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 mans 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 theres 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.

II.

Nursing Assessment

A. Personal History 1. Demographic Data Name: Patient VS Address: Cut-cot, Guiguinto, Bulacan Age: 64 years old Gender: Male Race: Asian Birthday: July 14, 1948 Religious Orientation: Roman Catholic Healthcare Financing: Philhealth of her Child Date of Admission: July 24, 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

B. Reasons for visit/ Chief complain

Para akong binabalisawsaw. Madalas akong naiihi, ngunit pakonti-konti lang ang lumalabas, at parang hindi lumalabas lahat ng ihi, as verbalized by the patient. On

July 24, 2011, Patient VS was admitted in Bulacan Polymedic Hospital for a scheduled Transurethral Resection of the Prostate (TURP). C. History of Past Illness Patient stated that he has complete immunization of tetanus toxoid and vaccination when she was born such as BCG, DPT, OPV, MMR and Hepa B. When the patient was 36 years old, he had his first hospitalization when he was diagnosed of having appendicitis and had an appendectomy as surgical intervention on the year 1975. His 2nd confinement in the hospital was when he was 59 years old and he had undergone cholecystectomy. Two months after the surgery the client had a checkup and was diagnosed of having Diabetes Mellitus Type II. Last June, 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. Patient is taking quadtabs (rifampicin, ethambutol, isonaizid, pyrazinamid) for his tuberculosis, and methformin for diabetes mellitus.

D. History of Present Illness Five months ago, patient VS stated that he started to experience frequency in urination. He further elaborated that his urination is painful and needs force to initiate. 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. He had these symptoms as it worsens until it was accompanied by fever, bladder distention and a burning sensation and more painful urination. Bothered by this, he sought help of a physician and was diagnosed of UTI. He was then given oral medications such as melastosil as treatment. He started the treatment but after a month when the symptoms persisted, he decided to consult a urologist for a more comprehensive medical assessment. The urologist then conducted several tests such as ultrasound and concluded that he was positive of Benign Prostatic Hyperplasia. He was then advised to undergo trans-urethral resection of the prostrate as surgical intervention (TURP).

E. Family Health Illness History Our client was not able to recall his grandparents on both sides. According to him, his father died of stroke but is unable to recall the details of his fathers death such as his fathers age when he died. His mother is 88 years old and still alive without any communicative or hereditary health problems. Among his siblings, our patient and the sister next to him were the only ones diagnosed with diabetes mellitus. 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. Along with \Diabetes Mellitus, our patient is also diagnosed of having tuberculosis.

PATERNAL

MATERNAL

A 71

L 88

B 83

L 76

C 65

VS DM 64

L DM 61

L 59

D 58

D 56

LEGEND: -Male -Female / - client -Deceased - stroke DM- Diabetes mellitus - tuberculosis

F. FUNCTIONAL HEALTH PATTERN

PRIOR TO HOSPITALIZATION

DURING HOSPITALIZATION

a. Health Perception and Health Management Pattern

When client was asked to rate his health before his hospitalization from 110, with one as the lowest, he answered 7 for besides his difficulty in urination and respiratory problems, he felt that he is physically fit. Client VS started smoking when he was 12 years old, and can consume about 30 cigarettes a day. He stops smoking 3 months ago, since he was diagnosed with tuberculosis. His physician advised him to avoid eating fatty and foods rich in carbohydrates due to his diabetes mellitus, but is having difficulty to follow those advices. For him, finances is also a factor that makes following doctors advised hard. He believes that his past surgery, which is cholecystectomy, 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.

He felt relieved after the surgery. He thinks that his recovery will be fast, and was able to go home immediately. During his hospitalization, he follows doctor s order regarding his diet, medication, and other treatment, with the help of his wife and daughter. In the hospital, he believed that resting can help him get well.

b. Nutritional Metabolic Pattern

Date July 21, 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, 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

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,

240 water

ml

1 small bowl of porridge 120ml water

--

--

Julyy 23, 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, for the preparation of his surgery. His doctor then ordered diet as tolerated 4 hours his surgery.

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

c. 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

9x

Scant

Aromati yello c and wish clear

July 24, 2011

7x

Scant

yellowi sh

July 22, 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 26, 2011

Catheter

10,000mL

Clear

reddis h

Catheter

13,000mL

clear

reddis h

--

July 23, 2011

Scant 10x

Aromati c and clear

yello wish

Bowel elimination

Date

Frequency

Characteristi cs

Color

Discomfort

July 24, 2011 Bowel elimination July 25, 2011 Characteri stics -Color Discomfort July 26, 2011

--

--

--

1x

Hard, compacted

Dark Brown

Difficult Straining

Date

Frequency

--

--

--

July 21, 2011 July 22, 2011 July 23, 2011

none

--

--

None

--

--

--

The client was catheterized with cystoclysis during his hospitalization. After the surgery, 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. No vomitus was noted.

none

--

--

--

Para akong binabalisawsaw. Madalas akong naiihi, ngunit pakonti-konti lang ang lumalabas, at parang hindi lumalabas lahat ng ihi, as verbalized by the patient. He described his urine to be in little amount every urination. He also said that he urinates more at night. There is pain experienced upon urinating at the perineal area. When he is defecating he feels that it is impeded. He told us that he usually suffers from constipation

and has a hard time ddefacating.

