Patient initials: MK Age: 60 Sex: M
Care Plan
Subjective
MK, the patient presents with a chief complaint of decreased urinary flow but has also had troublesome nocturia for the last two weeks as well as significant terminal dysuria.
History of present illness: Patients states that in the past day he has had significant difficulties especially in starting his urine flow and this has affected his ability to enrage in normal daily activities. Patient denies radiating pain.
Patient history: Patient has had a history of hypertension, hypercholesterolemia, costochondritis, as well as suspected angina characterized by chest wall syndrome which was however treated.
Significant family history: There is also a probable positive family history for cardiovascular or heart diseases
Objective:
Patient is a 60 y/o, Hispanic male of American originality
Vital signs as follows; BP at 140/92; Pulse rate: 80; Temperature: 99.0 Weight = 200 pounds; height = 71”, BMI = 27.9
Medication list at present
Cardizem 240mg QD
Zocor 20mg QD
Current Labs findings:
PSA 6.0
CBC WNL
Chem panel WNL
CXR – none
EKG – None
Physical Examination:
Patient demonstrates reasonable anxiety with no acute distress
Patient has low grade fever
Abdomen:
Android obesity, non-tender
Rectum:
Light brown stool, heme positive
Prostate:
Enlarged boggy, tenderness on palpitation
Heart:
RRR, with right sterna border Grade II/IV murmurs,
ROS within normal range
Psychosocial assessment and support systems:
MK is a US resident of Hispanic descent who lives in a suburban setting. He is married and has lived with the wife for a significantly long period of time and they both have excellent general health. MK has two sons who are doing well and living with theater families independently. Financially, MK is stable and he earns enough money to sustain a qulaoyt life for himself and the wife. He has a master’s in Engineering as part of his excellent educational background though he seemingly lacks extensive health knowledge. MK has a medical cover and he regularly sees his primary physician for assessment, checkups and evaluation.
Nutrition and exercise:
The patient takes most of his meals as prepared by the wife and he maintains that he gets enough exercise and activity suitable for his health.
Diagnoses:
272.0 Hypercholesterolemia
790.3 Elevated PSA
785.2 Undiagnosed cardiac murmur
578.1 Blood in stool
601.0 Acute Prostatitis
600.00 Hypertrophy of prostate
300.00 Anxiety state unspecified
327.01 Insomnia due to a medical condition classified elsewhere
401.9 Unspecified essential hypertension
599.00 UTI- Site not specified
Advanced Practice Nursing Intervention Plan
Consider the addition of a broad-spectrum antibiotic medication for prostatitis such as ciprofloxacin (Taylor & Gosney, 2011).
Consider the need for an antipyretic or analgesics for the management of pain and fever. Paracetamol or ibuprofen can do well for the patient (Jarvis, 2015)
Include medication for management of blood pressure preferably an alpha blocker such as doxazosin (Cardura)
Utilize a standard tool for assessment of benign prostatic hyperplasia (BPH) preferably the AUA BPH symptom index (Roehrborn, 2011)
Extensively evaluate the medical history of the patient in focus areas that is the bowel changes, bladder habits, sexual behaviors and mental/cognitive state (Jarvis, 2015)
A neurologic examination will be necessary to determine or rule out a neurologic disorder
Perform an ultrasound examination of the pelvic and refer the patient to an urologist
Perform an ECG and refer the patient to cardiologist for the appropriate determination of the causes of the murmurs (Jarvis, 2015)
Order:
STI screen
Electrocardiogram
Urinalysis with culture and sensitivity (U/A with c/s) (Taylor & Gosney, 2011)
Colonoscopy for the heme stool
Mental health provider and obstetrician for management of the changing sexual life, sexual dysfunction, and the associated issues of depression, insomnia and anxiety (Roehrborn, 2011)
Dietician/nutritionist advice for management of BP and cholesterol issues
A gastroenterologist to help follow up on the heme-positive findings
Education and Counseling:
The broad-spectrum antibiotic dosage calls for strict adherence to ensure reasonable period for administration and thus patient should be well advised on adherence to entire medication regimen (Jarvis, 2015).
On the BP and the major diseases or conditions the patient has, he will be informed of the disease process to ensure he can monitor any changes and report them appropriately (Jarvis, 2015)
Assist the patient recognize and identify with foods, drinks or environments that aggravate the illnesses and help develop avoidance strategies
Assist the patient develop an appropriate dietary plan especially by providing them with the basic knowledge on the food guide pyramid so that they can choose low-fat, low salt and low-sugar foods
Advice and help the patient appreciate new sexual behaviors such as condom use to ensure they are on the safe side in managing the bacterial infections (Taylor & Gosney, 2011)
Develop a regular checkup program for the patient preferably every two weeks
Rationale
Acute bacterial prostatitis is typically an infection caused by bacteria within the lower urethra and it is characterized by frequency, hesitancy and urgency of urination, nocturia, dysuria, a sensation of an incomplete bladder with elevated PSA levels (Anothaisintawee et al., 2011). Ciprofloxacin, ofloxacin and levofloxacin are the most common medications for such cases with a dosage that extends to about 4 weeks and an accompanying reevaluation (Roehrborn, 2011).
On the heme positive examination, there was indication of light brown stool which implied that the patient was positive for heme-positive stool. There is a need for a further digital examination of the rectum and anus region to determine any possible cases of tumors. On the other hand, a complete blood count would be necessary to determine any possibility of anemia. The need for a colonoscopy test is based on the American cancer society’s recommendation that adults beyond the age of 50 years should consider regular or routine tests to determine any possibility of colorectal and colon cancers (Jarvis, 2015).
References
Anothaisintawee, T., Attia, J., Nickel, J. C., Thammakraisorn, S., Numthavaj, P., McEvoy, M., & Thakkinstian, A. (2011). Management of chronic prostatitis/chronic pelvic pain syndrome: a systematic review and network meta-analysis. JAmA, 305(1), 78-86.
Jarvis, C. (2015). Physical examination & health assessment (6th ed.). St. Louis, MO: Saunders Elsevier.
Roehrborn, C. G. (2011). Male lower urinary tract symptoms (LUTS) and benign prostatic hyperplasia (BPH). Medical Clinics of North America, 95(1), 87-100.
Taylor, A., & Gosney, M. A. (2011). Sexuality in older age: essential considerations for healthcare professionals. Age and Ageing, afr049.
