Advanced Nursing Practice I Custom Essay

1. Please do this: review the care plan of two peers and provide constructive feedback. ( please provide one paragraph and one reference for each peer care plan; so total 2 paragraphs and 2 citations. Thank

you)

Week 4: Genitourinary Clinical Case

HPI
A 60-year-old Hispanic male presents with the chief complaint of decreased urinary flow. The patient has been experiencing this over the past two years, but for the past two weeks, the symptoms have

increased significantly. The current symptoms are similar to what he experienced in the past. However, for the past two weeks, he has had increased nocturia with decreased strength of urinary flow and slight

terminal dysuria. Patient has had no treatment in the past. The nocturia has been very troublesome over the past two weeks. Yesterday he had significant difficulty in starting his urine flow and this is interfering

with daily activities. He needs to pass urine four to five times every night. He has been urinating frequently and always needs to know if there are bathrooms around.

Patient does not complain of any other radiating pain. He has had no treatment or diagnostic work up in the past, but now the symptoms have been increasing in severity. He believes he had a low-grade fever

yesterday. The patient is not sure what is going on but thinks he may have cancer. He had significant obstructive symptoms two days ago. Gradual worsening of symptoms has compelled him to seek medical

help now.

PMH
Patient has not sought any medical care for this problem to date. He is being treated for hypertension and hypercholesterolemia. There is no known history of heart disease, but he was hospitalized five years

ago as a suspected case of angina. He was diagnosed with chest wall syndrome for which he was treated and then released. There are no recent hospitalizations and no surgeries.

ROS
Denies any other positive review of systems. Denies abdominal pain, nausea or vomiting. No blood in the stool. No gross hematuria.

MEDICATIONS
Cardizem 240mg daily Zocor 20mg daily
Patient is compliant with the prescribed regimen and knows why he is being treated.

ALLERGIES/REACTIONS
No known drug allergies

SOCIAL HISTORY
Patient has a master’s degree in engineering and his income is $65,000.00 per year. Though the patient is educated, he lacks an understanding of resources available to him. Patient has no problems with

finances. He has excellent access to healthcare, but most often does not utilize the services to the extent that is expected. He has an excellent health insurance coverage including a prescription plan.

Patient is married and his spouse has excellent general health. He has two grown-up sons who live with their own families. They are 35 and 37 years old, both alive and well. Although the patient has a master’s

in engineering, his knowledge of healthcare is inadequate. He believes that he is generally healthy.

His perception of self-efficacy is adequate. He has very little stress. His support systems include his wife and friends from work who provide him with the required emotional support. There is no family

dysfunction. The patient is high strung and an over achiever. He gets little from social support outside the home or work.

Patient is originally from United States. He lives in a suburban setting. His resources include his wife and the people he works with. Though there are other resources available to him, he is not sure what they

are.

HABITS
Smoking: Non smoker Alcohol: Does not drink
Substance use: Denies substance abuse

DIET HABITS
His wife does most of the cooking. He believes that he gets adequate exercise, eats healthy, and maintains a regular checkup regime with his physician.

WORK HABITS
He is an engineer and has always done the same work.

FAMILY HISTORY
He has one sister and one brother. Both are alive and well. There is a remote history of heart disease among his aunts and uncles.

PHYSICAL EXAMINTAION

Vital Signs: BP right arm sitting 140/92; T: 99 po; P:80 and regular; R 18, non-labored; Wt: 200#; Ht: 71”

HEENT: WNL

Lymph Nodes: None Lungs: Clear
Heart: RRR with Grade II/VI systolic murmur heard best at the right sternal border Carotids: No bruits
Abdomen: Android obesity, non-tender

Rectum: Stool light brown, heme positive. Prostate enlarged, boggy and tender to palpation.

Genital/Pelvic: Circumcised, no penial lesions, masses, or discharge.Testes are descended bilaterally, no tenderness or masses

Extremities, Including Pulses: 2+ pulse throughout, no edema in the lower legs.