d. 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- Full self-care Level 0- Full self-care Level I- Requires use of equipment or device Level II- Requires assistance or supervision from another person Level III- Requires assistance or supervision from another person or device, Level IV- Dependent and does not participate He stated that his hospitalization has decreased his ability to perform his Level I- Requires use of equipment or device Level II- Requires assistance or supervision from another person Level III- Requires assistance or supervision from another person or device Level IV- Dependent and does not participate

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. He considers his daily work as a farmer as his main exercise, 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. plays mahjong with his neighbors.

e. Sleep-Rest Pattern
Date Number of hours of Sleep 21, 8 Number of hours of Nap 2 Total Interpretation Date Number of hours of Sleep 24, 9 Number of hours of Nap 0 Total Interpretation

July 2011 July 2011 July 2011

10 hours 9 hours 7 hours

intermittent

July 2011 July 2011 July 2011

10

Uneasy

22,

intermittent

25, 9

Relaxed

23,

Intermittent

26, 10

13

Relaxed

Our client sleeps around 9pm and wakes up for every urge to void, about 4-5 times, and that impedes 1-2 hours of his sleep. Approximately, he is able to sleep for 7-8 hours. Whenever he felt that his tasks are exhausting, he usually takes a nap to regain his strength. 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, 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.

f. 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. Every time due to the fact that he doesn t find his eye condition troubling. He doesn t he feels any discomfort due to his condition, he rests to lessen it. wear any eye glasses or corrective lenses. He stated that he doesn t have any difficulty in hearing. He related that back when he was still working as a driver, he has this difficulty of remembering roadways, and insisted that this was because of his poor memory.

g. 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.

The hospitalization made him weak as he perceived himself but according to him, being in hospital help him to manage his symptoms and made him hopeful that his health will return as once it has been.

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. In terms of finances, his children do not ask him for anything and gives him financial support instead. They also share harmonious relationship with their neighbors and co-workers, and in fact, he was once elected as baranggay councilor. If problem within the family arises, they immediately talk it over and look for ways on how to resolve the conflict.

On the day of his operation, all of his children are present to give him their support, morally and financially. They also ensured the safety of their father and arranged everything to the benefit of their father s welfare. Upon his stay in the hospital, his wife and daughter were the ones attending to his needs.

i. Sexuality Reproductiv e Pattern

Our client is a male. He has 9 children, 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. The last time they have sexual intercourse sexuality and was even thankful that he had undergone the surgery thinking was 14 years ago. They stopped having sexual intercourse since her wife that the action stopped his condition from worsening. had her menopause.

j. 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. When he feels stressed, he sleeping or talking with his wife and daughter, those of which who just listens to the radio or takes a nap, for it is effective to make him feel accompanied him in the hospital. relaxed.

k. Value Belief Pattern

The patient s religion is Roman Catholic. 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. He prays to God rehabilitation. He continued to be devoted in his religion. Though, there have for blessings and above everything, he values his family most. been many trials that have already come to him and his family s way. He still believes firmly and has put his faith in God

G. Growth and Development FRUEDS PSYCHOSEXUAL DEVELOPMENT

STAGE Genital

AGE 12years and above

DEFINITION Energy is directed to physical and intellectual activities. Sexual maturity and function and development of skills needed to cope with the environment. Encourage separation from parents, achievement of independence and decision making.

RESOLUTION AND ACTUAL FINDIGS POSITIVE (+) Patient Vs is 64 years old under in genital stage. Patient VS has his own family he can decide on his own, with the help of his wife and 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.

ERIKSONS PSYCHOSOCIAL DEVELOPMENT STAGE Adulthood Generativity vs. stagnation AGE 12years and above DEFINITION For (+) Care. widening concern for what has been generated by love, necessity or accident, for ones, work or ideas. For (-) Self-indulgence, boredom, and interpersonal impoverishment. RESOLUTION AND ACTUAL FINDIGS POSITIVE(+) for generativity. Patient VS has satisfaction for his life for past 64 years. He is a farmer and believe and stated that he had accomplished what a father is worth for. He had also 18 grand children. He guides them for development of their wellbeing to become a responsible, productive and nature people.

PIAGETS COGNITIVE DEVELOPMENT STAGE AGE DEFINITION RESOLUTION AND ACTUAL FINDIGS

Formal Operation

11years and above

Thinking becomes abstract and symbolic. Reasoning skills develop. A sense of hypothetical developments.

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. Our Patient thinks rationally and logically.

KOLBERGS 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. RESOLUTION AND ACTUAL FINDIGS POSITIVE(+) the client distinguishes what is right and wrong regarding moral values and social norms. In decision making the patient considers the pro/cons of each action that will be made.

III.

