[Institution Title]
Care Plan Template
Patient Initials: Not Applicable Age: 60 years old Sex: Male
Subjective Data:
Patient was admitted for complaints of decrease urinary flow. In addition, patient also complains that he has been experiencing severe symptoms of what he had been experiencing for more than two years already. Patient complains that for the past 2 weeks he has had increased nocturia, associated with decreased strength of urinary flow and slight terminal dysuria.
HPI (History of Present Illness):
According to the patient he has had the same symptoms for more than two years. However, for the past two weeks, the patient’s symptoms seemed to have progress in severity causing him discomfort and disrupting his daily activities.
PMH (Past Medical History—include current medications, any known allergies, any history of surgery or hospitalizations):
The patient has been diagnosed with two conditions in the past. These include hypertension and hypercholesterolemia. This is the reason why patient is receiving a daily maintenance medication to control his blood pressure and manage his cholesterol level. Patient is taking Cardizem 240mg once daily for his blood pressure . Patient is also taking Zocor 20mg once daily to help regulate patient’s cholesterol level . Patient recalled having been hospitalized 5 years ago for angina but was found to have no basis for the diagnosis. Patient verbalized having no know medication allergies.
Significant Family History:
Patient has two alive and well siblings. One brother and one sister. There is a remote history of heart disease in the patient’s family involving his uncles and aunts.
Social/Personal History (occupation, lifestyle—diet, exercise, substance use):
Patient has earned a master’s degree in Engineering making him highly educated. Patient reports to make $65,000 annually but has not been specific about his job. Patient is married with two grown sons aged 35 and 37, both of whom are married and are living independently with their families. While patient is educated, he lacks the proper understanding of what qualifies to being “healthy”. Likewise, patient has no knowledge of the resources available to him in the community. Patient also has an expensive medical coverage which also includes a prescription plan.
According to the patient he is eating healthy. His wife prepares their meal. He also believes that he exercise adequately as well. He also regularly sees his physician for a medical check-up. Patient denies smoking, drinking and using drugs.
Description of Client’s Support System:
Patient noted his family and co-workers as his support system.
Behavioral or Nonverbal Messages:
Patient admits that while he is educated it cannot account for the fact that he knows nothing about health or that his understanding of health related topics are very limited. Patient is very obedient in following the prescription given to him. At the same time patient has adequately secured his health by getting a good health insurance plan that even covers prescription plan. However, patient has the habit to withheld seeing the doctor despite experiencing some physical symptoms. This is what happened with the patient’s complained conditioned. He delayed consultation for two years and only saw the doctor after the symptoms became severe and unbearable.
Patient is very educated but his definition of healthy might not be what the real word means. Otherwise, had the patient known he would not be reporting a medical condition. Patient is aware of his health needs that is why he got a good health insurance. However, patient also has some issues because he failed to consult the doctor for two years for his present condition.
Objective Data:
Vital Signs including BMI:
Patient’s blood pressure was abnormally high as 140/92. According to the American Heart Association, the patient blood pressure may be categorized under Hypertension Stage 1 . Patient also has a slight temperature as revealed by his temperature of 99° taken orally. This was slightly higher than the normal 98.6°. Patient’s pulse rate of 80 bpm and respiration of 18bpm are within normal values. Patient’s height is 5 ft. 11inches tall and weighs 200lbs. The patient’s BMI was computed at 27.9 which falls under the classification of overweight.
Physical Assessment Findings:
Patient’s physical assessment revealed significant findings on patient’s rectal examination. The assessment revealed a light brown stool which tested positive or heme. Enlarged, boggy and tender to palpation are the description of patient’s prostate. There was also a Grade II/VI systolic murmur heard best at the right sternal border and abdominal measurement confirmed that he is overweight.
Lab Tests and Results:
Patient was tested for the level of prostate-specific antigen and the results came in positive with PSA value at 6. This rating is already classified as suspicious and is recommended for further test.
Patient has exhibit his readiness to learn what could have been causing the physical symptoms. In addition, patient is determined at evaluating the different inclusive sign and symptoms
ICD-9 Diagnoses/Client Problems:
According to the ICD 9, patient had been presented with the following diagnosis:
- 79093 - Elevated prostate specific antigen [PSA]
- 27802 – Overweight.
- 78862 – Slow urinary stream
Advanced Practice Nursing Intervention Plan (including interdisciplinary collaboration, community resources and follow-up plans):
As per the result of the ICD 9 evaluation of the symptoms, this paper is proposing a Nursing Intervention Plan.
- Aim: Patient needs to re-evaluate his definition and classification of what is healthy.
Rationale: This will help advance the situation and out the ill practices and restored by a new one.
- NIC 5510 Health Education
Patients’ needs to be able to distinguish healthy from not healthy. Physical attributes are not enough qualification for healthy.
- NIC 7400 Health System Guidance
- Aim : To identify what is significantly causing the elevated PSA and manage the findings.
Rationale: the elevated PSA of the patient is very alarming. There is the need to bring the value down and effectively manage the PSA level.
- NIC 0590 Urinary Elimination Management
Patient has trouble with elimination. Thus, it is recommended that the attending nurses and doctors are able to help management the urinary output
References
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
The American Heart Association. (2014, November 17). Understanding Blood Pressure Readings. Retrieved from The American Heart Association Website: http://www.heart.org/HEARTORG/Conditions/HighBloodPressure/AboutHighBloodPressure/Understanding-Blood-Pressure-Readings_UCM_301764_Article.jsp
Vallerand, A. H., & Sanoski, C. (2014). Davis's Drug Guide for Nurses. Philadelphia, Pennsylvania: F.A. Davis Company.
