Bulacan State University College of Nursing City of Malolos, Bulacan

A case of a 64 years old PTB, Diabetic Male patient who was diagnosed with Benign Prostatic Hyperplasia and undergone Transurethral Resection of Prostate

BSN-3C Group 2 Dantes, Fernandez De Castro, Krizzia Jean Dela Cruz, Mary Grace Dela Cruz, Noemie Diaz, Angelo Paulo Evangelista, Mark Flores, Bren Daphne Gabriel, Aner Galang, Ronnamae Marie Hernandez, Mary Josephine Joson, Rosemarie

I.

Introduction

During our clinical exposure last July 26, 2011 at Bulacan Polymedic Hospital, we handled our patient named patient VS who is 64 years old with chief complaint for a scheduled of a Transurethral Resection Of Prostate(TURP).His admitting diagnosis was Benign Prostatic Hyperplasia with signs and symptoms of persistent on and off dysuria and frequency in urination. Benign Prostatic Hyperplasia is malignant (noncancerous) enlargement of the prostate gland, a common occurrence in older men. Benign Prostatic Hyperplasia generally begins in a man¶s 30s, evolves slowly, and most commonly only cause symptoms after 50. In Benign Prostatic Hyperplasia, the prostate gland grows in size. It may compress the urethra which courses through the center of the prostate. This can impede the flow of urine from the bladder through the urethra to outside. It can cause urine to back up in the bladder (retention) leading to the need to urinate frequently during the day and night. Other common symptoms include slow flow of urine, the need to urinate urgently and difficulty starting the urinary steam. More serious problems include Urinary Tract Infection and complete blockage of the urethra, which may be a medical emergency. Transurethral resection of the prostate (also known as TURP, plural TURPs and as a transurethral prostatic resection, TUPR) is a urologicaloperation. It is used to treat benign prostatic hyperplasia (BPH). As the name indicates, it is performed by visualising the prostate through the urethra and removing tissue by electrocautery or sharp dissection. This is considered the most effective treatment for BPH. This procedure is done with spinal or general anesthetic. A large triple lumen catheter is inserted through the urethra to irrigate and drain the bladder after the surgical procedure is complete. Outcome is considered excellent for 8090% of BPH patients. A.CURRENT TRENDS AND ISSUES Benign Prostatic Hyperplasia (BPH), is the most common benign neoplasm, is a chronic condition that increases in both incidence and prevalence with age. It is associated with progressive lower urinary tract symptoms and affects nearly three out of four men during the seventh decade of life. According in the Agency for Health Care Policy and Research (AHCPR) diagnostic and treatment guideline for Benign Prostatic Hyperplasia, In The World it is estimated that approximately 6.5million of the 27million men 50 to 79 years of age in 2010, while in USA the incidence rate of benign Prostatic Hyperplasia is approximately 1 in 627 or 0.16% or 433,216 people(2010). In 2005, the Philippines had recorded over 4,000 new cases of BPH and recorded 2,000 deaths due to this cause. According to 2010 statistics, there are about six million Filipino men over the age of 50 who are susceptible to develop BPH Probability increases when there¶s a family history of cancer. Aside from this, an elevated Prostate Specific Antigen (PSA) also triggers the development of BPH. B.REASON FOR CHOOSING SUCH CASE STUDY Our group had chosen Benign Prostatic Hyperplasia as our primarily because this case posed as a very intricate case requiring due understanding and knowledge about Benign Prostatic Hyperplasia, making this case a good avenue to broaden the proponent knowledge about the disease the nursing and medical management and the procedure involved.

C.OBJECTIVES: GENERAL OBJECTIVES y This study aims to broaden our knowledge regarding Benign Prostatic Hyperplasia as well as identify symptoms beforehand to prevent further complications. SPECIFIC OBJECTIVES Client Centered: 1. 2. 3. 4. 5. 1.Conduct thorough physical assessment and to interpret the assesment in order to give the care the patient needs. 2.To identify the interventions that are appropriate for the patient. 3Integrate psychosocial and spiritual considerations into plan of care for client with benign prostatic hyperplasia. To be able the patient to verbalized understanding about benign prostatic hyperplasia. To be able the patient to demonstrate behaviors or techniques to control condition to prevent complications..

Student Centered: 1. 2. 3. 4. 5. To be able to asses the client and identify the manifestation of Benign Prostatic Hyperplasia. To be able to formulate and prioritize nursing diagnosis applicable for client. To be able to plan and set goals to meet the needs of the client. To provide necessary nursing intervention that can be applied for patient with BPH. To evaluate the effectiveness of intervention rendered to the client.

1948 Religious Orientation: Roman Catholic Healthcare Financing: Philhealth of her Child Date of Admission: July 24. Demographic Data Name: Patient VS Address: Cut-cot. Personal History 1. 2011 Date of Discharge: July 28 2011 Initial Diagnosis: Benign Prostatic Hyperplasia Final Diagnosis: Benign Prostatic Hyperplasia Time of Admission: 3:00pm Time of Discharge: 10:15am . Nursing Assessment A.II. Guiguinto. Bulacan Age: 64 years old Gender: Male Race: Asian Birthday: July 14.

He also noticed that he has a scant amount of urine each time and feels that he has not been able to completely empty his bladder. MMR and Hepa B. . When the patient was 36 years old. History of Present Illness Five months ago. History of Past Illness Patient stated that he has complete immunization of tetanus toxoid and vaccination when she was born such as BCG. ngunit pakonti-konti lang ang lumalabas. as verbalized by the patient. ethambutol. Two months after the surgery the client had a checkup and was diagnosed of having Diabetes Mellitus Type II. patient VS stated that he started to experience frequency in urination. pyrazinamid) for his tuberculosis. isonaizid. Patient VS was admitted in Bulacan Polymedic Hospital for a scheduled Transurethral Resection of the Prostate (TURP). he sought help of a physician and was diagnosed of UTI. 2011. Madalas akong naiihi. Patient is taking quadtabs (rifampicin. and methformin for diabetes mellitus. He further elaborated that his urination is painful and needs force to initiate. at parang hindi lumalabas lahat ng ihi. His 2nd confinement in the hospital was when he was 59 years old and he had undergone cholecystectomy. OPV. Reasons for visit/ Chief complain Para akong binabalisawsaw. He started the treatment but after a month when the symptoms persisted. He had these symptoms as it worsens until it was accompanied by fever. bladder distention and a burning sensation and more painful urination. He was then given oral medications such as melastosil as treatment. C. Last June. The urologist then conducted several tests such as ultrasound and concluded that he was positive of Benign Prostatic Hyperplasia. DPT. He was then advised to undergo trans-urethral resection of the prostrate as surgical intervention (TURP). he had his first hospitalization when he was diagnosed of having appendicitis and had an appendectomy as surgical intervention on the year 1975. D. the client experienced difficulty of breathing and persistent cough and worsens during the night so he decided to consult his condition and was diagnosed of Tuberculosis.B. Bothered by this. On July 24. he decided to consult a urologist for a more comprehensive medical assessment.

our patient is also diagnosed of having tuberculosis. Along with \Diabetes Mellitus. our patient and the sister next to him were the only ones diagnosed with diabetes mellitus.E. Among his siblings. He also narrated that his eldest brother died due to cyst in the spleen while the one who followed the eldest died from ear infection. his father died of stroke but is unable to recall the details of his father¶s death such as his father¶s age when he died. Family Health Illness History Our client was not able to recall his grandparents on both sides. His mother is 88 years old and still alive without any communicative or hereditary health problems. According to him. PATERNAL MATERNAL R S A T I L A 71 L L 88 T B 83 L 76 R R C 65 VS DM 64 L DM 61 L 59 D 58 D 56 .

since he was diagnosed with tuberculosis. he believed that resting can help him get well. He believes that his past surgery. Health Perception and Health Management Pattern When client was asked to rate his health before his hospitalization from 110. Client VS started smoking when he was 12 years old. he felt that he is physically fit. FUNCTIONAL HEALTH PATTERN PRIOR TO HOSPITALIZATION DURING HOSPITALIZATION a. with the help of his wife and daughter. He felt relieved after the surgery. with one as the lowest. he follows doctor s order regarding his diet. His physician advised him to avoid eating fatty and foods rich in carbohydrates due to his diabetes mellitus. is the reason why he had his current disease. He also didn t consult a healthcare provider immediately when he experienced symptoms when the symptoms are still tolerable. but is having difficulty to follow those advices. He thinks that his recovery will be fast.tuberculosis F. and was able to go home immediately. In the hospital. medication.client -Deceased . and can consume about 30 cigarettes a day.stroke DM. finances is also a factor that makes following doctors advised hard. During his hospitalization. and other treatment.Diabetes mellitus .LEGEND: -Male -Female / . . which is cholecystectomy. he answered 7 for besides his difficulty in urination and respiratory problems. He stops smoking 3 months ago. For him.