Neurologic: Not examined

Lab Results/Radiological Studies/EKG Interpretation

Lab Results PSA: 6.0 CBC: WNL
Chem panel: WNL Radiological Studies: None EKG: None

Peer #1 Jean
Care Plan
Patient JD
Age 60
Sex M
S. Pt presented in clinic c/o decreased urinary flow, nocturia, decreased flow and terminal dysuria. Pt stated that he has had these symptoms for the past two years but they increased significantly in the past

two weeks. He denies any radiating pain.
O. 60 y/o Hispanic male, VS BP: 140/92 left/sitting, P: 80, T: 99.0, Wt: 200#, Ht: 71”, BMI 27.9. Hx of Hypertension, Hypercholesterolemia, suspected angina, costochondritis. Denies alcohol use, drug use

or tobacco use. Possible family hx of heart disease. NKDA. Current medications:
• Cardizem 240mg QD
• Zocor 20mg QD
Current Labs:
• PSA 6.0
• CBC WNL
• Chem panel WNL
CXR – none
EKG – None
A. On physical examination pt anxious with no acute distress noted. Low grade fever. Abdomen: android obesity non-tender. Rectum: stool light brown, heme positive. Prostate enlarged boggy and tender to

palpitation. Heart: RRR with Grade II/VI murmur heard best at the right sternal border.
ROS otherwise normal, neurologic not assessed
Psycho/Social assessment: Pt is originally from the US, married and lives with his wife. He has two grown sons who are alive and well with families of their own. He has a master’s degree in engineering. He

lives in a suburban setting, experiences very little stress and has a strong support system of family and friends. He is financially stable with excellent health insurance coverage. He sees his primary physician on a

regular basis.
Although he is well educated he lacks health literacy. He is unaware of resources available to him. Pt is compliant with mediation regime.
Nutrition and exercise: His wife cooks most of his meals. He feels he gets adequate exercise.
Diagnoses:
401.9 Unspecified essential hypertension
272.0 Hypercholesterolemia
790.3 Elevated PSA
601.0 Acute Prostatitis
600.00 Hypertrophy of prostate
599.00 UTI site not specified
300.00 Anxiety state unspecified
327.01 Insomnia due to medical condition classified elsewhere
V74.5 Screen for venereal disease
785.2 Undiagnosed cardiac murmur
578.1 Blood in stool
Plan:
Obtain complete medical hx including sexual behavior, & bowel, and bladder habits
Assess BPH using the American Urological Association Symptom Index
Consider additional medication to reduce BP, possibly an alpha antagonist such as doxazosin dependant on BPH diagnosis
Perform Neurological examination to r/o neurogenic bladder
Consider Trimethoprim-sulfamethoxazole or a fluoroquinolone antibiotic for suspected prostatitis
Consider and analgesic and/or antipyretic for fever and pain.
Recommend sitz bath or warm baths for perineal pain
Refer to cardiologist for echocardiogram and to assess murmur
Refer to urologist for evaluation and pelvic ultrasound.
Order:
STI screen
U/A with c/s
ECG
Consider colonoscopy for heme in stool if pt has not had a recent one
Refer to nutritionist to manage BP and cholesterol
Refer to mental health provider if there is any sexual dysfunction, depression due to insomnia or anxiety becomes unmanageable
Education and Counseling:
Counsel patient on treatment plan and importance of compliance. Antibiotic treatment can be lengthy and patient needs to be aware of the commitment. Educate patient on symptom monitoring and report any

changes to provider. Reinforce importance of condom use for sexual activity to eliminate the introduction of bacteria. Recommend eliminating any food, alcohol or caffeinated beverages that can exacerbate

symptoms. Maintain a low salt, low fat diet to reduce BP and cholesterol.
Give patient informational pamphlets and internet resources that are available regarding prostate disorders.

Follow up in two weeks to recheck BP and re-assessment of symptoms
Rationale:
Patient presents in clinic complaining of increased symptoms of nocturia, frequency, decreased flow, hesitancy, terminal, dysuria and fever. On examination his prostate is boggy, enlarged and tender on

palpitation. Rectal exam shows heme in stool. He admits to having chronic urinary problems for the past two years. Current PSA is 6.0. Differential diagnosis includes UTI, calculi, acute and/or chronic

prostatitis, obstruction, and prostate cancer. It is unlikely cancer since prostate CA usually presents with hematuria, back pain, and the prostate gland is asymmetrically enlarged (Buttaro, et al. 2013). This

patient does not have these symptoms however he does present with hesitancy, urgency, nocturia, and fever. These can also indicate prostate CA. Acute prostatitis presents with elevated PSA levels, enlarged

