Subjective Data
Client Complaints: Decreased urinary flow over the past two years; the condition turned acute during the last two weeks. Over this time, the client has been increasingly experiencing excessive nighttime urination urges while the urine flow strength has reduced. During the past 24 hours, the client has been struggling to pass urine while the nighttime urination frequency increased up to 5 times. The client reports the need to urinate and the difficulties in doing so are interference with his daily activities.
HPI (History of Present Illness): The client’s past experiences (from two years ago) are consistent with his current symptoms, the only difference being the gradual exacerbation of the condition and yesterday’s acuity.
PMH (Past Medical History—include current medications, any known allergies, any history of surgery or hospitalizations): The medications include Cardizem 240mg daily and Zocor 20mg daily for hypertension and hypercholesterolemia. Five years ago the client was hospitalized with chest wall syndrome. No other hospitalizations or surgeries occurred after the client’s discharge.
Significant Family History: No similar diseases reported.
Social/Personal History (occupation, lifestyle—diet, exercise, substance use): The client is an MS in engineering and working as one, with a yearly income of $65,000. Although his perceptions of his lifestyle and habits are not entirely adequate, he mostly eats homemade foods, does not consume alcohol or smoke.
Description of Client’s Support System: The client is emotionally supported by his spouse and colleagues but the family and work are the only sources of support he gets.
Behavioral or Nonverbal Messages: The client does not show any signs of depression or severe anxiety, has no mental health issues or substance abuse-related problems. He appears optimistic and has a positive body image. His distress with his disease is understandable as he suspects cancer.
Client Awareness of Abilities, Disease Process, Health Care Needs: His perception of self-efficacy is quite accurate. He takes his medications conscientiously and knows why and what for he is treated. However, his awareness of health care resources is poor as he does not use them as he should have, especially with his education level and socioeconomic status.
Objective Data
Vital Signs including BMI: Blood pressure in the right arm when seated – 140/92; temperature – 99; pulse – 80 and regular; respiration – 18, non-labored; weight – 200; height – 71’’; BMI – 29.5 (overweight).
Physical Assessment Findings: HEENT – normocephalic, atraumatic, EOM intact, pupils equal and react to light, no injections, no congestion, TM intact, oropharynx within normal limits, moist mucus membranes in the mouth, neck supple, thyroid within normal limits. No lymph nodes, clear lungs, no carotid bruits. Android obesity, no tenderness. The client is circumcised, with no discharges from the penis, testes within normal limits. Pulses slightly less than normal in the extremities (2+). Light-brown stool containing heme. Enlarged prostate, spongy and tender.
Lab Tests and Results: Chemistry panel and Complete blood count within normal limits. Prostate-specific antigen 6.0, calling for other tests.
Client’s Support System: The client’s support is confined to his family (spouse but not children) and his colleagues. He lives with his wife, with whom he maintains supportive relationships, and has several close friends, which he regards as important persons in his life. Although there are no familial dysfunctions or conflicts, he does not report being close to his children. The client’s spouse has been supposedly supportive in the past assisting the client in overcoming the surgery-related crisis. Notwithstanding the limited social support, the client does not experience much stress either at home or at work.
Client’s Locus of Control and Readiness to Learn: The client’s support is confined to his family (spouse but not children) and his colleagues. He lives with his wife, with whom he maintains supportive relationships, and has several close friends, which he regards as important persons in his life. Although there are no familial dysfunctions or conflicts, he does not report being close to his children. The client’s spouse has been supposedly supportive in the past assisting the client in overcoming the surgery-related crisis. Notwithstanding the limited social support, the client does not experience much stress either at home or at work.
ICD-10 Diagnoses/Client Problems: R39.12: Poor urinary stream with benign prostatic hyperplasia (ICD-10 Version: 2016, 2016).
Advanced Practice Nursing Intervention Plan (including interdisciplinary collaboration, community resources, and follow-up plans)
References
Abrams, P., Chapple, C., Khoury, S., Roehrborn, C., & de la Rosette, J. J. (2013). Evaluation and Treatment of Lower Urinary Tract Symptoms in Older Men. The Journal of Urology, 189(1), 93-101.
ICD-10 Version: 2016. (2016). Web.
Oelke, M., Bachmann, A, Descazeaud, A., Emberton, M., Gravas, S., Michel, M. C….de la Rosette, J. J. (2013). EAU Guidelines on the Treatment and Follow-up of Non-neurogenic Male Lower Urinary Tract Symptoms Including Benign Prostatic Obstruction. European Urology, 64(1), 118-140.
Review: Could Cardizem Cause Urine Flow Decreased? (2016). Web.
Review: Could Simvastatin Cause Urine Flow Decreased? (2016). Web.
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