HPI (History of Present Illness): the patient experiences the complications within last two weeks while he experienced the above symptoms during last two years. The patient received no treatment in the past. He had serious difficulties in starting his urine flow yesterday. Moreover, he has to pass urine four to five times per night. Consequently, the patient urinates often and has to be aware of the nearest restrooms.
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PMH (Past Medical History): The patient had the treatment for hypertension and hypercholesterolemia, but no treatment for his current disease. Five years ago, he was hospitalized suspected in angina. The patient considers that he has fever and suspects cancer. The deterioration in the state of health forced him to seek medical help. The following medications are taken daily by the patient: Cardizem 240mg and Zocor 20mg. There are no known drug allergies.
Significant Family History: The patient is married. His family consisting of his spouse and two sons of 35 and 37 years old is healthy. Some of his aunts and uncles suffered from heart disease.
Social/Personal History: The patient is an engineer with $ 65,000 income per year. He has full access to the healthcare services yet does not use them appropriately. The client lives in a suburban area; he does not smoke and drink alcohol, denies substance abuse, and gets exercises. His diet habits are healthy.
Description of Client’s Support System: The patient’s family and friends support his emotional system. He needs little outside social support as he is an over achiever.
Behavioral or Nonverbal Messages: The client expresses some confusion, yet generally he is quite confident in his health.
Client Awareness of Abilities, Disease Process, Health Care Needs: The patient thinks that he is well in general. He’s awareness of healthcare, health insurance, and self-efficiency is adequate.
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Vital Signs including BMI: BP right arm sitting 140/92; T: 99 po; P:80 and regular; R 18, non-labored; Wt: 200#; Ht: 71”.
Physical Assessment Findings: The patient’s lungs and carotids are clear. His heart has RRR with Grade II/VI systolic murmur heard best at the right sternal border. There is an android obesity. The rectum is normal, stool is brown, and prostate is enlarged and boggy.
Lab Tests and Results: PSA: 6.0, CBC: WNL, Chem panel: WNL, Radiological Studies: None, EKG: None.
Client’s Locus of Control and Readiness to Learn: He is ready to learn but not aware of the services available to him.
ICD-10 Diagnoses/Client Problems
- R35.1: Nocturia – need to urinate 4 to 5 times per night.
- R30.0: Dysuria – reported slight terminal dysuria.
- R35.0: Urinary frequency as the patient complains of urinating frequently.
- N41.0: Prostatitis is based on the above diagnoses and fever. Besides, palpation detected enlarged, boggy, and tender prostate.
- R97.2: Elevated PSA was detected according to lab results.
- I51.9: Heart Disease due to the objective data collected of a systolic murmur.
- E78.0: Hypercholesterolemia is based on taking Zocor 20 mg daily and the client’s PMH.
- I10: Hypertension is based on taking Cardizem 240 mg daily and the client’s PMH.
- E66.3: Overweight as the android abdomen obesity was detected and patient’s BMI is exceeded.
- R19.5: Blood in Stool – light brown stool.
- F41.9: Anxiety is based on patient’s report that he could have cancer.
Advanced Practice Nursing Intervention Plan
Taking into account all the above diagnoses, it is necessary to develop a comprehensive intervention plan reducing the patient’s chronic diseases and preventing potential complications. First, it is essential that an interdisciplinary collaboration should help the patient to achieve the better outcome. Such specialists as cardiologist, urologist, proctologist, and gastroenterologist should consult the patient and evaluate his symptoms as well as prescribe new analyses for the further treatment.
Speaking of the patient’s primary symptoms including decreased urinary flow, increased nocturia, and slight terminal dysuria, it is possible to discharge him alpha 1-adrenergic antagonists or inhibitors of 5a-reductase (Gratzke, Hennenberg, & Stief, 2014).
These medications can also be combined with each other. The dysuria treatment is usually prescribed after careful diagnosis of the doctor, which can include various types of surveys: a clinical analysis of urine, cystoscopy, and cystography. In order to optimize the patient’s night rest, it is possible to prescribe light hypnotic. Prostatitis treatment should be comprehensive and well-chosen. For example, antibacterial therapy, prostate massage, physiotherapy, and lifestyle correction might be used (Nickel, 2011). Only the complex of interventions can lead to the desired effect.
The patient needs rest period due to heart disease. Hypertension, hypercholesterolemia, heart disease, and obesity require the proper dietary nutrition (Gearhardt, Grilo, DiLeone, Brownell, & Potenza, 2011). In the treatment of hypertension, several major drug classes might be used involving beta blockers, diuretics, calcium antagonists, ACE inhibitors, blockers of alpha-1-adrenergic receptors, and angiotensin II receptor blockers.
However, all medications have contraindications, side effects, and characteristic features. In this connection, it is necessary to count for the patient’s detailed blood and urine analyses to prescribe fixed-dose combination (Wan, Ma, & Zhang, 2014). To avoid excess cholesterol in the diet, the patient should choose lean meat, vegetable products, and discard the processed meat. Saturated fats that significantly increase cholesterol are generally contained in foods of animal origin. On the contrary, vegetable fats make beneficial effect on cholesterol and promote its reduction. In other words, there should be a proper balanced diet to prevent cholesterol increase in blood. It is also important to pass colonoscopy to exclude the probability of the colon cancer.
What is more, it is necessary to explain the patient that he should follow the regimen and might appeal to available services if required.
Gearhardt, A. N., Grilo, C. M., DiLeone, R. J., Brownell, K. D., & Potenza, M. N. (2011). Can food be addictive? Public health and policy implications. Addiction, 106(7), 1208-1212.
Gratzke, C., Hennenberg, M., & Stief, C. (2014). Pharmacology of the lower urinary tract. Indian Journal of Urology, 30(2), 181-186.
Nickel, J. C. (2011). Prostatitis. Canadian Urological Association Journal, 5(5), 306-315.
Wan, X., Ma, P., & Zhang, X. (2014). A promising choice in hypertension treatment: Fixed-dose combinations. Asian Journal of Pharmaceutical Sciences, 9(1), 1-7.