Nutritional Metabolic Pattern Date July 21. . 2011 1 cup steamed rice 1 piece of fried egg 1 cup of coffee 1 cup (200ml) coffee 1 cup steamed rice 1 bowl of nilagang baboy 2 glasses (480ml) of water July 2011 July 2011 25. NPO NPO NPO 26. 1 cup of steamed rice 2 pieces regular sized fried hotdog 1 cup (200ml) coffee Lunch 1 cup of steamed rice 1 piece of small sized tortang talong 2 glasses (480ml) of water NPO Snack NPO Dinner NPO July 22. 2011 Breakfast 1 cup steamed rice 2 pieces medium sized tuyo 1 cup of coffee (200ml) Lunch 2 cups steamed rice 1 saucer of pork adobo 2 glasses (480ml) of water 2 cups steamed rice 1 bowl of nilagang baboy 2 glasses (480ml) of water Snack 2 pieces fried turon 1 cup (200ml) of coffee Dinner 1 cup steamed rice 1 saucer of adobo 1 glass (240ml) of water Date July 2011 Breakfast 24. 2011 1 cup steamed rice 2 cups steamed rice 1 slice of 1 cup (200ml) coffee 1 cup steamed rice 1 slice of He was in NPO diet since he was admitted to the hospital.b. 240 water ml 1 small bowl of porridge 120ml water -- -- Julyy 23. for the preparation of his surgery. His doctor then ordered diet as tolerated 4 hours his surgery.

When he was diagnosed of having diabetes. His meals usually consists of pork. since one of his children sell pork in the market. and 2 cups of coffee (one in the morning and another one in the afternoon). . he was advised by her doctor to avoid eating too much rice. and it is commonly a rice meal.1 cup (200ml) of coffee medium sized fried porkchop 3 glasses (720ml) of water medium sized fried porkchop 1 saucer of monggo 2 glass (480ml) of water The client admitted that he has big appetite. He usually uses condiments such as soy sauce and fish sauce for his meals. He consumes 56 glasses of water a day. but hesitates to follow because of his fondness of it. He is not used of going to work without having his breakfast. He affirmed that he has slow wound healing process and was aware that this is because of his diabetes mellitus.

2011 7x Scant yellowi sh July 22.000mL Clear reddis h Catheter 13. Elimination Pattern Urine Output Date Frequency Amount Charact eristics Color Discomfort Date Painful and difficult to initiate and unable to completely empty his bladder Painful and difficult to initiate and unable to completely empty his bladder Painful and difficult to initiate and unable to completely empty his bladder Frequency Amount Characte ristics Clear and aromatic Color Discomfort Urine Output July 21. 2011 Catheter 10. 2011 Scant 10x Aromati c and clear yello wish Bowel elimination Date Frequency Characteristi cs Color Discomfort . 2011 July 26.000mL clear reddis h -- July 23.c. 2011 9x Scant Aromati yello c and wish clear July 24. 2011 8x Scant Aromati yello c and wish clear Painful and difficult to initiate and unable to completely empty his bladder -- July 25.

2011 July 23.July 24. 2011 none -- -- None -- -- -- The client was catheterized with cystoclysis during his hospitalization. ngunit pakonti-konti lang ang lumalabas. 2011 July 22. There is pain experienced upon urinating at the perineal area. at parang hindi lumalabas lahat ng ihi. his urine was reddish. and he wasn t been able to defecate for 4 days continuously so the doctor ordered Dulcolax suppositories for the patient. After the surgery. 2011 0 -- -- -- 1x Hard. He also said that he urinates more at night. He told us that he usually suffers from constipation . as verbalized by the patient. compacted Dark Brown Difficult Straining Date Frequency 0 -- -- -- July 21. No vomitus was noted. Madalas akong naiihi. 2011 Bowel elimination July 25. 2011 Characteri stics -Color Discomfort July 26. none -- -- -- Para akong binabalisawsaw. When he is defecating he feels that it is impeded. He described his urine to be in little amount every urination.

Activity and Exercise Pattern _0_Feeding _0_Dressing _0_Home Maintenance _0_Bathing _0_Grooming _0_Toileting _0_General mobility _0_Bed mobility _II_Feeding _II_Dressing _IV_Bathing _0_ Grooming _I_Toileting _II_General mobility _II_Bed mobility Level 0.Requires use of equipment or device Level II.Dependent and does not participate .Full self-care Level I. Level IV.Dependent and does not participate He stated that his hospitalization has decreased his ability to perform his Level I.Requires assistance or supervision from another person Level III.Requires assistance or supervision from another person or device.Requires assistance or supervision from another person Level III. d.and has a hard time ddefacating.Full self-care Level 0.Requires assistance or supervision from another person or device Level IV.Requires use of equipment or device Level II.

9 Number of hours of Nap 0 Total Interpretation July 2011 July 2011 July 2011 10 hours 9½ hours 7 hours intermittent July 2011 July 2011 July 2011 10 Uneasy 22. 8 Number of hours of Nap 2 Total Interpretation Date Number of hours of Sleep 24.Patient VS stated that he has enough strength to do activities of daily activities of daily living due to generalized body weakness especially after the living. about 4-5 times. 8 1½ intermittent 25. e. since his surgery and admitted that he needs assistance from his significant others in activities in this job is tiring and strenuous already. During his free time. he accomplishing tasks. 9 0 9 Relaxed 23. He stated that he doesn t have any difficulties in falling asleep but complained that his frequent urination and occasional attacks of cough at nighttime caused disturbance in his sleep. . During his hospitalization. Approximately. plays mahjong with his neighbors. 7 0 Intermittent 26. and that impedes 1-2 hours of his sleep. Sleep-Rest Pattern Date Number of hours of Sleep 21. he is able to sleep for 7-8 hours. 10 3 13 Relaxed Our client sleeps around 9pm and wakes up for every urge to void. He gets adequate sleep but is unable to do it continuously for factors such as not getting used to the hospital environment and interruptions from medical personnel whenever he is given his medications at the middle of the night and for vital signs taking. Whenever he felt that his tasks are exhausting. He considers his daily work as a farmer as his main exercise. he usually takes a nap to regain his strength.

morally and financially. his children do not ask him for anything and gives him financial support instead. Every time due to the fact that he doesn t find his eye condition troubling. . In terms of finances. He doesn t he feels any discomfort due to his condition. Upon his stay in the hospital. all of his children are present to give him their support. On the day of his operation.f. The patient has 9 children but only his wife and a daughter was left living with him in their house because his other children have already formed families. He stated that he doesn t have any difficulty in hearing. They also share harmonious relationship with their neighbors and co-workers. they immediately talk it over and look for ways on how to resolve the conflict. Cognitive Perceptual Pattern Patient VS is farsighted but has never consulted an ophthalmologist for this His stay in the hospital didn t affect his thinking in any way at all. g. wear any eye glasses or corrective lenses. being in hospital help him to manage his symptoms and made him hopeful that his health will return as once it has been. They also ensured the safety of their father and arranged everything to the benefit of their father s welfare. and insisted that this was because of his poor memory. his wife and daughter were the ones attending to his needs. he has this difficulty of remembering roadways. he was once elected as baranggay councilor. he rests to lessen it. He related that back when he was still working as a driver. and in fact. SelfPerception and SelfConcept Pattern h. RoleRelationship Pattern He perceived himself as a strong individual given that he is a famer and this made him physically fit. If problem within the family arises. The hospitalization made him weak as he perceived himself but according to him.