and tender prostate, fever, chills, malaise, frequency nocturia, and dysuria (Buttaro, et al. 2013). Chronic prostatitis presents with tender and boggy prostate and the s/s of acute prostatitis minus fever and

chills. Prescribing an analgesic, antipyretic and antibiotic has the potential of relieving acute symptoms. Referral to a urologist is necessary for further imaging and assessment to r/o cancer, calculi, obstruction

and stricture (Buttaro, et al. 2013),
A complete medical history including sexual behavior is important to r/o any STIs and to assess bowel and bladder changes. Obtaining a UA with c/s is necessary to determine hematuria and bacteria level to

r/o a UTI. A neurological exam would indicate whether there is any nerve damage causing a neurogenic bladder.
Patient’s stool was positive for blood. Since the rectal exam was negative for hemorrhoids or fissures, a colonoscopy is recommended if not done recently to r/o colon cancer, metastatic cancer or fistula.
Although patient is compliant with his BP medication his readings are still slightly elevated according to the JNC7 report. This could be a result of current stress and discomfort. Adding another BP medication

should be considered, possibly and alpha antagonist such as doxazosin to reduce BP and treat BPH (Lehne, 2013).
References:
Buttaro, T.M., Trubulski, J., Bailey, P.P., & Sandberg-Cook, J. (2013). Primary care: A collaborative practice (4th ed.). St. Louis, MO: Elsevier.
CMS.gov (2014). ICD-9 Code Lookup. Retrieved from http://www.cms.gov/medicare-coverage-database/staticpages/icd-9-code-lookup.asp
Lehne, R.A. (2013). Pharmacology for nursing care (8th ed.). St. Louis, MO: Elsevier.
Reference Card From the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNR7) Retrieved from

https://www.nhlbi.nih.gov/guidelines/hypertension/phycard.pdf

Peer #2 Kelly
Patient Initials: _J.D._____ Age: ___60____________ Sex: ____M_______

Subjective Data:

Client Complaints:
• Decrease urinary flow for two years, but increased in the last two weeks
• Slight terminal dysuria
• Nocturia 4-5 times a night
• Urinating frequency
• Low grade temp

HPI (History of Present Illness):
The patient is a 60 year old male with the complaints above. Patient has not had treatment in the past although he has been present with these symptoms for the past two years. He is not sure what is going on,

and thinks he may have cancer.

PMH (Past Medical History—include current medications, any known allergies, any history of surgery or hospitalizations):
• Hypertension
• Angina
• Hypercholesterolemia
• Hospitalized for chest wall syndrome five years ago
• Cardizem 240mg daily
• Zocor 20mg daily

Significant Family History:
• Heart Disease among aunts and uncles

Social/Personal History (occupation, lifestyle—diet, exercise, substance use)
• Engineering (Master Degree)
• Lack of exercise
• Nonsmoker
• Does not drink
• Denies substance abuse

Description of Client’s Support System:
Patient wife and friends from work provide emotional support from patient.

Behavioral or Nonverbal Messages:
Patient thinks he may have cancer based on his symptoms.

Client Awareness of Abilities, Disease Process, and Health Care Needs:
Patient has a master’s degree in engineering. He has excellent access to healthcare, but does not utilize them. He has excellent health insurance coverage including a prescription plan. He is unaware of other

resources available to him, and is not sure what they are. He also thinks he may have cancer based on his symptoms.
Objective Data:

Vital Signs including BMI:
• BMI 27.7
• B/P 140/92 right arm/sitting
• Temp 99
• Pulse 80
• RR 18 reg/unlabored
Physical Assessment Findings:
• HEENT: WNL
• Lymph Nodes: None
• Lungs: Clear
• Heart: RRR with Grade II/VI systolic murmur heard best at the right sternal border
• Carotids: No bruits
• Abdomen: Android obesity, non-tender
• Rectum: Stool light brown, heme positive. Prostate enlarged, boggy and tender to palpation.
• Genital/Pelvic: Circumcised, no penial lesions, masses, or discharge.Testes are descended bilaterally, no tenderness or masses
• Extremities, Including Pulses: 2+ pulse throughout, no edema in the lower legs.
• Neurologic: Not examined

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:
Patient shows readiness to learn. He is educated and has a good support system. Patient needs education on resources available.

