Case Study and Care Plan

| July 12, 2016

Paper , Order, or Assignment Requirements

Criteria:

  • Case Study Evaluation

o Analyze the disorder addressing the following elements: pathophysiology, signs/symptoms, progression trajectory, diagnostic testing, and treatment options.

o Differentiate the disorder from normal development.

o Discuss the physical and psychological demands the disorder places on the patient and family.

o Explain the key concepts that must be shared with the patient and family to achieve optimal disorder management and outcomes.

o Identify key interdisciplinary team personnel needed and how this team will provide care to achieve optimal disorder management and outcomes.

o Interpret facilitators and barriers to optimal disorder management and outcomes.

o Describe strategies to overcome the identified barriers.

  • Care Plan Synthesis

o Design a comprehensive and holistic recognition and planning for the disorder.

o Address how the patient’s socio-cultural background can potentially impact optimal management and outcomes.

o Demonstrate an evidence-based approach to address key issues identified in the case study.

o Formulate a comprehensive but tailored approach to disorder management.

 

PATIENT INFO

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 lowgrade 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

 

 

Care Plan Template

 

Patient Initials: ______ Age: _______________ Sex: ___________

 

Subjective Data:

 

Client Complaints:

 

HPI (History of Present Illness):

 

PMH (Past Medical History—include current medications, any known allergies, any history of surgery or hospitalizations):

 

Significant Family History:

 

Social/Personal History (occupation, lifestyle—diet, exercise, substance use)

 

Description of Client’s Support System:

 

Behavioral or Nonverbal Messages:

 

Client Awareness of Abilities, Disease Process, Health Care Needs:

 

Objective Data:

 

Vital Signs including BMI:

 

Physical Assessment Findings:

 

Lab Tests and Results:

 

Client’s Support System:

 

Client’s Locus of Control and Readiness to Learn:

 

ICD-10 Diagnoses/Client Problems:

 

Advanced Practice Nursing Intervention Plan (including interdisciplinary collaboration, community resources and follow-up plans):

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