Anatomy and Physiology

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

Physical Assessment Name: Patient VS Age: 64y/o T 38.0C P 82bpm GENERAL APPEARANCE

Date of assessment July 26,2011 R 15cpm BP 110/80

Method 1. Body Built Ht.: 5'4'' Wt.: 68 BMI : Inspection and observation

Normal Findings Proportionate, normal BMI in relation to age

Actual Findings Not Proportionate Ht.: 5'4'' Wt.: 68 BMI : Clean and neat ; no body and breath odor Facial Grimace noted

Remarks Normal

3. Over-all Hygiene and Grooming

Inspection and Observation Inspection and observation

Clean and neat

Normal

4. Signs of Distress

No signs of distress

Deviation from normal dueto flank pain

5. Obvious signs of health or illness MENTAL STATUS Level of Consciousness/ Orientation 3. Attitude 4. Affect/mood, appropriateness of responses SKIN 1. 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; Oriented to time, place and situation Cooperative Appropriate to the situation

Oriented to date, place and time situation Cooperative during assessment Responses are appropriate to the situation

Normal Normal Normal

Inspection

Uniform in color

Light brown complexion.

Normal

Uniform in color 2. Presence of Edema Inspection and Palpation Inspection Palpation Palpation Absence of Edema Absence of edema Normal

3. Presence of Lesions 4. Moisture of the skin 5. 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. Skin Turgor

Palpation

When pinched, it springs back within 3 seconds

It springs back to previous state <3 seconds Dry wavy skin noted

NAILS 1. Fingernail plate shape Inspection Convex curvature, angle of nail plate is approx. 160 Highly vascular and pink in light skin clients Convex curvature, angle of nail plate 160 Pale in color Normal

2. Fingernail and toenail bed color

Inspection

Deviation from normal due to decreased effective lung field Normal Normal Normal

3. Fingernail and toenail texture 4. Tissue surrounding nails 5. Blanch Test of Capillary refill HEAD SKULL 1. 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, Normocephalic and

Normal

symmetrical with frontal, parietal and occipital prominences. 2. Presence of nodules, masses and depressions 3. Evenness of hair growth over the scalp 4. Hair thinness or thickness 5. Hair texture and oiliness Palpation Inspection and Palpation Inspection Inspection and Palpation Smooth uniform consistency, absence of nodules and masses Hair evenly distributed Thick hair Silky and resilient hair

symmetrical with frontal, parietal and occipital prominences. Smooth uniform consistency, absence of nodules and masses Hair evenly distributed Thick hair Silky and resilient hair Normal

Normal Normal Normal

FACE 1. Facial Features 2. Symmetry of facial movements EYES EYEBROWS 1. Hair distribution 2. Alignment 3. Skin quality and movement

Inspection Inspection

Symmetric or slightly asymmetric facial features Symmetric facial movements

Slightly asymmetric, saggy facial features, 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, equal movements the eyebrows

Hair evenly distributed Symmetrically aligned intact skin, equal movements

Normal Normal Normal

EYELASHES 1. Evenness of hair distribution 2. Direction of curl EYELIDS Surface characteristics

Inspection Inspection

Equally distributed Curl slightly outward

Equally distributed Curl slightly outward

Normal Normal

Inspection

Skin intact, no discharge and discoloration Approximately 15-20 involuntary

Skin intact, no discharge and no discoloration 18 blinks/min.

Normal

Frequency of blinking

Inspection

Normal

blinks per minute CONJUNCTIVA BULBAR CONJUNCTIVA 1. Color, texture and presence of lesions Inspection by reverting the eyelids Transparent. Capillaries sometimes evident. No presence of lesions Transparent. Capillaries sometimes evident. No presence of lesions Normal

PALPEBRAL CONJUNCTIVA 1. Color, texture and presence of lesions Inspection, by retracting Shiny, smooth, pink or red in color the eyelids with thumb and index finger and asking the client to look up and down, side to side. Pale pink in color, smooth and shiny Deviation from normal due to decreased effective lung field

SCLERA 1. Color CORNEA 1. Clarity and texture PUPIL 1. Color, shape and symmetry of size EARS AURICLES Inspection Black in color, round equal in size Black in color, round equal in size Normal Inspection using a penlight Transparent, shiny and smooth Transparent, shiny and smooth Normal Inspection Sclera appears white Sclera appears white Normal

1. Color, symmetry of size and position

2. Texture, elasticity and areas of tenderness

Inspecting for position. Note the level at which the superior aspect of the auricle attaches to the head in relation to the eyes. Palpation by gently pulling the auricle downward then backward and folding the pinna.

Color same as the facial skin, symmetrical, auricle aligned with the outer canthus of the eye.

Same color with the facial skin

Normal

Mobile, firm and not tender.

Mobile, firm and not tender. Pinna recoils after being folded.

