{Author Name [first-name middle-name-initials last-name]}
{Institution Affiliation [name of Author’s institute]}
Care plan for a GU clinical Case
Patient Initials: ABC Age: 60 Sex: Male
Subjective Data:
HPI:
Decreased urinary flow, symptoms exist for last two years
Symptoms got worse in last two days
Patient has been suffering from increased nocturia from last two weeks
Slight terminal dysuria with weak strength of urinary flow
Significant difficulty in starting urine flow that impacts his routine actions
Passes urine four to five times during night
No symptoms of any radiating pain
Symptoms are turning severe
Patient feels mild fever yesterday
Severity of urinary obstruction led him to visit healthcare provider
PMH:
No diagnostic investigation or treatment has been taken in the past for the similar problem
Patient has only received medication for hypertension and hypercholesterolemia.
No history of heart disease
Patient was hospitalized five years back for a suspected case of angina, but his diagnosis exhibited the symptoms were related to chest wall syndrome
He received treatment for chest wall syndrome and post relief got released
No evidence of recent hospitalizations or surgeries.
ROS normal
Healthy abdomen, no nausea or vomiting, and normal stool
No gross hematuria
Patient is taking: Cardizem 240mg daily
Zocor 20mg daily
No known drug allergies
Significant Family History:
No history of family dysfunction
A distant history of cardiac problems among uncles and aunts
Social/Personal History
Patient owns a master’s degree in engineering
Annual income of $65,000.00
Financially stable with good access to healthcare
Patient is unaware of available resources and does not use the healthcare services to the fullest
Possessor of outstanding health insurance coverage with a prescription plan
Patient is married to a healthy person
Father of two grown-up, healthy sons who are 35 and 37 years old and live with their families
Unaware of healthcare facilities
Considers himself healthy and fit with sufficient self-efficacy
Very little stress and no depression
Patient lives in a suburban setting
Non-smoker and non-alcoholic; no substance use
Mostly eats at home and prefers healthy eating
Patient is confident that he is getting sufficient exercise with healthy diet
He insists that he maintains a regular checkup schedule to his healthcare provider
Engineer by profession and so always performed similar work
Description of Client’s Support System
The patient is highly occupied in responsibilities and has been an over achievers
Patient has strong financial and sufficient emotional support from wife and friends from workplace
Little social support from outsiders
Behavioral or Nonverbal Messages:
Patient is scared of having Cancer
Have complaints about prescribed medications
Patient thinks he knows sufficiently, about his health, diet, and exercise requirements
Similarly, he assumes about accessible healthcare amenities and insurance
Objective Data:
Vital Signs including BMI:
Wt: 200#; Ht: 71”, BMI: 27.9
Slightly overweight (BMI Calculator (Body Mass Index) - Adult Men, 2016)
Physical Assessment Findings:
Vital Signs: BP-140/92;
T: 99 po; P:80 and regular; R 18, non-labored;
HEENT: WNL Lymph Nodes: None Lungs: Clear
Abdomen: Android obesity, Carotids: No bruits;
Rectum: heme positive light brown Stool
Heart: RRR, Grade II/VI systolic murmur
Prostate enlarged, boggy and tender to palpation
Genital/Pelvic: Circumcised, no penial masses, lesions, or discharge.
Testes are normal, descended bilaterally, no tenderness or masses
Extremities, Including Pulses: 2+ pulse throughout,
Neurologic: Not examined, no edema in the lower legs.
Lab Tests and Results:
Lab Results PSA: 6.0, CBC: WNL Chem panel: WNL
Radiological Studies: None, EKG: None
Wife and friends from workplace; client does not much socialize
Highly educated, successful, confident, well-oriented
Aware of surroundings but health and related services
High internal locus of control, educated enough to understand the situation so expected to be ready to learn
ICD-10 Diagnoses/Client Problems:
According, to ICD-10 diagnosis the client’s problem is included under code N40-N51 Diseases of the genitourinary system or urinary system. Code N40-N51 covers male genital organs while N00-N39 includes every other problem relevant to urinary problems (Apps.who.int, 2016).
Advanced Practice Nursing Intervention Plan
Diagnosis: Patient may have been suffering from chronic prostatitis and Benign Prostate Hyperplasia. The symptoms of the client are indicating the probability of the urethral obstruction and restriction of the urinary flow due to the enlarged and boggy prostate. The age of the client and being overweight are additional risk factors (Rees, Abrahams, Doble & Cooper, 2015).
Desired Outcomes
Emptying of bladder in sufficient amount without any palpable bladder distension
Relief of pain or discomfort, the client looks relaxed and can sleep without interruption.
Maintain enough hydration
Articulate, precise knowledge of the situation and patient can feel stress-free with reduced anxiety and fear. An open conversation made to describe disease process, prognosis, and whole treatment. The patient is motivated to bring changes in lifestyle and interact with physicians without hesitation.
Intervention Plan
References
Avery, K. N., Donovan, J. L., Horwood, J., Neal, D. E., Hamdy, F. C., Parker, C., & Lane, A.
(2014). The importance of dietary change for men diagnosed with and at risk of prostate
cancer: a multi-centre interview study with men, their partners and health
professionals. BMC family practice,15(1), 81.
Apps.who.int,. (2016). ICD-10 Version:2016. Retrieved 27 January 2016, from
http://apps.who.int/classifications/icd10/browse/2016/en
BMI Calculator (Body Mass Index) - Adult Men, T. (2016). BMI Calculator (Body Mass Index)
– Adult Men, Women, Teens & Kids. Halls.md. Retrieved 27 January 2016, from
http://halls.md/body-mass-index/av.htm
Rees, J., Abrahams, M., Doble, A., & Cooper, A. (2015). Diagnosis and treatment of chronic
bacterial prostatitis and chronic prostatitis/chronic pelvic pain syndrome: a consensus
guideline. BJU international.
