members, room number and more.
Emotional effect:
Dementia can alter a person’s emotional responses, leading to either reduced or aggravated
reaction to any stimulus, leading them to either be socially distant or violent. The most
significant emotional modification that can be expected in Mr. M is the reduced self-esteem and
confidence due to the emotional and physical dependence in performing basic ADL’s (Kales,
Gitlin & Lyketsos, 2015).

4HEALTH HISTORY AND MEDICAL INFORMATION
These aggravated negative emotional and psychological effects can lead to:
 Difficulty in effectively communicating with their family members
 Difficult for the family members, to handle the patient if not properly guided by the
healthcare professionals.
Interventions
The four interventions are as follows:
 Cognitive Stimulation Therapy –
This method incorporates the benefits of therapeutic group sessions by trained
practitioners and nurses; with patients of dementia and helps them understand their
situation better as well as train them in effectively managing their symptoms and
controlling their mood swings, in order to avoid aggression (Orrell et al., 2017).
 Validation Therapy –
This therapy focuses on knowing the feelings and emotional condition of the patient
better and in order to help in the accurate incorporation of interventions. These help
in making the patients comfortable and elevate their self-confidence and importance
(Mitchell & Agnelli, 2015).
 Reminiscence Therapy –

5HEALTH HISTORY AND MEDICAL INFORMATION
These therapy sessions focus on reminding the patients of the good times and
memories, in order to uplift their mood and help them be aware of their situation
better.
 Physical exercise and physiotherapy –
Considering that Mr. M medical history of appendix surgery and tibia fracture, he has
become physically defendant on the care facility professionals for executing his
ADL’s, physiotherapy and some routine physical exercises can help him improve his
cognitive status (Hall et al., 2017).
Actual and potential issues
Considering his signs and symptoms, the four actual or potential problems Mr. M faces are:
 Disrupted sleeping pattern:
Mr. M can be clearly seen to exhibit sleep maintenance insomnia. The dementia
patients are seen to have a higher REM latency which contributes to the overall
decrease in the REM phase (de Almondes et al., 2016). The dementia induced neural
degeneration often damages the two regions of the brain responsible for sleep- basal
forebrain and reticular formation of the brainstem (Skottheim et al., 2018). Increased dependence on executing his ADL’s:
This is mainly because of his cognitive impairment which is caused due to the sudden
onset of dementia, leading to delirium and psychosis induced mental instability (Toot
et al., 2017). Urinary tract infection:

6HEALTH HISTORY AND MEDICAL INFORMATION
This can be linked with his decreased mental presence and memory loss which will
evidently reduce his hygiene and can be considered as the reason behind the
contraction of the urinary tract infection.
 Memory loss:
Memory loss in dementia is often associated with damage in the hippocampus of the
brain, which is responsible for the execution of the day to day activities of a person.
Increased plaque formation can lead to Alzheimer’s and the misbalanced pressure in
the brain can cause vascular dementia, which results in significant memory loss.
Conclusion
Thus, from this essay it can be concluded that Mr. M has acquired a neurodegenerative disease
along with a urinary tract infection which would require not only pharmacological interventions
but also therapeutic interventions like Validation Therapy, Cognitive Stimulation Therapy, and
physiotherapy to help him cope with his current difficulties. The essay includes the different
potential health risks and issues he is or might be facing and the plausible reasons behind them,
which can help build effective nursing interventions against them. These nursing interventions, if
incorporated in his lifestyle, might improve his overall wellbeing and regain some normalcy in
his life, by helping him cope with the different symptoms of his acquired neurodegenerative
disorder and urinary tract infection.

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References
de Almondes, K. M., Costa, M. V., Malloy-Diniz, L. F., & Diniz, B. S. (2016). Insomnia and risk
of dementia in older adults: systematic review and meta-analysis. Journal of psychiatric
research, 77, 109-115. Retrieved from: https://doi.org/10.1016/j.jpsychires.2016.02.021
Hall, A. J., Lang, I. A., Endacott, R., Hall, A., & Goodwin, V. A. (2017). Physiotherapy
interventions for people with dementia and a hip fracture—a scoping review of the
literature. Physiotherapy, 103(4), 361-368. Retrieved from:
https://doi.org/10.1016/j.physio.2017.01.001
Kales, H. C., Gitlin, L. N., & Lyketsos, C. G. (2015). Assessment and management of behavioral
and psychological symptoms of dementia. Bmj, 350, h369. Retrieved from:
https://doi.org/10.1136/bmj.h369
Mitchell, G., & Agnelli, J. (2015). Non-pharmacological approaches to alleviate distress in
dementia care. Nursing Standard (2014+), 30(13), 38. Doi:10.7748/ns.30.13.38.s45
Orrell, M., Yates, L., Leung, P., Kang, S., Hoare, Z., Whitaker, C., ... & Pearson, S. (2017). The
impact of individual Cognitive Stimulation Therapy (iCST) on cognition, quality of life,
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https://doi.org/10.1371/journal.pmed.1002269
Skottheim, A., Lövheim, H., Isaksson, U., Sandman, P. O., & Gustafsson, M. (2018). Insomnia
symptoms among old people in nursing homes. International psychogeriatrics, 30(1), 77-
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Steis, M. R., Behrens, L., Colancecco, E. M., Mogle, J., Mulhall, P. M., Hill, N. L., ... &
Kolankowski, A. M. (2015). Licensed nurse and nursing assistant recognition of delirium
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https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5193367/
Toot, S., Swinson, T., Devine, M., Challis, D., & Orrell, M. (2017). Causes of nursing home
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