Normal

NOSE 1. External nose for deviations in shape, size or color and flaring or discharge from the nares. 2. External nose for any areas of tenderness, masses and displacements of bone and cartilage

Inspection Palpation

Symmetric; no discharge or flaring; uniform color No tenderness masses and displacements

Symmetric; no discharge or flaring; uniform color No tenderness masses and displacements

Normal Normal

3. Patency

Inspection (by asking the client to close the mouth and then exert pressure or the nares, 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. Mucosa 5. Nasal Septum 6. Sinuses MOUTH

clear watery discharge; No lesions and swelling intact and in midline Not tender

No lesions, discharge and swelling noted intact and in midline No tenderness noted

Normal Normal Normal

LIPS AND BUCCAL MUCOSA 1. Outer lips for symmetry of contour, color and texture

Inspection

Uniform pink color; soft, moist, smooth texture

Pale in color

Deviation from normal due to decreased effective lung field Normal

2.Inner lips and buccal mucosa for color, moisture, texture and the presence of lesions TEETH AND GUMS 1. Characteristics

Inspection and palpation

Uniform color; moist, no lesions

Uniform color; moist, no lesions

Inspection

Smooth white tooth enamel, pink gums with moist, firm texture.

Yellowish tooth enamel, pale gums with moist, firm texture,

Deviation from normal due to decreased effective lung field Normal

2.Tongue movement

Inspection

Central position, smooth lateral Central position, smooth lateral margins; no lesions; raised papillae margins; no lesions; raised papillae; moves freely Smooth base of the tongue with prominent veins Smooth with no palpable nodules Smooth base of the tongue with prominent veins Smooth; no palpable nodules

3. Base of the tongue, floor of the mouth and frenulum 4. Presence of nodules, lumps or excoriated areas PALATES AND UVULA 1. Hard and soft palate for odor, shape, texture and presence of bony prominences

Inspection

Normal

Inspection and Palpation

Normal

Inspection

Light pink, smooth soft palate; lighter pink, hard palate; no bony growths.

Pale in color, smooth soft palate; pale in color, hard palate more irregular texture; no bony growths. Positioned in midline of soft palate

Deviation from normal due to decreased effective lung field

2. Uvula for position and mobility TRACHEA

Inspection

Positioned in midline of soft palate

Normal

1. Lateral Deviations THORAX AND LUNGS 1. Shape and symmetry of the thorax from posterior and lateral views 2. Respiratory Excursion 3. 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- 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; equal vibration Rales present on right apex and right lower lobe of lungs

Normal Normal Normal

4. Breath sounds

Auscultation

Deviation from normal due to decreased effective lung field

ABDOMEN 1. Skin integrity Inspection Unblemished skin; uniform color Unblemished skin; uniform in color Flat; Symmetrical Symmetric movements Normal

2. Contour and symmetry 3. Abdominal movements associated with respirations 4. Bowel sounds

Inspection Observation

Flat, rounded or scaphoid; symmetrical Symmetric movements

Normal Normal

Auscultation

Audible bowel sounds

active bowel sounds (27 bowel sound/min) No tenderness; relaxed abdomen

Normal

5. Areas of tenderness MUSCLES 1. Size

Palpation

No tenderness; relaxed abdomen

Normal

Inspection

Equal in size in both sides of the

Equal in size in both sides of the

Normal

2. Contractures (Softening) 3. Fasciculations and tremors 4. Muscle tonicity UPPER EXTREMITIES 1. Motor strength 2. Muscle tone 3. Presence of lesions, deformities and varicosities 4. Presence of edema LOWER EXTREMITIES 1. 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, no deformities, varicosities may be present No edema

body No contractures No tremors Firm Can perform ROM exercise Smooth and firm No lesions, 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, varicosities may be present, no deformities

Can perform ROM

Normal

2. Muscle tone 3. Presence of lesions, deformities and varicosities

Palpation Inspection

muscle tone not firm No lesions, no deformities

Normal Normal

4. Presence of edema

Inspection and Palpation

No edema

No edema

Normal

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, 2011 Date In: July 25, 2011

> A RBC count is used >4.7 10^ 12/L to evaluate any type of decrease or increase in the number of red blood cells as measured per liter of blood. These changes must be interpreted in conjunction with other parameters, such as hemoglobin,hematocrit .A RBC count is ordered as a part of the complete blood count (CBC), often as part of a routine physical, presurgical procedure, or for other clinical reasons. > A white blood cell >6.5 10^9/L count is a determination of number of WBC or leukocytes/unit volume in a sample of venous blood. The test

>4.5-5.8 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

>5.0-10.0 10^9/L

>Normal

>Use standard procedure and sterile technique when getting the specimen >Secure the patient's arm during blood extraction

is used to detect infection or inflammation and also used to help monitor the bodys response to various treatments and to monitor bone marrow function, and to determine the need for further tests, such as differential count. >Hemoglobin >The hemoglobin test >140.0 is normally ordered as a part of the complete blood count (CBC, which is ordered for many different reasons, including for a general health screen. The test is also repeated in patients who have ongoing bleeding problems or chronic anemias o polycythemia. >The hematocrit is normally ordered as a part of thecomplete blood count (CBC). It is also repeated at regular intervals for >0.45 >140.-180 g/L >Normal

>Apply pressure on the venipucture site after withdrawing specimen After: >Label the specimen container with patients name, age, date and time the specimen was ontained and room number. >Send the specimen to the laboratory immediately. >If the patint feels dizzy after the extraction, instruct the patient to rest for a while

>Hematocrit

>0.42-0.52

>Normal

many conditions, including: the monitoring of treatment for anemia, recovery from dehydration, and monitoring of ongoing bleeding to check its severity. >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.