he sleeping or talking with his wife and daughter. he values his family most. Sexuality Reproductiv e Pattern Our client is a male. those of which who just listens to the radio or takes a nap. They stopped having sexual intercourse since her wife that the action stopped his condition from worsening. k.i. When he feels stressed. He and his family manage to They are devoted in their prayers to ask for the Almighty for his faster attend masses in an average of two Sundays every month. The last time they have sexual intercourse sexuality and was even thankful that he had undergone the surgery thinking was 14 years ago. He has 9 children. for it is effective to make him feel accompanied him in the hospital. relaxed. He still believes firmly and has put his faith in God G. had her menopause. Though. He prays to God rehabilitation. and he and his wife didn t use any Our client did not felt that his hospitalization caused him changes in his form of contraception before. Growth and Development FRUED¶S PSYCHOSEXUAL DEVELOPMENT . Value ± Belief Pattern The patient s religion is Roman Catholic. j. He continued to be devoted in his religion. there have for blessings and above everything. been many trials that have already come to him and his family s way. Coping ± Stress Tolerance Pattern His family is always supportive to whatever he is doing and is always there His activities during his hospital days are mostly watching television or either if he has problems or when he needed help.

PIAGET¶S COGNITIVE DEVELOPMENT STAGE AGE DEFINITION RESOLUTION AND ACTUAL FINDIGS . and interpersonal impoverishment. necessity or accident. work or ideas. He guides them for development of their wellbeing to become a responsible.STAGE Genital AGE 12years and above DEFINITION Energy is directed to physical and intellectual activities. achievement of independence and decision making. RESOLUTION AND ACTUAL FINDIGS POSITIVE(+) for generativity. with the help of his wife and he can decide on his own. He had also 18 grand children. Sexual maturity and function and development of skills needed to cope with the environment. He is a farmer and believe and stated that he had accomplished what a father is worth for. stagnation´ AGE 12years and above DEFINITION For (+) Care. Patient VS has his own family he can decide on his own. but sometimes he need the help of his wife and he also respect the opinion of other family members. for one¶s. boredom. productive and nature people. Patient VS has satisfaction for his life for past 64 years. For (-) Self-indulgence. widening concern for what has been generated by love. Encourage separation from parents. ERIKSON¶S PSYCHOSOCIAL DEVELOPMENT STAGE Adulthood ³Generativity vs. RESOLUTION AND ACTUAL FINDIGS POSITIVE (+) Patient Vs is 64 years old under in genital stage.

III. Our Patient thinks rationally and logically. Reasoning skills develop. In decision making the patient considers the pro/cons of each action that will be made. POSITIVE (+)According to our patient even though he is sick he can do things like solving family issues by advising different reasonable opinions in the family. RESOLUTION AND ACTUAL FINDIGS POSITIVE(+) the client distinguishes what is right and wrong regarding moral values and social norms. Anatomy and Physiology .Formal Operation 11years and above Thinking becomes abstract and symbolic. A sense of hypothetical developments. KOLBERG¶S COGNITIVE DEVELOPMENT STAGE Post-conventional AGE 9 and above DEFINITION The persons lives autonomously and defines moral values and principles that are distinct from personal identification with group values. He lives according to principles that are universally agreed on and that the person consider appropriate for life.

Prostate

The function of the prostate is to store and secrete a slightly alkaline fluid, milky or white in appearance,[5] that usually constitutes 20-30% of the volume of the semen along with spermatozoa and seminal vesicle fluid. The alkalinity of semen helps neutralize the acidity of the vaginal tract, prolonging the lifespan of sperm. The alkalinization of semen is primarily accomplished through secretion from the seminal vesicles.[6] The prostatic fluid is expelled in the first ejaculate fractions, together with most of the spermatozoa. In comparison with the few spermatozoa expelled together with mainly seminal vesicular fluid, those expelled in prostatic fluid have better motility, longer survival and better protection of the genetic material (DNA). The prostate also contains some smooth muscles that help expel semen during ejaculation. Secretions Prostatic secretions vary among species. They are generally composed of simple sugars and are often slightly alkaline. In human prostatic secretions, the protein content is less than 1% and includesproteolytic enzymes, prostatic acid phosphatase, and prostate-specific antigen. The secretions also contain zinc with a concentration 500-1,000 times the concentration in blood. Regulation To work properly, the prostate needs male hormones (androgens), which are responsible for male sex characteristics. The main male hormone is testosterone, which is produced mainly by the testicles. Some male hormones are produced in small amounts by the adrenal glands. However, it is dihydrotestosterone that regulates the prostate.

IV.

Patient and his illness

A. Pathophysiology a. Schematic diagram

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no body and breath odor Facial Grimace noted Remarks Normal 3. place and situation Cooperative Appropriate to the situation Oriented to date. Over-all Hygiene and Grooming Inspection and Observation Inspection and observation Clean and neat Normal 4.2011 R ±15cpm BP ± 110/80 Method 1.Physical Assessment Name: Patient VS Age: 64y/o T ±38.: 68 BMI : Clean and neat . Normal . Body Built Ht. appropriateness of responses SKIN 1. place and time situation Cooperative during assessment Responses are appropriate to the situation Normal Normal Normal Inspection Uniform in color Light brown complexion.: 5'4'' Wt.: 68 BMI : Inspection and observation Normal Findings Proportionate. Signs of Distress No signs of distress Deviation from normal dueto flank pain 5. Color Inspection and observation No signs of illness or disease Weak in appearance Deviation from normal due to fatigue Inspection Inspection Inspection Conscious and coherent. normal BMI in relation to age Actual Findings Not Proportionate Ht. Oriented to time. Obvious signs of health or illness MENTAL STATUS Level of Consciousness/ Orientation 3.: 5'4'' Wt.0ºC P ±82bpm GENERAL APPEARANCE Date of assessment ± July 26. Affect/mood. Attitude 4.

Temperature No Lesions Moist in Axilla and skin folds Uniform temperature No lesions noted Moist in axilla and skin folds Skin is warm to touch Normal Normal Deviaion from normal due to inflammatory process Normal in elderly 6. Tissue surrounding nails 5. Blanch Test of Capillary refill HEAD SKULL 1. Fingernail plate shape Inspection Convex curvature. it springs back within 3 seconds It springs back to previous state <3 seconds Dry wavy skin noted NAILS 1. Skin Turgor Palpation When pinched. angle of nail plate is approx. Moisture of the skin 5. Fingernail and toenail texture 4. Normocephalic and Normal . 160° Highly vascular and pink in light skin clients Convex curvature. Presence of Edema Inspection and Palpation Inspection Palpation Palpation Absence of Edema Absence of edema Normal 3. Fingernail and toenail bed color Inspection Deviation from normal due to decreased effective lung field Normal Normal Normal 3. angle of nail plate 160° Pale in color Normal 2.Uniform in color 2. Shape Inspection and Palpation Inspection Inspection and Palpation Smooth texture Intact epidermis Prompt return to pink or usual color within 3 seconds Smooth texture Intact epidermis The color returns to usual for more than 3 seconds(5-6seconds) Inspection Rounded. Normocephalic and Rounded. Presence of Lesions 4.

