ITS IN FILE Case study Mr. Johnson is a 75-year-old man, was brought to the emergency department...

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Case study Mr. Johnson is a 75-year-old man, was brought to the emergency department (ED) by his daughter with concerns about his increasing levels of pain, intermittent periods of acute confusion and deteriorating overall general health. Initial Assessment Mr. Johnson is alert but disorientated to time and place. He appears dishevelled and malnourished, with a strong odour of urine. He was brought in a wheelchair and was guarding his L knee. Daughter stated Mr. Johnson took two (2) Ibuprofen (neurofen) tablets couple of hours ago with minimal effect. BP - 140/93 HR - 96 bpm and regular Peripheral pulses - Present RR - 18 rpm Temp - 37.0C (tympanic) Sa02 - 98% RA BGL – 9 mmol/L Height -170 cm Weight - 74 kg (weighed 80 kgs six months ago) ECG - NAD MMSE – 23/30 L Knee Xray- NAD Urinalysis - dark concentrated yellow, clear urine, SG 1.010, pH 7, Leukocytes and nitrite- positive. Medical history Mr. Johnson has a history of multiple chronic medical conditions, including osteoarthritis, osteoporosis, hypertension, and diabetes. He is on several medications and has regular visits with his primary care physician. Medications Ibuprofen Panadol osteo Alendronate (Fosamax) Norvasc Cholecalciferol Calcium supplements Metformin Hydrochloride Gliclazide Hydrochlorothiazide Patient history Mr. Johnson lives independently in his own home and usually cooks his own meals at home. His daughter visits him couple of times each week. Mr. Johnson walks for an hour daily and catches up with his friends at the nearby park once a week. He enjoys spending time with his grandchildren. He never smoked and drinks a bottle of beer after dinner while watching TV. He wears glasses for long distance and bilateral hearing aids. Recently the daughter noticed Mr. Johnson increasingly neglecting his personal hygiene, nutrition, and household upkeep. Mr. Johnson has been socially isolated. and had multiple falls at home recently. Admitting diagnosis: Early signs of dementia. You are the registered nurse looking after Mr. Johnson, and you are required to plan her care guided by a clinical reasoning framework and the provided case study information. Sections you need to respond to include: 1. Patient assessment (500 words) · Provide an initial impression by identifying relevant and significant features from Mr. Johnson’s current ED presentation. · Discuss the possible causes for Mr. Johnson’s intermittent cognitive impairment. Do you agree or disagree with Mr. Johnson’s diagnosis of an early onset of dementia. Justify your opinion and support your discussion with evidence from the case study. • Evaluate the impact a misdiagnosis may have on the care provided for Mr. Johnson. Mr. Johnson’s intermittent confusion resolved after 3 days. He was assessed by the Aged Care Assessment Team (ACAT) and was eligible for a community care package. Mr. Johnson was discharged home with regular codeine for his chronic pain. 2. Physiological changes of ageing and identify patient issues (500 words) · Discuss how the normal physiological changes of ageing may increase Mr. Johnson’s risk of falls. Identify three (3) evidence-based nursing interventions with rationales that should be implemented for Mr. Johnson to reduce the risk of falls. (Do not include referrals in your answer). · Evaluate how Mr. Johnson’s chronic pain would impact on his capacity to complete two of his activities of daily living (ADL’s) ensuring you have justified your choice of ADL’s. 3. Pharmacological management and nursing considerations (500 words) · Discuss why Mr. Johnson, as an older adult, is more vulnerable to adverse drug. effects. Ensure you include factors related to the anatomical, physiological and behavioural considerations associated with ageing. · Identify with rationale two (2) nursing interventions you would consider when caring for Mr. Johnson who takes multiple medications (polypharmacy). (Do not include referrals in your answer.)

