Care Plan: Genitourinary Case Essay

Subjective Data

Client Complaints: The patient reports decreased urinary flow and dysuria, but there is no radiating pain.

HPI: The symptoms have worsened during two recent weeks. The patient reports increased nocturia, decreased strength of the urinary flow, and terminal dysuria. A low-grade fever is observed. There is no abdominal pain, blood in the stool, or gross hematuria.

PMH: The symptoms are observed for two years, and there was no treatment. The patient has a history of hypertension, hypercholesterolemia, and chest wall syndrome. He takes Cardizem (240 mg daily) and Zocor (20 mg daily), NKDA.

Significant Family History: He has a sister and a brother without health problems. Heart disease was observed in aunts and uncles.

Social/Personal History: The patient is married and has two sons. He has a Master’s degree in Engineering. He does not smoke or drink, reports healthy eating habits, but exercise is not adequate.

Description of Client’s Support System: The patient does not understand what healthcare resources are available and how to utilize the provided services. The support system includes the wife and colleagues. The health insurance coverage is appropriate to address his needs.

Behavioral or Nonverbal Messages: The patient is concerned regarding the possibility of having cancer.

Client Awareness of Abilities, Disease Process, and Health Care Needs: The patient lacks the understanding of his healthcare problems and the resources available to address them.

Objective Data

Vital Signs including BMI: BP 140/92, right arm; T: 99°F; P: 80, regular; R 18, non-labored, BMI = 28.

Physical Assessment Findings: Heart: RRR, Grade-II/VI systolic murmur, the right sternal border. Carotids: No bruits. Android obesity. Rectum: light brown heme positive stool. The prostate is boggy and enlarged, tender to palpation. No penial lesions or discharges.

Lab Tests and Results: PSA: 6.0, CBC: WNL, EKG: None.

Client’s Support System: The patient contacts the physician, and his wife is in a good health.

Client’s Locus of Control and Readiness to Learn: The patient does not understand why he needs to take medications, as well as the causes and consequences of the observed symptoms.

ICD-10 Diagnoses/Client Problems

• D291 Benign neoplasm of the prostate;
• N410 Acute prostatitis;
• N411 Chronic prostatitis;
• N390 Urinary tract infection, site not specified;
• R972 Elevated prostate-specific antigen [PSA];
• R351 Nocturia;
• R300 Dysuria;
• I10 Essential (primary) hypertension;
• E663 Overweight;
• Z8249 Family history of ischemic heart disease and other diseases of the circulatory system;
• E780 Pure hypercholesterolemia;
• E785 Hyperlipidemia, unspecified (Centers for Medicare and Medicaid Services, 2016);
• Costochondritis (chest wall syndrome);
• Aortic valve stenosis.

Advanced Practice Nursing Intervention Plan

Goal and Outcomes: The patient will cope with the present problems related to dysuria and nocturia, control the BP and cholesterol, and maintain the weight.

Interventions

1. Benign Prostatic Hyperplasia (BPH), Prostatitis, Urinary Tract Infections (UTIs), Dysuria, Nocturia, Elevated PSA.

1. Diagnostic Tests:
   1. Urinalysis;
   2. Ultrasound testing to examine the bladder;
   3. Biopsy;
   4. Testing for UTIs and sexually transmitted diseases (STDs).
2. Medications: Antibiotics to address UTIs, STDs, or bacterial prostatitis (ciprofloxacin); alpha-blockers (terazosin); DHT inhibitors.
3. Conservative treatment: The bed rest; the diet without acids and spices; warm baths.

Education: Educate the patient regarding the antibiotic treatment; the necessity of voiding every 2-3 hours; the importance of hygiene; the importance of observing the urinary stream; the use of condoms; the diet. Educate regarding the symptoms to decrease the level of anxiety.

Rationale: The comparably high PSA is often discussed as one of the indicators of cancer. In addition, the patient has a heme-positive stool, and this abnormal condition can also be associated with cancer (Pontari & Giusto, 2013). Therefore, the ultrasound tests for investigating the bladder and the biopsy are required to conclude about the presence of BPH and differentiate the diagnosis because of risks associated with the patient’s age (Parsons, Sarma, McVary, & Wei, 2013). The focus on UTIs is important because of the observed fever.

2. Hypertension, Hypercholesterolemia, Hyperlipidemia, Costochondritis, Aortic valve stenosis, Overweight.

1. Diagnostic Tests:
   1. EKG;
   2. tests to check the level of cholesterol and lipids;
   3. BP monitoring.
2. Medications: Continue taking Cardizem (240 mg daily) and Zocor (20 mg daily).
3. Conservative treatment: The low-fat and highly nutritional diet decreases the levels of cholesterol and increases the value of the food.

Education: Self-monitoring regarding the diet and measuring BP. The male should weigh and measure BP daily and control changes in a diary.

Rationale: Constant monitoring is important to check changes associated with Aortic valve stenosis (Silverman & Gertz, 2015). In addition, the patient requires the constant control over the levels of cholesterol and changes in BP in order to predict the development of heart diseases (Wadden, Webb, Moran, & Bailer, 2012; Weisbrod, Shiang, Fry, & Bajpai, 2013).

3. Heme positive stool.

Diagnostic Tests:

1. Examination of the rectum;
2. tests to rule out GI problems.

Rationale: The presence of blood or the heme-positive stool can indicate a variety of problems in the organism, and additional tests are required (Moreno, Mittal, Sullivan, Rutherford, & Staley, 2015). It is also important to rule out colorectal cancer.

Collaboration and referrals:

1. Urologist – ultrasound testing;
2. Cardiologist – EKG;
3. Nutritionist – develop the diet to manage the BP and cholesterol levels;
4. Gastroenterologist – colonoscopy.

Follow-ups: In three and six weeks during and after taking antibiotics; in four weeks – to evaluate the weight and cholesterol levels.

References

Centers for Medicare and Medicaid Services. (2016). 2016 ICD-10-CM and GEMs. Web.

Moreno, C. C., Mittal, P. K., Sullivan, P. S., Rutherford, R., & Staley, C. A. (2015). Colorectal Cancer initial diagnosis: Screening colonoscopy, diagnostic colonoscopy, or emergent surgery, and tumor stage and size at initial presentation. Clinical Colorectal Cancer, 15(1), 67-73.

Parsons, J. K., Sarma, A. V., McVary, K., & Wei, J. T. (2013). Obesity and benign prostatic hyperplasia: Clinical connections, emerging etiological paradigms and future directions. The Journal of Urology, 189(1), 102-106.

Pontari, M., & Giusto, L. (2013). New developments in the diagnosis and treatment of chronic prostatitis/chronic pelvic pain syndrome. Current Opinion in Urology, 23(6), 565-569.

Silverman, B., & Gertz, A. (2015). The present role of the precordial examination inpatient care. The American Journal of Cardiology, 115(2), 253-255.

Wadden, T. A., Webb, V. L., Moran, C. H., & Bailer, B. A. (2012). Lifestyle modification for obesity new developments in diet, physical activity, and behavior therapy. Circulation, 125(9), 1157-1170.

Weisbrod, R. M., Shiang, T., Fry, J. L., & Bajpai, S. (2013). Arterial stiffening precedes systolic hypertension in diet-induced obesity. Hypertension, 62(6), 1105-1110.