2. no discharge and no discoloration 18 blinks/min. Direction of curl EYELIDS Surface characteristics Inspection Inspection Equally distributed Curl slightly outward Equally distributed Curl slightly outward Normal Normal Inspection Skin intact. Hair thinness or thickness 5.symmetrical with frontal. Symmetric facial movements Normal in elderly Normal Inspection Hair evenly distributed Inspection Symmetrically aligned Inspection by asking the client to raise and lower intact skin. parietal and occipital prominences. saggy facial features. Normal Frequency of blinking Inspection Normal . parietal and occipital prominences. Evenness of hair distribution 2. Presence of nodules. equal movements Normal Normal Normal EYELASHES 1. Hair distribution 2. Facial Features 2. Evenness of hair growth over the scalp 4. Hair texture and oiliness Palpation Inspection and Palpation Inspection Inspection and Palpation Smooth uniform consistency. equal movements the eyebrows Hair evenly distributed Symmetrically aligned intact skin. absence of nodules and masses Hair evenly distributed Thick hair Silky and resilient hair Normal Normal Normal Normal FACE 1. masses and depressions 3. Skin quality and movement Inspection Inspection Symmetric or slightly asymmetric facial features Symmetric facial movements Slightly asymmetric. Alignment 3. Smooth uniform consistency. Symmetry of facial movements EYES EYEBROWS 1. no discharge and discoloration Approximately 15-20 involuntary Skin intact. absence of nodules and masses Hair evenly distributed Thick hair Silky and resilient hair symmetrical with frontal.

side to side. Color. Clarity and texture PUPIL 1. Pale pink in color.blinks per minute CONJUNCTIVA BULBAR CONJUNCTIVA 1. No presence of lesions Normal PALPEBRAL CONJUNCTIVA 1. shiny and smooth Transparent. Capillaries sometimes evident. texture and presence of lesions Inspection by reverting the eyelids Transparent. shiny and smooth Normal Inspection Sclera appears white Sclera appears white Normal . round equal in size Normal Inspection using a penlight Transparent. pink or red in color the eyelids with thumb and index finger and asking the client to look up and down. texture and presence of lesions Inspection. round equal in size Black in color. by retracting Shiny. smooth and shiny Deviation from normal due to decreased effective lung field SCLERA 1. Color. smooth. Color. No presence of lesions Transparent. Color CORNEA 1. shape and symmetry of size EARS AURICLES Inspection Black in color. Capillaries sometimes evident.

uniform color No tenderness masses and displacements Symmetric. Same color with the facial skin Normal Mobile. Nasal Septum 6. Pinna recoils after being folded. discharge and swelling noted intact and in midline No tenderness noted Normal Normal Normal . and breathe through the opposite nares and repeat for the other) Observation and inspection Inspection Palpation Air moves freely as the client breathes through the nares Air moves freely as the client breathes through the nares Normal 4. elasticity and areas of tenderness Inspecting for position. Texture. No lesions and swelling intact and in midline Not tender No lesions. Color.1. firm and not tender. size or color and flaring or discharge from the nares. firm and not tender. Palpation by gently pulling the auricle downward then backward and folding the pinna. Mobile. no discharge or flaring. Normal NOSE 1. no discharge or flaring. External nose for deviations in shape. auricle aligned with the outer canthus of the eye. symmetrical. Mucosa 5. uniform color No tenderness masses and displacements Normal Normal 3. Note the level at which the superior aspect of the auricle attaches to the head in relation to the eyes. Sinuses MOUTH clear watery discharge. symmetry of size and position 2. Color same as the facial skin. 2. Patency Inspection (by asking the client to close the mouth and then exert pressure or the nares. masses and displacements of bone and cartilage Inspection Palpation Symmetric. External nose for any areas of tenderness.

raised papillae margins. color and texture Inspection Uniform pink color.Inner lips and buccal mucosa for color. moist. hard palate. pink gums with moist. smooth texture Pale in color Deviation from normal due to decreased effective lung field Normal 2. hard palate more irregular texture. shape. no lesions Uniform color.LIPS AND BUCCAL MUCOSA 1. moisture. no bony growths. moist. no bony growths. no lesions. soft. Base of the tongue. lighter pink. pale in color. lumps or excoriated areas PALATES AND UVULA 1. no lesions Inspection Smooth white tooth enamel. Positioned in midline of soft palate Deviation from normal due to decreased effective lung field 2. Outer lips for symmetry of contour. Characteristics Inspection and palpation Uniform color. smooth soft palate. raised papillae. floor of the mouth and frenulum 4. moves freely Smooth base of the tongue with prominent veins Smooth with no palpable nodules Smooth base of the tongue with prominent veins Smooth. moist. firm texture. texture and presence of bony prominences Inspection Normal Inspection and Palpation Normal Inspection Light pink. Pale in color. Deviation from normal due to decreased effective lung field Normal 2. Uvula for position and mobility TRACHEA Inspection Positioned in midline of soft palate Normal . Yellowish tooth enamel. Presence of nodules.Tongue movement Inspection Central position. firm texture. pale gums with moist. smooth lateral Central position. texture and the presence of lesions TEETH AND GUMS 1. smooth soft palate. Hard and soft palate for odor. no palpable nodules 3. no lesions. smooth lateral margins.

rounded or scaphoid. Vocal (tactile) Fremitus Palpation Central Placement in midline of neck Antero-posterior to transverse diameter ratio of 1:2 Full symmetric chest expansion Bilateral symmetry of vocal fremitus Vesicular and broncho. Size Palpation No tenderness. Bowel sounds Inspection Observation Flat. equal vibration Rales present on right apex and right lower lobe of lungs Normal Normal Normal 4. Lateral Deviations THORAX AND LUNGS 1. Skin integrity Inspection Unblemished skin. uniform in color Flat. Abdominal movements associated with respirations 4. Respiratory Excursion 3. Areas of tenderness MUSCLES 1. uniform color Unblemished skin. Contour and symmetry 3. symmetrical Symmetric movements Normal Normal Auscultation Audible bowel sounds active bowel sounds (27 bowel sound/min) No tenderness.vesicular breath sounds Central Placement in midline of neck Normal Inspection Palpation Palpation Ratio of 1: 2 Thumb separated 3cm Bilateral symmetry of vocal fremitus. relaxed abdomen Normal 5. Symmetrical Symmetric movements Normal 2.1. Breath sounds Auscultation Deviation from normal due to decreased effective lung field ABDOMEN 1. Shape and symmetry of the thorax from posterior and lateral views 2. relaxed abdomen Normal Inspection Equal in size in both sides of the Equal in size in both sides of the Normal .

Fasciculations and tremors 4. Presence of lesions. no deformities Normal Normal 4. no deformities Normal Normal Normal Normal Normal Normal Inspection and Palpation no edema noted Normal Inspection Can perform ROM exercise for lower extremities easily Firm muscle tone No lesions. Contractures (Softening) 3. varicosities may be present. varicosities may be present No edema body No contractures No tremors Firm Can perform ROM exercise Smooth and firm No lesions. Presence of edema Inspection and Palpation No edema No edema Normal . no deformities. no deformities Can perform ROM Normal 2.2. Motor strength Inspection Inspection Palpation Palpation Inspection Palpation Inspection body No contractures No tremors Normally firm Can perform ROM exercise for upper extremities easily Smooth and firm No lesions present. Motor strength 2. deformities and varicosities Palpation Inspection muscle tone not firm No lesions. Presence of lesions. Muscle tone 3. Muscle tonicity UPPER EXTREMITIES 1. deformities and varicosities 4. Muscle tone 3. Presence of edema LOWER EXTREMITIES 1.

2011 > A RBC count is used >4. 2011 Date In: July 25.A RBC count is ordered as a part of the complete blood count (CBC). > A white blood cell >6. The test >4.hematocrit .5 10^9/L count is a determination of number of WBC or leukocytes/unit volume in a sample of venous blood. presurgical procedure.5-5. often as part of a routine physical.0-10.8 10^12/L Prior: >Check the Doctor's order for CBC laboratory >Explain the procedure to the patient: y explain what you are going to do y why is it necessary y how the patient can cooperate During: >WBC >5.Diagnostics and laboratory procedures Diagnostic Laboratory Date Ordered and Date Indications or Purpose Result Procedure In Normal Values Analysis and Interpretation of the Results Normal Nursing Responsibilities Complete Blood Count >RBC Date Ordered: July 24. or for other clinical reasons.0 10^9/L >Normal >Use standard procedure and sterile technique when getting the specimen >Secure the patient's arm during blood extraction . These changes must be interpreted in conjunction with other parameters. such as hemoglobin.7 10^ 12/L to evaluate any type of decrease or increase in the number of red blood cells as measured per liter of blood.