y y y y

0.60 0.34 0.04 0.02

y y y y

0.50-0.66 0.20-0.40 0.02-0.08 0.01-0.04

>Normal

Blood Chemistry >Glucose (FBS) Date Ordered: July 24, 2011 Date In: July 25, 2011 >The blood glucose test is ordered to >368.5 mg/dL measure the amount of glucose in the blood right at the time of sample collection. It is used to detect both hyperglycemia an d hypoglycemia, to

>75-115 mg/dL

>Normal

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

>0.7-1.5 mg/dL

>Normal

>Sodium (Na)

>136.00mEq/L

>135-153 mEq/L

>Normal

patients. It is one of the blood electrolytes, which are often ordered as a group. It is also included in the basic metabolic panel, widely used when someone has non-specific health complaints, and in monitoring treatment involving IV fluids or when there is a possibility of developing dehydration. > Potassium (K) >Serum or plasma test s for potassium levels >4.30 mEq/L are routinely performed in most patients when they are investigated for any type of serious illness. Potassium testing is frequently ordered, along with other electrolytes, as part of a routine physical. It is used to detect concentrations that are too high (hyperkalemia) or too

>3.5-5.3 mEq/L

>Normal

low (hypokalemia). The most common cause of hyperkalemia iskidney disease, but many drugs can decrease potassium excretion from the body and result in this condition.

Diagnostic Laboratory Date Ordered and Date Indications or Purpose Result Procedure In

Normal Values

Analysis and Interpretation of the Results >PTB, 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, 2011 Date In: July 24, 2011

>A chest x ray is a procedure used to evaluate organs and structures within the chest for symptoms of disease. Chest x rays include views of the lungs, heart, small portions of the gastrointestinal tract, thyroid gland, and the bones of the chest area. X rays are a form of radiation that can penetrate the body and produce an image on an x-ray film.

>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. >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

patients body. >During >Assist the client in the radiology room. >Instruct proper positioning during the procedure. After; >Document the procedure >Secure X-ray res ult. >Refer to the doctor.

V.

The Patient and his care A. Medical Management a. IVF, BT, Nebulizations, TPN, NGT, Oxygen Therapy etc.

MEDICAL MANAGEMENT PNSS

DATE ORDERED/ DATE RESULT IN July 24, 2011- July 28, 2011

GENERAL DESCRIPTION - 0.9% Sodium Chloride Solution - It contains no

INDICATION/ PURPOSES -Normal Saline is a sterile, non-pyrogenic. solution for fluid and

CLIENTS RESPONSE

NURSING RESPONSIBILITIES

-The client maintain fluid and electrolyte balance. -The patient gets sufficient fluid

PRIOR: -read doctor`s order -assess v/s for baseline data -assess skin turgor, any skin allergy, disease or injuring agent

antimicrobial agents.

electrolyte and electrolytes and minimal -determine veni-puncture site Consider : -how long patient is likely to

- The pH is 5.0 (4.5 to replenishment. 7.0). -It contains 9 g/L Certain concentrations of both sodium and calories from dextrose. Also, he received sufficient nutrients from the IVF. an osmolarity of 308 mOsmol/L. - It contains 154 mEq/L Sodium and Chloride. - 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, changed body and the blood or if the IVF therapy is done are essential for DURING: normal body -verify doctor`s order functions. Saline -identify client check IVF if solutions are commonly infusing well. used in medicine as fluid -note IVF name, level, regulation replacements to treat -observe veni-puncture site for or prevent dehydration. any problem.

have IVF, what kind of IVF, medications to be administered

Sodium Chloride with chloride in the blood

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.

B. Drugs Generic Name/ Brand Name

Date Ordered/ Date Given/ Date Discontinue

Route of Administration/ Dossage/ Frequency Oral 500mg/cap.

Action/ Classification

Indication

Clients Response

Nursing Intervention

Cefuroxime Ceftin

Date ordered: 7-25-11 Date given: 7-25,26,27,28-11 Date discontinue: 7-28-11

Bactericidal, inhibits synthetic of bacterial cell wall, causing cell death. Antibiotic, cephalosporin, 2nd generation.

Perioperative prophylaxis.

Signs of infection are minimized.

OD

Prior: Assess if patient has allergy to the drug. During: y Give oral drug with food to decrease G.I. Upset. After: y Instruct patient to take full course of therapy even if you are feeling better. y Swallow tablets whole, do not crush them. y Instruct patient that

side effects are: Stomach upset or diarrhea.

Celecoxib Celebrex, Celexib

Date ordered: 7-25-11 Date given: 7-25,26,27,28-11 Date discontinue: 7-28-11

Oral 200 mg/tab OD

Inhibits prostagladin synthesis by selectively inhibiting cyclo-oxygenase (COX-2). Relieves pain and inflammation. Analgesic(nonopioid),NSAID, Specific COX-2 enzyme inhibitor.

