Subjective Data
Client Complaints: acute abdominal pain, gnawing and acute umbilical pain, nausea without vomiting, last night fever, heartburn.
HPI (History of Present Illness): The patient thinks he has a heart attack in addition to umbilical and abdomen pain. He had the same symptoms during the past 24 hours that could subside after sitting on a chair for several hours.
PMH (Past Medical History—include current medications, any known allergies, any history of surgery or hospitalizations): The patient has three health problems: hypercholesterolemia, hypertension, and gout. As he was young, he had stomach problems. 20 years ago, he had appendectomy without any complications. To control his gout problems, he uses non steroidal anti-inflammatory drugs. No drug allergies. He was prescribed Indocin 50 mg Q, Zocor 20 mg QD, and Propanolol 50 mg BID, but does not follow the regimen set. He uses Saint John’s wort 3 times a day as an alternative therapy to avoid depression.
Significant Family History: gout problems; two older brothers with blood pressure and high cholesterol problems. His father died at the age of 60 because of a heart attack.
Social/Personal History (occupation, lifestyle—diet, exercise, substance use): The patient is a retired teacher, who does some teaching on the side. His and his wife’s (who is working at a grocery shop) medium income is $50,000 per year. They are satisfied with their life and finance. Though, they would like to have more money for travelling, they do not want to change their lifestyle. They have good relations with their two children (a son and a daughter), who live outside. The patient does not have special hobbies; he likes doing something around the house. He refuses the use of tobacco and drugs, but drinks wine every evening. His wife prefers healthy food at home, but he uses fast food frequently.
Description of Client’s Support System: He has a health insurance that covers any prescription. In spite of the fact that his wife with osteoarthritis of both knees and hips, she becomes his best support as well as several colleagues.
Behavioral or Nonverbal Messages: The patient may get anxious easily but does not show it.
Client Awareness of Abilities, Disease Process, Health Care Needs: He has an access to his primary care provider and visits him 3-4 times per year.
Objective Data
Vital Signs including BMI: blood pressure 175/70, pulse – 64, temperature – 99.0, respirations – 18 (non-labored), BMI – impossible to identify as no weight or height data.
Physical Assessment Findings: within normal limits
Lab Tests and Results: light brown stool, negative heme, amylase and lipase, CBC and LFTs within normal limits, positive H.pylori, EKG – normal sinus rhythm.
Client’s Support System: The patient is informed that some medicines may considerably improve his health, still, he is not usually compliant with the pieces of advice given because he learns a lot about the negative side effects of medications (Girdwain, 2013).
Client’s Locus of Control and Readiness to Learn: The patient does not want to follow his father example and die at 60s. He is ready to be treated the way it will be prescribed.
ICD-9 Diagnoses/Client Problems
- 536.1 – acute dilatation of stomach (Centers for Medicare & Medical Services, 2014)
- 536.9 – unspecified functional disorder of stomach
- 274.04 – acute gouty arthropathy
- V77.8 – screening for obesity
- 29.19 – unspecified alcohol-induced mental disorders
Advanced Practice Nursing Intervention Plan
- High blood pressure control as he had some problems in the past.
- Obesity control as he likes fast food.
- Discussions of his wine addiction to reduce the use of alcohol at his age.
- Necessity to go outdoors and improve mobility to avoid bowel movement problems.
- The use of prescribed medicines to reduce pain.
- Prevention of obesity and hypertension as it decreases the cases of gout (Singh, Reddy, & Kundukulam, 2011).
- Cooperation with nurses, who can help to identify the deviation factors and overcome possible health problems (Doenges, Moorehouse, & Murr, 2014).
Reference List
Centers for Medicare & Medical Services. (2014). ICD-9 Code Lookup. Web.
Doenges, M., Moorehouse, M., & Murr, A. (2014). Nursing care plans: Guidelines for individualizing client care across the life span. Philadelphia: F.A. Davis Company.
Girdwain, J. (2013). Surprising good side effects of your meds. AARP. Web.
Singh, J.A., Reddy, S.G., & Kundukulam, J. (2011). Risk factors for gout and prevention: A systematic review of the literature. Current Opinion in Rheumatology, 23(2), 192-202.