>Hemoglobin >The hemoglobin test >140.0 is normally ordered as a part of the complete blood count (CBC.45 >140. age.is used to detect infection or inflammation and also used to help monitor the body¶s response to various treatments and to monitor bone marrow function. instruct the patient to rest for a while >Hematocrit >0. It is also repeated at regular intervals for >0.42-0. The test is also repeated in patients who have ongoing bleeding problems or chronic anemias o polycythemia. and to determine the need for further tests. including for a general health screen. >The hematocrit is normally ordered as a part of thecomplete blood count (CBC). such as differential count.-180 g/L >Normal >Apply pressure on the venipucture site after withdrawing specimen After: >Label the specimen container with patients name. >Send the specimen to the laboratory immediately. date and time the specimen was ontained and room number. >If the patint feels dizzy after the extraction.52 >Normal . which is ordered for many different reasons.

It is used to detect both hyperglycemia an d hypoglycemia.04 >Normal Blood Chemistry >Glucose (FBS) Date Ordered: July 24.01-0.02-0. 2011 Date In: July 25.60 0.34 0. including: the monitoring of treatment for anemia.02 y y y y 0. >Schilling's Differential Count y Segmenters y Lymphocytes y Monocytes y Eosinophils > A method of counting blood cells in which the polymorphonuclear neutrophils are separated into four groups according to the number and the arrangement of the nuclear masses in each cell.5 mg/dL measure the amount of glucose in the blood right at the time of sample collection. 2011 >The blood glucose test is ordered to >368. and monitoring of ongoing bleeding to check its severity. to >75-115 mg/dL >Normal .08 0. recovery from dehydration.66 0.20-0.50-0.many conditions. y y y y 0.04 0.40 0.

and to monitor glucose levels in persons with diabetes. As the kidneys become impaired for any. It is for this reason that standard blood tests routinely check the amount of creatinine in the blood. Blood glucose may be measured on a fasting basis (collected after an 8 to 10 hour fast). Abnormally high levels of creatinine thus warn of possible malfunction or failure of the kidneys.00mEq/L >135-153 mEq/L >Normal .7-1. >Creatinine >Creatinine has been found to be a fairly >1.3 mg/dL reliable indicator of kidney function. >This test is a part of the routine lab evaluation of most >0.5 mg/dL >Normal >Sodium (Na) >136. the creatinine level in the blood will rise due to poor clearance by the kidneys. reason.help diagnose diabetes.

> Potassium (K) >Serum or plasma test s for potassium levels >4. which are often ordered as a group. and in monitoring treatment involving IV fluids or when there is a possibility of developing dehydration. It is used to detect concentrations that are too high (hyperkalemia) or too >3. as part of a routine physical.5-5. along with other electrolytes.30 mEq/L are routinely performed in most patients when they are investigated for any type of serious illness. Potassium testing is frequently ordered. It is also included in the basic metabolic panel. It is one of the blood electrolytes.patients. widely used when someone has non-specific health complaints.3 mEq/L >Normal .

X rays are a form of radiation that can penetrate the body and produce an image on an x-ray film. but many drugs can decrease potassium excretion from the body and result in this condition. and the bones of the chest area. thyroid gland. 2011 Date In: July 24. >Explain the procedure to the patient: y explain what you are going to do y why is it necessary y how the patient can cooperate >Remove all jewelries or any metal in the . >Confluent hazy opacities are seen in the right apex >An ovoid opacity is noted in the right lower lobe Prior: >Check doctor's order >Assess clients need for the procedure.low (hypokalemia). Diagnostic Laboratory Date Ordered and Date Indications or Purpose Result Procedure In Normal Values Analysis and Interpretation of the Results >PTB. Chest x rays include views of the lungs. small portions of the gastrointestinal tract. The most common cause of hyperkalemia iskidney disease. 2011 >A chest x ray is a procedure used to evaluate organs and structures within the chest for symptoms of disease. heart. right Apex >Ovoid opacity is noted in the right lower lobe could be part of PTB or pneumonic consolidation Nursing Responsibilities > Chest X-ray Date Ordered: July 24.

July 28. After. BT. NGT.0. any skin allergy. Oxygen Therapy etc. 2011 GENERAL DESCRIPTION . -The patient gets sufficient fluid PRIOR: -read doctor`s order -assess v/s for baseline data -assess skin turgor. MEDICAL MANAGEMENT PNSS DATE ORDERED/ DATE RESULT IN July 24. 2011.9% Sodium Chloride Solution . disease or injuring agent . >During >Assist the client in the radiology room. The Patient and his care A.patients body. non-pyrogenic. solution for fluid and CLIENT´S RESPONSE NURSING RESPONSIBILITIES -The client maintain fluid and electrolyte balance. IVF. Medical Management a. >Document the procedure >Secure X-ray res ult.It contains no INDICATION/ PURPOSES -Normal Saline is a sterile. TPN. V. >Instruct proper positioning during the procedure. Nebulizations. >Refer to the doctor.

0 (4.antimicrobial agents.5 to replenishment. electrolyte and electrolytes and minimal -determine veni-puncture site Consider : -how long patient is likely to . Also. any problem. . 7. . medications to be administered Sodium Chloride with chloride in the blood . he received sufficient nutrients from the IVF. used in medicine as fluid -note IVF name. level. changed body and the blood or if the IVF therapy is done are essential for DURING: normal body -verify doctor`s order functions. what kind of IVF.The pH is 5. -It contains 9 g/L Certain concentrations of both sodium and calories from dextrose. regulation replacements to treat -observe veni-puncture site for or prevent dehydration.It contains 154 mEq/L Sodium and Chloride. have IVF.0). an osmolarity of 308 mOsmol/L. Saline -identify client check IVF if solutions are commonly infusing well.Isotonic solution: A solution that has the same salt POST: concentration as the -verify doctor`s order if IVF normal cells of the needs to be discontinued.

already -explain to the client that the cannula will be remove -prepare dry cotton ball & tape -instruct client to take a deep breath while removing the cannula. -re-assess site for any problem -apply pressure w/ dry cotton ball on the site to prevent excessive bleeding & to promote blood clot -documentation. .

27. After: y Instruct patient to take full course of therapy even if you are feeling better. y Swallow tablets whole. causing cell death. cephalosporin. OD Prior: Assess if patient has allergy to the drug.B.28-11 Date discontinue: 7-28-11 Bactericidal. Perioperative prophylaxis. Action/ Classification Indication Clients Response Nursing Intervention Cefuroxime Ceftin Date ordered: 7-25-11 Date given: 7-25. Upset.I. y Instruct patient that . 2nd generation. Signs of infection are minimized. During: y Give oral drug with food to decrease G. Drugs Generic Name/ Brand Name Date Ordered/ Date Given/ Date Discontinue Route of Administration/ Dossage/ Frequency Oral 500mg/cap. Antibiotic.26. inhibits synthetic of bacterial cell wall. do not crush them.

Relieves pain and inflammation.28-11 Date discontinue: 7-28-11 Oral 200 mg/tab OD Inhibits prostagladin synthesis by selectively inhibiting cyclo-oxygenase (COX-2). Post surgical pain Patient pain subsides for 1 hour Prior: check for any allergies check for the physician's order check vital sign note skin color During: y adnibister drug with food or after meals After: y Provide other comfort measures like positioning y Teach patient to take with a full glass of water enhance absorption.NSAID.26. y Instruct . Celecoxib Celebrex. Analgesic(nonopioid).side effects are: Stomach upset or diarrhea. Celexib Date ordered: 7-25-11 Date given: 7-25. Specific COX-2 enzyme inhibitor.27.

cramping. y Discuss with the patient that adequate . Relief of constipation. black tarry stool. During: y Place patient in side lying position.patient to report bleeding. and malaise. After: y teach patient about dietary sources of fiber. fatigue. Bisacodyl Dulcolax Date ordered: 7-25-11 and 7-2711 Date given: 7-25-11 and 7-2711 Date discontinue: Stimulants Rectal 1 suppository Increses peristalsis and motor activity of the small intestines by acting directly on the smooth muscles. y Insert sopposotory slowly. The patient defecates the compacted feces. Prior: Lubricate before insertion. patient should retain for 30 mins. bruising. May stimulate colonic intramural plexux and promote fluid accumulation in the intestines and colon.

