Patient Initials: PK Age: 60 years Sex: Male
Subjective Data
Client Complaints: Patient reported to clinic complaining of decreased urinary flow, nocturia and dysuria. Patient has been experiencing these symptoms for two years but they have worsened in the past two weeks. He has not experienced any form of radiating pain.
Significant Family History: Patient was born in the United States and has one sister and one brother. He has two sons, who are both married. There was no report of a dysfunctional family.
Client’s support system: Wife and friends from work.
Behavioral or Nonverbal Messages: The patient believes he could be suffering from prostate cancer, based on recent symptoms.
Client awareness of abilities, disease process, health care needs
He is well educated and has a Master’s degree in Engineering, but he is not properly informed about the healthcare resources at his disposal. He is an over-achiever and is satisfied with his life. Patient believes he is generally healthy and that he gets adequate exercises. He sees his physician regularly.
Objective Data
Vital Signs: Blood Pressure: 140/92 right/sitting, T: 99 po; P: 80 and regular; R 18, non-labored; Wt: 200#; Ht: 71”.
History of Hypertension, Hypercholesterolemia, suspected angina, costochondritis. Denies using alcohol, drugs and cigarettes. There is a history of heart disease in his family with his aunts and uncles having suffered it before.
Current medications
- Cardizem 240mg daily
- Zocor 20mg daily
Physical assessment findings
The patient was anxious during the examination but no acute distress was detected.
Low grade fever:
- Abdomen: android obesity non-tender.
- Rectum: stool light brown, heme positive.
- Lungs: Clear
Prostate enlarged boggy and tender to palpitation:
- Heart: RRR with Grade II/VI murmur heard best at the right sternal border.
Neurologic not assessed:
- Genital/Pelvic: No penial lesions, masses, or discharge.
- Extremities: No edema in the lower legs.
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: The patient is well educated and he is ready to learn. He has a strong support system, which will also help in the treatment process.
ICD-9 Diagnoses/Client Problems
- Unspecified essential hypertension 401.9
- Hypercholesterolemia 272.0
- Elevated PSA 790.93
- Blood in stool 578.1
- Heart disease unspecified 429.9
- Prostatitis 601.9
- Prostate hypertrophy 600.01
- Slow urine stream 788.69
- Nocturia 788.43
- Dysuria 788.1
- Anxiety state unspecified 300.00
- Insomnia state unspecified 780.52
- Undiagnosed cardiac murmur 788.2
- Slow of urine stream 788.69
- Urinary frequency 788.41
Advanced practice nursing intervention plan
Clerk the patient for a complete medical history including sexual behavior.
Assess Benign Prostatic Hyperplasia, guided by the American Urological Association Symptom Index.
Review the medication being used for efficacy. Possibly add more medication to reduce the blood pressure. The later recourse, however, depends on the outcome of the BPH analysis.
Refer to cardiologist for echocardiogram.
Refer to urologist for evaluation and pelvic ultrasound.
Consider prescribing an antibiotic for suspected prostatitis.
Consider prescribing an analgesic for the pain.
Order
- STI screen
- U/A with c/s
- ECG
Consider a colonoscopy to check the blood in the stool if patient.
Refer to nutritionist to manage the blood pressure and cholesterol levels.
Refer to counsellor to deal with any incidence of depression and anxiety due to the illness.
Education and Counseling
The patient needs to be properly informed of the plan and the importance of compliance. The patient needs to understand the importance of committing to all medication that is prescribed. The patient needs to be aware of the dangerous symptoms to look out for. He should also be advised to see a doctor anytime he notices something unusual.
Any kinds of foods and drinks that may worsen the situation should be discouraged among them alcohol and caffeinated drinks. The patient should be advised to stick to recommended healthy diets, which should have low salt content.
The patient should be encouraged to use protection as a way of preventing bacterial contamination between him and his partner.
The patient’s wife should also be advised to regularly monitor the patient and report any symptoms. If possible, his friends from work should also be encouraged to keep an eye on the patient. The members of the patient’s support system need to be encouraged to regularly keep him company, in order to reduce incidence of him getting stressed. Follow up should be done after one week to re-assess the symptoms.
Rationale
The patient came in complaining of nocturia, terminal dysuria and fever.
Patient presents in clinic complaining of increased symptoms of nocturia, frequency. A physical examination showed that his prostate was enlarged, boggy and tender. His PSA is 6.0.
Differential diagnosis includes obstruction, UTI, acute prostatitis, and prostate cancer.
Cancer was ruled out because although the patient presented with hesitancy and fever, hematuria and back pain, which usually present in CA diagnoses, were not reported (Buttaro, et al. 2013). In addition, no asymmetrical enlargement of the prostate gland was detected.
Acute prostatitis is detected by elevated PSA levels, enlarged and tender prostate, fever, chills, malaise, frequency nocturia, and dysuria (Buttaro, et al. 2013). An analgesic, antipyretic and antibiotic could help relieve acute prostatitis.
Chronic prostatitis comes with a tender and boggy prostate frequency nocturia, and dysuria. Patients with an elevated PSA and prostatitis should be treated with antibiotics for 4-6 weeks followed by a re-evaluation (Shoskes, 2008). Dietary changes are recommended and foods to avoid are hot spices, strong acids, coffee, alcohol, and acidic juices (Daniels and Nicoll, 2011).However, the patient needs to be assessed by a urologist to rule out cancer, calculi, obstruction and stricture (Buttaro, et al. 2013).
Assessing the patient’s sexual behavior will help to rule out any sexual transmitted infections and any form of bladder infections.
The patient should have a neurologic examination in order to rule out incidence of nerve injury that could be associated with neurogenic bladder.
A colonoscopy should be done to rule out colon cancer because there was blood in the patient’s stool.
The patient has been taking his blood pressure medication as required but his readings are still on the higher side. The increase in blood pressure could be related to the stress the patient has been experiencing in the past two weeks.
Prescribing additional BP medication should be considered. An alpha antagonist such as doxazosin can help reduce BP and treat BPH (Lehne, 2013).
Referrals
The patient should urgently see a urology specialist for prostatitis and STI tests.
The patient should see a nutritionist for guidance on proper diet.
Patient needs to see a cardiologist to check the systolic heart murmur.
The patient needs to see a gastroenterologist to find out the cause of the heme positive reading.
Reference list
Buttaro, T., Trybulski, J., Bailey, P., & Sandberg-Cook, J. (2013). Primary Care. St. Louis, Missouri: Elsevier Mosby.
Daniels, R. & Nicoll, L. (2011). Contemporary Medical-Surgical Nursing. Boston: Cengage Learning.
Lehne, R.A. (2013). Pharmacology for nursing care. St. Louis, MO: Elsevier.
Shoskes, D.A. (2008). Chronic Prostatitis/Chronic Pelvic Pain Syndrome. Berlin: Springer Science & Business Media.