[Institution Title]
Care Plan Template
Patient Initials: N/A Age: 60 years old Sex: Male
Subjective Data:
HPI (History of Present Illness): Patient has already been experiencing similar symptoms for the past two years. Similar symptoms of decrease in urinary flow, however, of a much lesser degree of severity.
PMH (Past Medical History—include current medications, any known allergies, any history of surgery or hospitalizations):
Patient has been previously diagnosed with hypertension and hypercholesterolemia. Client was also hospitalized five years ago for assumed angina but was overruled after. Patient is under maintenance medication of two drugs, specifically Cardizem 240mg and Zocor 20mg both taken once daily. Patient denies any medication allergy.
Significant Family History: Patient has two siblings—one sister and one brother. Patient reported remote history of heart condition amongst uncles and aunts.
Social/Personal History (occupation, lifestyle—diet, exercise, substance use):
Patient is highly educated, has master’s degree in engineering. Patient is married with two grown-up sons ages 35 and 37, both have families of their own. Very limited and inadequate knowledge of health. Patient has an excellent health insurance that includes a prescription plan. Patient has no vices. Denies smoking, drinking and taking illicit drugs. Patient also believes he is generally healthy. He gets adequate exercise, eats healthy foods and attends to a regular medical check-up.
Description of Client’s Support System: Patient’s support system includes wife, children and people from his place of work. According to patient his social support is limited only to his family and a few people from work.
Behavioral or Nonverbal Messages: Patient has a very positive outlook about health and wellness. This is why patient has invested on an excellent health insurance that cover drug prescription. However, patient’ tend to delay consultation for medical condition similar to this incident. The patient has have had the symptoms for two years but delayed getting treatment until after the problem becomes too overwhelming.
While the patient is highly educated, his knowledge about health is very limited. In addition, the patient also has very limited knowledge of the resources available at his dispense in relation to his health situation.
Objective Data:
Vital Signs including BMI: Patient’s vital signs were documented at 140/92 Blood pressure taken from patient’s right arm while sitting down. Blood pressure is considered abnormally high. Temperature was also records at 99°F obtained orally. Patient’s temperature has been reported to be slightly higher than the normal temperature which was 98°F. Pulse was also recorder within normal ranges of 80. Respiration was not labored and within normal range of 18bpm. Patient stands 5ft 11 inches. Gave a BMI reported at 27.9 which falls under the classification overweight.
Physical Assessment Findings: After physical assessment, patient’s recorded assessment all shows normal finding except for the Grade II/VI systolic murmur heard best at the right sternal border. Also patient’s abdominal measurement suggest android obesity. In addition, patient’s manifested significant findings related to patient’s rectum examination which reports a light brown stool, heme positive. Patient’s prostate is also enlarged, boggy and tender to palpation.
Lab Tests and Results: Patient’s lab test also revealed findings within normal level except for the PSA value of 6. A prostate-specific antigen value of 6 is already considered suspicious and must undergo further testing.
ICD-9 Diagnoses/Client Problems: Patient is diagnosed with following condition according to ICD 9-
- 27802 – Overweight.
- 78843 – Nocturia
- 78862 – Slow urinary stream
- 78863 – Urgency in urination only during the night
Advanced Practice Nursing Intervention Plan (including interdisciplinary collaboration, community resources and follow-up plans):
- Patient needs health education on the description of “healthy”
Patient believes that he is healthy amidst the presence of medical symptoms. He also admits that his knowledge of health-related information is limited.
- NIC 5510 Health Education
Patient assumes that he is healthy despite the presence of symptoms. Patient needs to be educated on the definition of healthy and the scope of health .
- NIC 7400 Health System Guidance
Although patient is covered with an expensive Medicare insurance, patient needs to be informed of the available resources that he can used from the community.
- 6520 Health Screening
Patient should be advised to have some screenings to determine condition. Among the tests include 1) Digital rectal exam (DRE; Urologists examine manually the prostate), 2) trans-rectal ultrasound (TRUS), or 3) MRI (magnetic resonance imaging). Necessary refer to lab experts.
- Urinary related assistance
Patient has been experiencing various urinary related discomforts and needs a care plan that would sufficiently covers the concerns.
- 0560 Pelvic Muscle Exercise
Since patient is experiencing decrease urinary stream, pelvic muscle exercise can help with the urine flow .
- 0570 Urinary Bladder Training
Patient reported nocturia which is especially bothersome at night. Hence, patient should be taught how to improving bladder function through urinary bladder training at least for those with urge incontinence
- 0582 Urinary Catheterization: Intermittent
Since patient reported decrease decreased strength of urinary flow and slight terminal dysuria. Patient should be evaluated if there is a need for catheterization.
References
Armstrong, J. (2014, October 7). Florida's State Surgeon General. Retrieved from Florida Department of Health: http://www.floridahealth.gov/about-the-department-of-health/about-us/ssg/index.html
Dorey, G., Speakman, M. J., Feneley, R. C., Swinkels, A., & Dunn, C. D. (2005). Pelvic floor exercises for erectile dysfunction. British Journal of Urology International, 595–597.
National Health, Lungs and Blood Institute. (2014, November 5). Aim for a Healthy Weight. Retrieved from National Health, Lungs and Blood Institute Website: http://www.nhlbi.nih.gov/health/educational/lose_wt/BMI/bmicalc.htm