Prior: Hand washing. . Anti-diabetic. Non-insulin The patient blood dependent diabetes glucose decreases mellitus to control from ___ to ____ hyperglycemia in glibenclamide responsive DM of stable. Inform patient that normal bowel movements do not occur daily.y y fluid bulk consumption and exercise facilitates bowel movements. May also decrease hepatic glucose production or increase response of insulin. Check for Blood Glucose Obtain patient allergies. Daonil Date ordered: 7-27-11 Date given: 7-27. Warn patient about exessive use of drug. Glibenclamide Gluban. nausea. Teach patient not to use in presence of abdominal pain.28-11 Date discontinue: 7-28-11 Oral 5mg/tab OD Decrease blood glucose b stimulating insulin release from pancreas. vomiting. Instruct to take drug with meal.

26-11 Date discontinue: Date ordered: 7-24-11 It is a hormone secreted by Dosage depends on beta cells of the pancreas that.25. Prior: Hand washing Checks clients allergy Check for the CBG of the patient. SQ Insulin Humulin R Date given: 7-24. dr's Quetua's by receptor ± mediated insulin scale: effects. The patient's blood glucose decreases to normal level. After: y Monitor urine output and glucose level y Instruct patient to notify physician if he/she experience signs of hyperglycem ia.During: y Maintain medical techniques in administratio n of medication. facilitating <80mg/dl the transport of metabolites No insulin ± 81 and ions through cell Treatment of type II Diabetes Mellitus that cannot be controlled by diet and oral drugs. promotes the storage 1 vial D5050 of the body's fuel. . y Give patient glass of water.

201 250mg/dl 12 ³u´ . y Ask the patient to notify if he is expieriencing any symptoms of hypoglycemi a.25. y Store insulin . of fats from lipids.301 350mg/dl 18 ³u´ .7-26-11 120mg/dl 5 ³u´ . y Instruct patient to inject the insulin in rotating in his abdomen. During: y Inject the insulin SQ using medical techniques.>400mg/dl 07 ± 24 -11 6am ± 10 ³u´ 12am ± 10 ³u´ 07 .151 ± 200mg/dl Antidiabetic Hormones 10 ³u´ .351 ± 400mg/dl 20 ³u´ .121 ± 150mg/dl 7 ³u´.11 12 noon ± 12´u´ 07 -26 ± 11 12 MN ± 15 ³u´ 6am ± 10 ³u´ membrane and stimulating the synthesis of glycogen from glucose. After: y Teach patient not take any new medication during therapy without consulting physician.251 ± 300mg/dl 15 ³u´ .

It also improve insulin sensitivity.in a cool place away from direct sunlight.27. Non-insulin dependent diabetes mellitus (NIDOM)(type 2) The patient Glucose level decreases to normal. Antidiabetic.28-11 Date discontinue: 7-28-11 Oral 200 mg/tab OD Decreases intestinal absorption of glucose and hepatic glucose production. After: y Monitor patient blood glucose level and for signs and symptoms of hypoglycemi a. During: y Maintain medical techniques in administerin g medication. Prior: Check patient's allergy Check vital signs Check the clients glucose level. Vimetrol Date ordered: 7-26-11 Date given: 7-26. y Advice patient to take in the . Metformin Pharex metformin.

The patient decreases symptoms of TB.monitoring to prevent hypoglycemi a at night. Checks clients allergy. After: y Teach patient not take any new medication during therapy without . During: y Better to administer on empty stomach 1 hour before meals or 2 hours meals with full glass of water. highly specific and bactericidal for mycobacterium tuberculosis hominis. Pulmonary and extra pulmonary tuberculosis.28-11 Date discontinue: 7-28-11 Oral 3 tabs OD Mechanism unknown. Rifampicin/ Isoniazid/ Pyrazinamide/ Ethambutol Quadtab Date ordered: 7-27-11 Date given: 7-27. Antituberculotic. Prior: Hand washing and wear protective mask.

Management of reversible bronchospasm associated with obstructive airway desease. After: y Tell patient to avoid . consulting physician. During: y Maintain medical technique in administratio n of medication. Hand washing. Use solution in nebulizer with a mouthpiece rather than a facial mask. effective breathing Assess for any pattern and gas drug allergy exchange. of the patient. Instruct patient to take drug in an empty stomach.y y Ipratropium/ Salbutamol Combivent Date ordered: 7-25-11 Date given: 7-25-11 Date discontinue: 7-25-11 Nebuluzation 1 neb. BID Stimulates beta-2 receptors of bronchioles by increasing levels of cAMP which ralaxes smooth muscles to produce bronchodilation. The patient Prior: demonstrate Hand washing. Respiratory drug.

During: y Maintain medical technique during administratio n. Clean injection port before administerin g. Prior: Hand washing. antiinflammatory. Disscuss to patient the drug side effect. . Ketorolac Kortezor. Analgesic. Short-term management of moderate to severe acute postoperative pain. Toradol Date ordered: 7-26-11 Date given: 7-26-11 Date discontinue: 7-26-11 TIV 30mg OD Inhibits prostagladin synthesis by inhibition of cyclooxygenase enzymes. antipyretic. Patient post operative pain is reduced. tubing. and injection port.y accidentally spraying into eye. Check IV site. Patient improved mobility. After: y Advice patient to report persistence orworsening of pain.

Alcohol overdoses that result in in any type of food or vomiting also warrant NPO instructions for a liquid by mouth. or .Doctors use this on those with weak swallowing musculature. general anaesthetic. pneumonia. 2011 (11pm) GENERAL DESCRIPTION INDICATION/ PURPOSES CLIENT`S RESPONSE NURSING RESPONSIBILITIES NPO -NPO stands for Nothing Typical reasons for NPO -Increased thirst. Discuss to patient about side effect.(+) Body weakness. For PRIOR: -read doctor`s order regarding client`s diet -assess client`s condition -determine client`s need for his/her diet.y y Instruct patient to report any bleeding. Diet MEDICAL MANAGEMENT DATE ORDERED/ DATE RESULT IN July 24. who will undergo -cooperative. fatigue. orders when they do not or in case of gastrointestinal bleeding want the patient to take or gastrointestinal blockage. -assess client`s awareness & understanding before instructing about his/her diet & it`s . in those nothing by mouth.g. instructions are the Per Orem which means prevention of aspiration . C. bruising. e.

when a patient purpose -instruct & explain to client his/her diet. MEDICAL MANAGEMENT DATE ORDERED/ DATE RESULT IN GENERAL DESCRIPTION INDICATION/ PURPOSES CLIENT`S RESPONSE NURSING RESPONSIBILITIES . is getting ready for a DURING: surgery. they are ordered -verify doctor`s order for NPO.period of time. -identify the client -encouraged client to comply with his/her diet POST: -provide health teachings: -encouraged to eat nutritious foods that will boost immune system -instructed to avoid eating street foods that is exposed to microorganism to prevent acquiring other diseases. instance.