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. y Instruct

patient to report bleeding, bruising, black tarry stool, cramping, fatigue, and malaise. 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. May stimulate colonic intramural plexux and promote fluid accumulation in the intestines and colon. Relief of constipation. The patient defecates the compacted feces. Prior: Lubricate before insertion, patient should retain for 30 mins. During: y Place patient in side lying position. y Insert sopposotory slowly. After: y teach patient about dietary sources of fiber. y Discuss with the patient that adequate

fluid bulk consumption and exercise facilitates bowel movements. Warn patient about exessive use of drug. Inform patient that normal bowel movements do not occur daily. Teach patient not to use in presence of abdominal pain, nausea, vomiting.

Glibenclamide Gluban, Daonil

Date ordered: 7-27-11 Date given: 7-27,28-11 Date discontinue: 7-28-11

Oral 5mg/tab OD

Decrease blood glucose b stimulating insulin release from pancreas. May also decrease hepatic glucose production or increase response of insulin. Anti-diabetic.

Non-insulin The patient blood dependent diabetes glucose decreases mellitus to control from ___ to ____ hyperglycemia in glibenclamide responsive DM of stable.

Prior: Hand washing. Check for Blood Glucose Obtain patient allergies. Instruct to take drug with meal.

During: y Maintain medical techniques in administratio n of medication. y Give patient glass of water. After: y Monitor urine output and glucose level y Instruct patient to notify physician if he/she experience signs of hyperglycem ia. SQ Insulin Humulin R Date given: 7-24,25,26-11 Date discontinue: Date ordered: 7-24-11 It is a hormone secreted by Dosage depends on beta cells of the pancreas that, dr's Quetua's by receptor mediated insulin scale: effects, promotes the storage 1 vial D5050 of the body's fuel, 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. The patient's blood glucose decreases to normal level. Prior: Hand washing Checks clients allergy Check for the CBG of the patient.

7-26-11

120mg/dl

5 u - 121 150mg/dl 7 u- 151 200mg/dl Antidiabetic Hormones 10 u - 201 250mg/dl 12 u - 251 300mg/dl 15 u - 301 350mg/dl 18 u - 351 400mg/dl 20 u - >400mg/dl 07 24 -11 6am 10 u 12am 10 u 07 - 25- 11 12 noon 12u 07 -26 11 12 MN 15 u 6am 10 u

membrane and stimulating the synthesis of glycogen from glucose, of fats from lipids.

During: y Inject the insulin SQ using medical techniques. After: y Teach patient not take any new medication during therapy without consulting physician. y Instruct patient to inject the insulin in rotating in his abdomen. y Ask the patient to notify if he is expieriencing any symptoms of hypoglycemi a. y Store insulin

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

monitoring to prevent hypoglycemi a at night.

Rifampicin/ Isoniazid/ Pyrazinamide/ Ethambutol Quadtab

Date ordered: 7-27-11 Date given: 7-27,28-11 Date discontinue: 7-28-11

Oral 3 tabs OD

Mechanism unknown, highly specific and bactericidal for mycobacterium tuberculosis hominis. Antituberculotic.

Pulmonary and extra pulmonary tuberculosis.

The patient decreases symptoms of TB.

Prior: Hand washing and wear protective mask. Checks clients allergy. During: y Better to administer on empty stomach 1 hour before meals or 2 hours meals with full glass of water. After: y Teach patient not take any new medication during therapy without

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. Respiratory drug. Management of reversible bronchospasm associated with obstructive airway desease.

consulting physician. Instruct patient to take drug in an empty stomach. Hand washing.

The patient Prior: demonstrate Hand washing. effective breathing Assess for any pattern and gas drug allergy exchange. of the patient. Use solution in nebulizer with a mouthpiece rather than a facial mask. During: y Maintain medical technique in administratio n of medication. After: y Tell patient to avoid

accidentally spraying into eye. Disscuss to patient the drug side effect.

Ketorolac Kortezor, 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. Analgesic, antipyretic, antiinflammatory.

Short-term management of moderate to severe acute postoperative pain.

Patient post operative pain is reduced. Patient improved mobility.

Prior: Hand washing. Check IV site, tubing, and injection port. Clean injection port before administerin g. During: y Maintain medical technique during administratio n. After: y Advice patient to report persistence orworsening of pain.

Instruct patient to report any bleeding, bruising, fatigue. Discuss to patient about side effect.

C. Diet MEDICAL MANAGEMENT DATE ORDERED/ DATE RESULT IN July 24, 2011 (11pm) GENERAL DESCRIPTION INDICATION/ PURPOSES CLIENT`S RESPONSE NURSING RESPONSIBILITIES

NPO

-NPO stands for Nothing Typical reasons for NPO -Increased thirst. instructions are the Per Orem which means prevention of aspiration - (+) Body weakness. pneumonia, e.g. in those nothing by mouth. who will undergo -cooperative. general anaesthetic, or - Doctors use this on those with weak swallowing musculature, orders when they do not or in case of gastrointestinal bleeding want the patient to take or gastrointestinal blockage. Alcohol overdoses that result in in any type of food or vomiting also warrant NPO instructions for a liquid by mouth. For

PRIOR: -read doctor`s order regarding client`s diet -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

period of time. instance, when a patient

purpose -instruct & explain to client his/her diet.

is getting ready for a DURING: surgery, they are ordered -verify doctor`s order for NPO. -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. MEDICAL MANAGEMENT DATE ORDERED/ DATE RESULT IN GENERAL DESCRIPTION INDICATION/ PURPOSES CLIENT`S RESPONSE NURSING RESPONSIBILITIES

DAT Diet as tolerated

July 25, 2011

DAT- Any nutritious foods that can be tolerated or desired by the client.