case-study-533chcee.docx

Dr Insiyah R. · Accepted Answer

Addressing each section one by one	2
1. Patient Assessment	2
2. Physiological Changes of Ageing and Patient Issues	4
3. Pharmacological Management and Nursing Considerations	5
Conclusion	7
Reference	8
Addressing each section one by one 
1. Patient Assessment
Initial Impression:
Mr. Johnson, a 75-year-old male with multiple chronic conditions, presents to the ED with increasing pain, intermittent periods of acute confusion, and a general decline in overall health. Significant features from his current ED presentation include:
Disorientation to Time and Place:- This suggests cognitive impairment and can be indicative of various underlying issues ranging from infections to neurological disorders.
Malnourished Appearance & Weight Loss:- A loss of 6 kg over six months is concerning and may suggest neglect, decreased appetite, or underlying metabolic abnormalities (Hazan,2020).
Odour of Urine & Positive Urinalysis:- These symptoms, along with leukocytes and nitrite in the urine, suggest a urinary tract infection (UTI), which is known to cause acute confusion in the elderly.
Guarding of the Left Knee and Chronic Pain:- This indicates a possible musculoskeletal issue, potentially related to his osteoarthritis.
MMSE Score of 23/30:- Indicates mild cognitive impairment.
Possible Causes for Intermittent Cognitive Impairment:
1. Urinary Tract Infection (UTI):- UTIs are known to cause acute confusion, particularly in the elderly. The presence of leukocytes and nitrites in Mr. Johnson's urinalysis strongly points towards a UTI (Fortea et al,2021).
2. Pain & Discomfort:- Uncontrolled pain can lead to distress and cognitive impairment.
3. Malnutrition and dehydration:- These can affect cognitive function, especially in the elderly.
4. Medication Side Effects:- Mr. Johnson is on multiple medications, and polypharmacy can lead to drug interactions and adverse effects, including cognitive impairment.
5. Underlying Neurological Condition:- Given his age and the MMSE score, an underlying onset of a neurological condition like dementia cannot be ruled out (Ulugut Erkoyun et al,2019).
Agreement with Diagnosis of Early-Onset Dementia:
While the MMSE score and his intermittent confusion suggest possible early-onset dementia, the resolution of confusion after 3 days and the presence of a UTI make it crucial to consider other reversible causes of cognitive impairment. I would recommend a cautious approach, addressing the reversible causes first and then reassessing his cognitive function before confirming a diagnosis of dementia (Hazan,2020).
Impact of Misdiagnosis:
Misdiagnosing Mr Johnson with early-onset dementia without addressing other potential causes of his symptoms could have several negative impacts:
Overlooking Treatable Conditions:- Conditions like UTIs and malnutrition, which are treatable, might be overlooked, leading to unnecessary suffering and potential complications (Alty, Farrow & Lawler,2020).
Psychological Impact:- A diagnosis of dementia can be distressing for both the patient and the family, potentially leading to anxiety and depression.
Inappropriate Treatment:- Mr Johnson might receive treatments and interventions for dementia that are not only unnecessary but could also have adverse effects, given his polypharmacy and multiple comorbidities.
Mr. Johnson’s presentation is multifaceted with several reversible factors contributing to his cognitive impairment. While early-onset dementia is a possibility, a thorough and holistic approach is required to address all reversible causes before confirming such a diagnosis (Dekhtyar et al,2019). Misdiagnosis can lead to inappropriate care, psychological distress, and overlooking of treatable conditions, underscoring the importance of careful and comprehensive assessment and management.
2. Physiological Changes of Ageing and Patient Issues
Risk of Falls:-
The normal physiological changes associated with ageing can significantly increase Mr Johnson's risk of falls. These changes include:
1. Musculoskeletal Changes:- Ageing is associated with a decrease in bone density, muscle mass, and joint mobility. Mr. Johnson’s pre-existing osteoarthritis and osteoporosis exacerbate these changes, increasing his susceptibility to falls (Alty, Farrow & Lawler,2020).
   
2. Neurological Changes:- Age-related changes in the nervous system can affect balance and coordination. Sensory deficits, including changes in vision and proprioception, can impair Mr. Johnson’s ability to navigate his environment safely.
   
3. Cardiovascular Changes:- Ageing affects the cardiovascular system, impacting blood pressure regulation. This, coupled with Mr. Johnson’s history of hypertension, can lead to orthostatic hypotension,

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