-assess client`s condition determine client`s need for his/her diet -assess client`s awareness & understanding before instructing about his/her diet& it`s lead to any purpose complications and if the -instruct & explain to client his/her diet client needs further DURING: monitoring for lab test.Any nutritious foods that can be tolerated or desired by the client. diet intake to sustain energy -Replenishment of Nutrients.³DAT´ Diet as tolerated July 25. DAT. if this will not -The patient was able to PRIOR: -read doctor`s order regarding client`s gave enough calorie. -his particular diet is only given when client can now tolerate any food she desires that is nutritious. -verify doctor`s order -identify the client -encouraged client to comply with his/her diet POST: -provide health teachings: -encouraged to eat nutritious foods that will . 2011 DAT.

may be used for glands of varying size and is ideal for patients who have small glands and for those who are considered poor surgical risks. hypovolemia). which can then be viewed directly. The surgical and optical instrument is introduced directly through the urethra to the prostate. Outcome is considered excellent for 80-90% of BPH patients. C. . it can be carried out through endoscopy. and repeated procedures may be necessary because the residual prostatic tissue grows back.) This is considered the most effective treatment for BPH.TURP usually requires an overnight hospital stay.boost immune system -instructed to avoid eating street foods that is exposed to microorganism to prevent acquiring other diseases. Urethral strictures are more frequent than with (non-trans-urethral procedures. It is the most common procedure and considered as gold standard of prostate procedure used to treat benign prostatic hyperplasia (BPH). TUPR) is a urological operation. This procedure is done with spinal or general anesthetic and requires no incision. TURP rarely causes erectile dysfunction. A large triple lumen catheter is inserted through the urethra to irrigate and drain the bladder after the surgical procedure is complete. The gland is removed in small chips with an electrical cutting loop (electrocautery or sharp dissection. SURGICAL MANAGEMENT Transurethral resection of the prostate (also known as TURP. Surgical Management B. As the name indicates. but may trigger retrograde ejaculation because removal of the prostatic tissue at the bladder neck can cause seminal fluid to flow backward into the bladder rather forward through the urethra during ejaculation. and as a transurethral prostatic resection. Newer technology uses bipolar electro surgery and reduces the risk of TURP syndrome (hyponatremia.

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and even coma. including catheter drainage. This complication can lead to confusion. 5. 4. changes in mental status. Inform consent secured. Kept the patient comfortable. irrigation and monitoring of hematuria. . Monitor vital sign Inform the patient about the procedure and the expected postoperative care. there would be a verbalization of a decrease in pain of urination from the patient as he could do splinting properly and adhere to medication therapy for pain. nausea. 2. The client is discharge three days after the surgery. 8.PATIENT¶S RESPONSE TO OPERATION: As the days go by after the surgery. 7. vomiting. y Bladder neck stenosis y Retrograde ejaculation due to injury of preprostatic (internal) sphincter system y Incontinence or dribbling of urine up to 1 year after surgery Maintained NPO Prepared for oral and body hygiene Prophylactic antibiotics are administered as ordered. Pre-operative Management: 1. 3. To prevent TURP syndrome the length of the procedure is limited to less than one hour in more centers. 6. Discuss the complications of surgery which include: y Bleeding (most common) y Clot retention and clot colic y Bladder wall injury such as perforation (rare) y TURP Syndrome: Hyponatremia and water intoxication (symptoms resembling brain stroke in an elderly presenting patient) caused by an overload of fluid absorption from the open prostatic sinusiods during the procedure.

7. Monitor vital signs 6. 3. 9. Keep cystoclysis clear. Draped the patient accordingly 11. Placed the patient in lithotomy position. Spinal preparation for induction of anesthesia. 5. Secured specimen for biopsy. Post-operative Management: 1. Referred to ward with cystoclysis. 2. Placed the patient in supine position. 10. thrombosis and pneumonia. Vital sign monitored every 15 minutes then every 2 hours till stable. 6. 7. Reduce anxiety by providing realistic expectations about postoperative discomfort and overall progress. 15. Foley catheter connected to urine bag inserted after the operation or procedure. Maintain bed rest for the first 24 hours. Maintained sterility throughout the procedure. Keep flat on bed at least 4 hours. Penile preparation. 13. 12. 10. Administer anti-cholinergic medications to reduce bladder spasms as ordered. 8. Promote comfort through proper positioning. Encourage patient to express fears related to sexual dysfunctions and to discuss with partner. . 4. Maintain patency of urethral catheter. 2. 5.Intra-operative Management: 1. 9. 11. 14. 3. Instructed the patient regarding deep breathing exercises. Discuss recommended follow-up management and home medication as prescribed. 4. thereafter to prevent embolism. Teach measures to regain urinary control. Urinary drainage is maintained and observed for signs of hemorrhage. Cleansed patient thoroughly. Administer pain medications. 8. Encourage early ambulation.

physical aspects of an individual belong to safety and security needs. However. If pain is present in the body. Therefore. breathing. based on Maslow s Hierarchy of Needs. it is crucial for survival. temperature maintenance belongs to physiologic needs. an individual may not feel safe and might be anxious about her health condition. Nursing Problem Prioritization Nursing Diagnosis Hyperthermia related to inflammatory response PRIORITIZATION 1 JUSTIFICATION Hyperthermia is considered as a high priority problem because according to ABCs of life.B. Acute pain neither belongs to airway. which is one of the highest priorities the nurse must address. temperature has the possibility to affect the respiration or breathing of an individual. which is the first and most important level. which is the second level. This is the reason why it is considered as a high priority problem. nor circulation (ABCs) of the body. based on Maslow s Hierarchy of Needs. Acute Pain related to bladder irritation 2 Activity intolerance related to generalized body weakness 3 . Activity belongs to physiologic needs of Maslow s Hierarchy of needs. It requires immediate intervention to prevent the occurrence of further complication. In addition.

Knowledge deficit related to information misinterpretation 4 Knowledge belongs to physiologic needs of Maslow s Hierarchy of needs. Anxiety related to information misinterpretation 5 ASSESSMENT DIAGNOSIS SCIENTIFIC KNOWLEDGE PLANNING INTERVENTION RATIONALE EVALUATION . however it does not need immediate attention for our nursing intervention is just to provide health teaching. Anxiety belongs to safety and security of Maslow s Hierarchy of needs. anxiety will be lessen after providing sufficient information.

normal range.oC Short term: INDEPENDENT After 30 mins. Cool was free of convection environment complications such (Ref. Edition 11 ± p. yung mata ko ang init din. macrophages.: Nurse¶s client was able to Pocket Guide ± maintain core Diagnoses. . Eighth Edition. renal failure.0C >flushed skin observed >skin warm to touch Hyperthermia related to inflammatory response as manifested by flushed skin.´ as verbalized by the patient O>T=38. After  to monitor for the 1hour of nursing changes interventions the (Ref. Bladder irritation Short term: Goal Met. 531) . Rationales.: Kozier and (fans) as irreversible brain Erb¶s Fundamentals or neurological of Nursing ± damage or acute Concepts. Monitor core interventions client temperature Release of pyrogenic will be able to cytokines (endogenous maintain core pyrogen) by temperature within monocytes.S> ³ Ang init ng init pakiramdam ko. Process. or acute renal failure. Volume Two ± p. helper Tcells and fibrolasts Production of prostaglandin by Long term: endogenous pyrogens After 2-8 hours of nursing Raises hypothalamic interventions client thermoregulatory set. After 4 hours of nursing interventions client  heat loss by 2. skin warm to touch and T=38. and Practice. Interventions.384) Long term: Goal met. temperature within Prioritized normal range.1 Injury/infection hour of nursing 1.will be free of point complications such as neurological hyperthermia damage like seizure.

: Kozier and rest Erb¶s Fundamentals of Nursing ± . Volume Two ± p.386) to limit heat production 4.-cool tepid sponge bath y heat loss by evaporation and conduction (Ref. and Practice. 531) 3. Edition 11 ± p.: Kozier and Erb¶s Fundamentals of Nursing ± Concepts. Prioritized Interventions. Maintain bed (Ref. Rationales. Process.: Nurse¶s Pocket Guide ± Diagnoses. Eighth Edition. Wrap extremities with bath towels to minimize shivering (Ref.

Prioritized Interventions. Administer  to support circulating volume and tissue perfusion (Ref.: Nurse¶s . 531) 5. Process. Rationales. Volume One ± pg. and Practice (Eighth Edition.: Nurse¶s Pocket Guide ± Diagnoses. Edition 11 ± p.385) DEPENDENT 1.Concepts. Increase adequate fluid intake to support circulating volume and tissue perfusion (Ref.