DAT, -his particular diet is only given when client can now tolerate any food she desires that is nutritious, if this will not

-The patient was able to PRIOR: -read doctor`s order regarding client`s gave enough calorie. diet intake to sustain energy -Replenishment of Nutrients. -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. -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

boost immune system -instructed to avoid eating street foods that is exposed to microorganism to prevent acquiring other diseases.

C. Surgical Management B. SURGICAL MANAGEMENT Transurethral resection of the prostate (also known as TURP, and as a transurethral prostatic resection, TUPR) is a urological operation. It is the most common procedure and considered as gold standard of prostate procedure used to treat benign prostatic hyperplasia (BPH). As the name indicates, it can be carried out through endoscopy. The surgical and optical instrument is introduced directly through the urethra to the prostate, which can then be viewed directly. The gland is removed in small chips with an electrical cutting loop (electrocautery or sharp dissection.) This is considered the most effective treatment for BPH. This procedure is done with spinal or general anesthetic and requires no incision, 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. Newer technology uses bipolar electro surgery and reduces the risk of TURP syndrome (hyponatremia, hypovolemia).TURP usually requires an overnight hospital stay. Urethral strictures are more frequent than with (non-trans-urethral procedures, and repeated procedures may be necessary because the residual prostatic tissue grows back. TURP rarely causes erectile dysfunction, 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. 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 80-90% of BPH patients.

PATIENTS RESPONSE TO OPERATION: As the days go by after the surgery, 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. The client is discharge three days after the surgery. Pre-operative Management: 1. 2. 3. 4. 5. Inform consent secured. Kept the patient comfortable. Monitor vital sign Inform the patient about the procedure and the expected postoperative care, including catheter drainage, irrigation and monitoring of hematuria. 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. This complication can lead to confusion, changes in mental status, vomiting, nausea, and even coma. To prevent TURP syndrome the length of the procedure is limited to less than one hour in more centers. 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.

6. 7. 8.

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

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

Acute Pain related to bladder irritation

Activity intolerance related to generalized body weakness

Knowledge deficit related to information misinterpretation

Knowledge belongs to physiologic needs of Maslow s Hierarchy of needs, 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.

Anxiety related to information misinterpretation

ASSESSMENT

DIAGNOSIS

SCIENTIFIC KNOWLEDGE

PLANNING

INTERVENTION

RATIONALE

EVALUATION

S> Ang init ng init pakiramdam ko, yung mata ko ang init din. as verbalized by the patient

O>T=38.0C >flushed skin observed >skin warm to touch

Hyperthermia related to inflammatory response as manifested by flushed skin, skin warm to touch and T=38.oC

Short term: INDEPENDENT After 30 mins. - 1 Injury/infection hour of nursing 1. Monitor core interventions client temperature Release of pyrogenic will be able to cytokines (endogenous maintain core pyrogen) by temperature within monocytes, normal range. macrophages, helper Tcells and fibrolasts Production of prostaglandin by Long term: endogenous pyrogens After 2-8 hours of nursing Raises hypothalamic interventions client thermoregulatory set- will be free of point complications such as neurological hyperthermia damage like seizure, or acute renal failure.

Bladder irritation

Short term: Goal Met. After  to monitor for the 1hour of nursing changes interventions the (Ref.: Nurses client was able to Pocket Guide maintain core Diagnoses, temperature within Prioritized normal range. Interventions, Rationales; Edition 11 p.384)

Long term: Goal met. After 4 hours of nursing interventions client  heat loss by 2. Cool was free of convection environment complications such (Ref.: Kozier and (fans) as irreversible brain Erbs Fundamentals or neurological of Nursing damage or acute Concepts, Process, renal failure. and Practice; Eighth Edition, Volume Two p. 531)

-cool tepid sponge bath

y heat loss by evaporation and conduction (Ref.: Kozier and Erbs Fundamentals of Nursing Concepts, Process, and Practice; Eighth Edition, Volume Two p. 531)

3. Wrap extremities with bath towels

to minimize shivering (Ref.: Nurses Pocket Guide Diagnoses, Prioritized Interventions, Rationales; Edition 11 p.386)

to limit heat production 4. Maintain bed (Ref.: Kozier and rest Erbs Fundamentals of Nursing

Concepts, Process, and Practice (Eighth Edition, Volume One pg. 531)

5. Increase adequate fluid intake

to support circulating volume and tissue perfusion (Ref.: Nurses Pocket Guide Diagnoses, Prioritized Interventions, Rationales; Edition 11 p.385)

DEPENDENT 1. Administer

 to support circulating volume and tissue perfusion (Ref.: Nurses

replacement fluids and electrolytes (PNSS)

Pocket Guide Diagnoses, Prioritized Interventions, Rationales; Edition 11 p.385)

2. Administer antipyretics (Paracetamol)

>to lower body temperature (Ref.: Nurses Pocket Guide Diagnoses, Prioritized Interventions, Rationales; Edition 11 p.386)

ASSESSMENT S>Sumasakit yung pinagkayuran sakin. 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, 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. Provided comfort interventions client measures (touch, will be able to report use of mentholated decrease in painful ointments, quiet experience, pain environment, nurses scale of 8/10 will be presence). decrease to 6/10 and below.