ICD-9 Diagnoses/Client Problems:
• Elevated prostate specific antigen 790.3
• Nonspecific abnormal finding in stool contents 792.1
• Prostatitis 601.9
• Nocturia 788.43
• Dysuria 788.1
• Unspecified essential hypertension 401.9
• Hypercholestemia 272.0
• Overweight 278.02
• Other unspecified angina pectoris 413.9
• Heart disease unspecified 429.9
• Urinary hesitancy 788.64
• Slow of urine stream 788.69
• Urinary frequency 788.41
1. Undiagnosed cardiac murmur 788.2 (CMS.gov, 2014)

Advanced Practice Nursing Intervention Plan (including interdisciplinary collaboration, community resources and follow-up plans):
1. Prostatitis- This is a 60 year old male that complains of decrease in urine flow, Nocturia 4-5 times a night, dysuria, frequency, temperature of 99, prostate enlargement, boggy and tenderness to palpation.
Acute bacterial prostatitis is a collection of bacteria from the lower urethra to the prostate and may be caused by infection or normal fecal flora. The signs and symptoms of fever hesitancy, frequency, urgency,

Nocturia, dysuria, sensation of incomplete bladder emptying PSA levels are often elevated (Buttaro, Trybulski, Bailey, & Sandberg-Cook, 2013). Patients with an elevated PSA and prostatitis should be

treated with antibiotics for 4-6 weeks and a re-evaluation in 6wks (Jack & Zeitlin, 2005). Typical antibiotic used are ciprofloxacin, levofloxacin, ofloxacin to provide the patient with relief. High dose of anti-

inflammatory therapy NSAIDS help with inflammation. Dietary changes may help with symptoms. Foods to avoid are hot spices, strong acids, coffee, alcohol, and acidic juices (Jack & Zeitlin, 2005).

Prostatitis can have the ability to become chronic and co-management with a urologist is necessary, and if it is resulted in urinary retention, and urinary catheterization is not recommended but percutaneous

suprapubic tube is preferred until inflammation decreases (Buttaro, Trybulski, Bailey, & Sandberg-Cook, 2013).
2. Heme Positive- examination of the rectum showed light brown stool and patient was positive of heme positive stool.
Digital examination of the anus should be performed to evaluate tumors. Laboratory testing of a complete blood count (CBC) to assess for anemia (Buttaro, Trybulski, Bailey, & Sandberg-Cook, 2013).

Referral for the gastroenterologist should be given to perform a colonoscopy to have direct visualization, and allow for biopsy’s to perform (Buttaro, Trybulski, Bailey, & Sandberg-Cook, 2013, p. 717).

Patients older than 50 should be screened for colorectal cancer with annual fecal occult blood testing. The American cancer society recommends that routine screening for colon cancer is every 10 years for

colonoscopy and every 5 years for sigmoidscopy (Buttaro, Trybulski, Bailey, & Sandberg-Cook, 2013).
3. Grade 11/V1 systolic murmur heard best at right sternal border
Patient should be referred to a cardiologist and an echocardiogram should be performed to assess for valvular heart disease or innocent murmurs. Laboratory test results, chest x ray, electrocardiograms should

be provided. Systolic murmur should be graded for loudness on cordant findings (Reichlin, Dieterle, Camli, Leirnenstoll, Schoenenberger, & Martina, 2004).
Follow Up/ Referrals
• Patient should follow up with a urologist for prostatitis
• Patient should follow up with gastroenterologist for heme positive
• Nutritional consult for diet and exercise for overweight
• Cardiologist for systolic heart murmur
• Social worker for available resources in patient area

References

Buttaro, T., Trybulski, J., Bailey, P., & Sandberg-Cook, J. (2013). Primary Care. St. Louis, Missouri: Elsevier Mosby.
CMS.gov (2014). ICD-9 Code Lookup. Retrieved from http://www.cms.gov/medicare-coverage-database/staticpages/icd-9-code-lookup.aspx
Jack, G., & Zeitlin, S. (2005). Treatment strategies for the patient with chronic prostatitis. Patient Care, 18-24.
Reichlin, S., Dieterle, T., Camli, C., Leirnenstoll, B., Schoenenberger, R., & Martina, B. (2004). Initial clinical evaluation of cardiac systolic murmurs in the ED by noncardiologist. American Journal of

Emergency Medicine, 22(2), 71-75.

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