Rationales. Prioritized Interventions.: Nurse¶s Pocket Guide ± Diagnoses.replacement fluids and electrolytes (PNSS) Pocket Guide ± Diagnoses. Prioritized Interventions. Edition 11 ± p. Edition 11 ± p.386) .385) 2. Administer antipyretics (Paracetamol) >to lower body temperature (Ref. Rationales.

positioning keeps pressure off the area of pain (Ref. 2. Edition 11 ± p. Rationales. Prioritized Interventions. will be able to report use of mentholated decrease in painful ointments.´ As verbalized by te patient > Pain scale of 8/10 O> Q= Dull R= Flank area S= moderate severe > Facial grimace observed DIAGNOSIS Acute Pain related to bladder irritation as manifested by verbalization of flank pain SCIENTIFIC KNOWLEDGE Bladder irritation tissue damage stimulation chemical of pain mediators receptors (nociceptors) Pain pathways to brain PLANNING INTERVENTION RATIONALE EVALUATION Short-term Goal:0 painful experience. quiet experience. nurses scale of 8/10 will be presence).ASSESSMENT S>´Sumasakit yung pinagkayuran sakin. decrease to 6/10 and below. pain environment.) . Encouraged use of relaxation activities (focus/ deep breathing. Eighth Edition. pain scale of 8/10 decrease to 5/10 Long-term Goal: After 6 hours of nursing interventions client reported that pain is controlled from tolerable level of pain Short-term Goal: INDEPENDENT After 30 minutes to 1 hours of nursing 1.: Nurse¶s Pocket Guide ± Diagnoses. Process.919) >To distract attention and reduce tension.: Kozier and Erb¶s Fundamentals of Nursing ± Concepts. Volume Two ± p.501) Long-term Goal: Sensory experience After 2 to 8 hours of nursing Pain perception interventions client will be able to report that pain is controlled. Provided comfort interventions client measures (touch. to distract attention and reduce tension (Ref. and Practice. calm activities. >To promote non pharmacological management.

3. (Ref.: Nurse¶s Pocket Guide ± Diagnoses. Encourage >to monitor the verbalization of condition feelings about pain.: Nurse¶s Pocket Guide ± Diagnoses.502) 4. Rationales.501) . Rationales. Encourage adequate >To prevent fatigue rest periods. Edition 11 ± p. Edition 11 ± p. Prioritized Interventions. Prioritized Interventions.: Nurse¶s Pocket Guide ± Diagnoses.501) 5. >to distract attention and reduce tension (Ref. Edition 11 ± p. (Ref. Rationales. Prioritized Interventions. Encourage diversional activities like watching TV.

>To maintain acceptable level of pain.502) . Prioritized Interventions. Administer analgesic (Ketorolac).: Nurse¶s Pocket Guide ± Diagnoses.DEPENDENT: 1. Edition 11 ± p. (Ref. Rationales.

72) 2.72) Long term: Muscle weakness After 1 to 2 days of nursing Activity intolerance interventions client will be able to report measurable increase in activity tolerance. Edition 11 ± p.: Nurse¶s Pocket Guide ± Diagnoses. >to conserve energy (Ref. SCIENTIFIC KNOWLEDGE Fever/pain sensation Increase cell metabolism Increase energy consumption in cells Depletion of energy PLANNING INTERVENTION RATIONALE EVALUATION Short term: Goal Met. Rationales. hindi ko tuloymagawa ung mga dati kong ginagawa. teach methods such as taking a rest for about 3 minutes in any activity. >to prevent fatigue interventions client (Ref. Rationales.: Nurse¶s Pocket Guide ± will be able to Diagnoses. Prioritized . After 1 hour of nursing interventions client participated willingly in necessary activities. Long term: After 2 days of nursing interventions client reported measurable increased in activity tolerance. Edition 11 ± p.ASSESSMENT S> ³ Nanlalata ako. O>body weakness observed >pallor noted Short term: INDEPENDENT: After 30 minutes to 1 hour of nursing 1. activities.: Nurse¶s Pocket Guide ± Diagnoses. Increase activity levels gradually. >to reduce fatigue (Ref.´ DIAGNOSIS Activity intolerance related to generalized body weakness as manifested by pallor. Prioritized Interventions. Assist in any activities. participate willingly Prioritized in necessary Interventions.

Edition 11 ± p. Prioritized Interventions. Edition 11 ± p.72) 4. Edition 11 ± p.72) 5. Instruct in monitoring . Promote comfort measures and provide for relief of pain. Interventions. >to prevent fatigue (Ref. >to enhance ability to participate in activities (Ref. Prioritized Interventions. Plan care to carefully balance rest period with activities. Rationales.: Nurse¶s Pocket Guide ± Diagnoses. Provide adequate rest periods. Rationales.3. Rationales.72) 6.: Nurse¶s Pocket Guide ± Diagnoses.

response to activity. Rationales.: Nurse¶s Pocket Guide ± Diagnoses. Prioritized Interventions.72) . Edition 11 ± p. >to indicate need to alter activity level (Ref.

Discharge Planning EXERCISES ‡ Advice patient ‡ not to start any other vigorous exercises until approved by the physician ‡ Tell patient to do deep breathing exercise. low intake of oily foods. banana. ‡ ‡ ‡ Each medication should be taken according to the physician¶s order. Increase fluid intake. Keep the private organ clean always. cefuroxime ‡ 500mg tab BID x 1 week ‡ tritab 3 tabs. MEDICATION ‡ Instruct the patient to take doctors prescribed medication: cefuroxime 500mg tab BID x 1 week tritab 3 tabs. Wash hands before eating. before breakfast x 4 months Glibenclamide 5 mg tab BID before meal Metformin 500 mg tab TID HYGEINE Take a bath every day. ‡ ‡ . ‡ ‡ ‡ ‡ ‡ ‡ Have a regular check-up ‡ after hospitalization to monitor the condition. Council the patient to eat foods such fruits (pineapple. after urinating wash the private organ with warm water and mild soap. etc.). ‡ OUT PATIENT Follow the doctor¶s order for the follow up check up. August 4 10:00 in the morning August 11 5-6:00 in the afternoon ‡ DIET Instruct the patient for DAT Encourage the client to eat a well-balanced meal. ampalaya and other green leafy vegetables. ‡ ‡ TREATMENT Medication should ‡ be given in right dosage. before breakfast x 4 months Glibenclamide 5 mg tab BID before meal Metformin 500 mg tab TID Continuously treat the patient Teach patient to avoid self care medication.VI.

Conclusion Based on our comprehensive study our subject case of a 64 years old male client who was diagnosed with Benign Prostatic Hyperthropy can experience different kinds of symptoms that alters patient's ability to move or produce energy to do her activities of daily living.com Wikipedia.com eMedicine.com Google. as we implement the different nursing plan of action thought to be done Bibliography VIII. Rationales. This also facilitated in enhancing our abilities and rational thinking in terms of caregiving.medscape. Process.org . Edition 11 Nursing Drug Handbook 11th edition by Lippincott-William Anatomy and Physiology 2nd edition by Stephen tate Microbiology 5th edition by Nester Medical-Surgical Nursing 11th edition by Brunner-Suddarth Nursing Scribd. The provided health teachings for our patient was effective as manifested by our patients verbalization and demonstration of the given health teaching which then lead her in achieving self-wellness. the student nurses of BulSU-CON conclude that our patient was able to receive the best nursing care that fits to her condition: all of our nursing care plans have met it's goal that aim to the wellness of our patient. Prioritized Interventions. This knowledge and skills help us to formulate a sound and effective plan of care in relation to our patient's precondition. We have also concluded that this case have benifited us with knowledge and skilss in providing rational methods of care to our patient. We have learned how important the role of reproductive system to human life. Damage to the reproductive system might put your life at risk. We. y y y y y y y y y Kozier and Erb¶s Fundamentals of Nursing ± Concepts.VII. and Practice (Eighth Edition Nurse¶s Pocket Guide ± Diagnoses. We need to take good care of our reproductive system and never undervalue it's purpose in our lives.

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