>To promote non pharmacological management. positioning keeps pressure off the area of pain (Ref.: Kozier and Erbs Fundamentals of Nursing Concepts, Process, and Practice; Eighth Edition, Volume Two p.919) >To distract attention and reduce tension. to distract attention and reduce tension (Ref.: Nurses Pocket Guide Diagnoses, Prioritized Interventions, Rationales; Edition 11 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.

2. Encouraged use of relaxation activities (focus/ deep breathing, calm activities,)

3. Encourage adequate >To prevent fatigue rest periods. (Ref.: Nurses Pocket Guide Diagnoses, Prioritized Interventions, Rationales; Edition 11 p.502) 4. Encourage diversional activities like watching TV. >to distract attention and reduce tension (Ref.: Nurses Pocket Guide Diagnoses, Prioritized Interventions, Rationales; Edition 11 p.501)

5. Encourage >to monitor the verbalization of condition feelings about pain. (Ref.: Nurses Pocket Guide Diagnoses, Prioritized Interventions, Rationales; Edition 11 p.501)

DEPENDENT: 1. Administer analgesic (Ketorolac). >To maintain acceptable level of pain. (Ref.: Nurses Pocket Guide Diagnoses, Prioritized Interventions, Rationales; Edition 11 p.502)

ASSESSMENT S> Nanlalata ako, hindi ko tuloymagawa ung mga dati kong ginagawa.

DIAGNOSIS Activity intolerance related to generalized body weakness as manifested by pallor.

SCIENTIFIC KNOWLEDGE Fever/pain sensation Increase cell metabolism Increase energy consumption in cells Depletion of energy

PLANNING

INTERVENTION

RATIONALE

EVALUATION Short term: Goal Met. After 1 hour of nursing interventions client participated willingly in necessary activities.

O>body weakness observed >pallor noted

Short term: INDEPENDENT: After 30 minutes to 1 hour of nursing 1. Assist in any activities. >to prevent fatigue interventions client (Ref.: Nurses Pocket Guide will be able to Diagnoses, participate willingly Prioritized in necessary Interventions, activities. Rationales; Edition 11 p.72) 2. Increase activity levels gradually, teach methods such as taking a rest for about 3 minutes in any activity. >to conserve energy (Ref.: Nurses Pocket Guide Diagnoses, Prioritized Interventions, Rationales; Edition 11 p.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.

Long term: After 2 days of nursing interventions client reported measurable increased in activity tolerance.

>to reduce fatigue (Ref.: Nurses Pocket Guide Diagnoses, Prioritized

3. Plan care to carefully balance rest period with activities.

Interventions, Rationales; Edition 11 p.72)

4. Provide adequate rest periods.

>to prevent fatigue (Ref.: Nurses Pocket Guide Diagnoses, Prioritized Interventions, Rationales; Edition 11 p.72)

5. Promote comfort measures and provide for relief of pain.

>to enhance ability to participate in activities (Ref.: Nurses Pocket Guide Diagnoses, Prioritized Interventions, Rationales; Edition 11 p.72)

6. Instruct in monitoring

response to activity.

>to indicate need to alter activity level (Ref.: Nurses Pocket Guide Diagnoses, Prioritized Interventions, Rationales; Edition 11 p.72)

VI.

Discharge Planning EXERCISES Advice patient not to start any other vigorous exercises until approved by the physician Tell patient to do deep breathing exercise. TREATMENT Medication should be given in right dosage, cefuroxime 500mg tab BID x 1 week tritab 3 tabs, before breakfast x 4 months Glibenclamide 5 mg tab BID before meal Metformin 500 mg tab TID HYGEINE Take a bath every day. Wash hands before eating. Keep the private organ clean always, after urinating wash the private organ with warm water and mild soap. OUT PATIENT Follow the doctors 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. Council the patient to eat foods such fruits (pineapple, banana, etc.), ampalaya and other green leafy vegetables, low intake of oily foods. Increase fluid intake.

MEDICATION Instruct the patient to take doctors prescribed medication: cefuroxime 500mg tab BID x 1 week tritab 3 tabs, 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.

Have a regular check-up after hospitalization to monitor the condition.

Each medication should be taken according to the physicians order.

VII.

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. 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 need to take good care of our reproductive system and never undervalue it's purpose in our lives. We, 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. 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. We have also concluded that this case have benifited us with knowledge and skilss in providing rational methods of care to our patient. This knowledge and skills help us to formulate a sound and effective plan of care in relation to our patient's precondition. This also facilitated in enhancing our abilities and rational thinking in terms of caregiving, as we implement the different nursing plan of action thought to be done Bibliography

VIII. y y y y y y y y y

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