prostatic ncp

NURSING CARE PLAN

Patient’s Name:A.P.D Hosp. No.: 090022532042Age:80 years old Room No.: 8B-844Impression/Diagnosis: Acute Urinary Retention sec. to Prostatic malignancy Physician Dr. W. LimquicoNurse’s Name & Signature: Bulalaque, Jhanine

CLINICAL PORTRAIT PERTINENT DATAI. ASSESSMENT

-Upon assessment patient is conscious, coherent, oriented to time, person and place, and responsible to questions being asked.

-Patient skin is uniform in brown color, warm and smooth to touch. Her head is normocephalic, hair is not equally distributed and white in color. Chest wall are symmetrical no abnormalities noted. Nutrition approach is through oral.

II. SIGNIFICANT FINDINGS

-One day prior to admission noted difficulty in urinating associated with hematuria, no other associated signs and symptoms.

III. Vital Signs taken during 1st contact:Temperature: 37.2 degrees celciusBlood Pressure:150/100 mmHgPulse Rate:84 bpmRespirations:20 cpm

IV. 5 Priority Nursing Problems

I. HISTORY OF PRESENT ILLNESSOne day prior to admission noted difficulty in urinating associated with hematuria, no other associated signs and symptoms.

II. CHIEF COMPLAINTSPatient came in due to pain in the suprapubic area and hematuria noted during urination.

III. PAST HEALTH HISTORYThe patient had experienced fever, cough, measles, and mumps when he was young. He had experienced hospitalization when he 1st experience UTI. Patient claimed that his immunizations when he was young are up-to-date and has no allergies from drugs and foods.

IV. VITAL SIGNSTemperature: 37.1 degrees CelsiusBlood Pressure:130/90 mmHgPulse Rate:92 bpmRespirations:20 cpm

V. LABORATORY REPORTHEMATOLOGY REPORT

08-30-2011 09-02-2011 09-06-2011Complete Blood Count

Alteration in comfort: Pain related to urinary retention sec. to prostatic malignancy Hyperthermia related to disease process Risk for infection related to catheter insertion Deficient knowledge related to the diagnosis of : cancer, urinary difficulties, and

treatment modalities Disturbed sleep pattern related to interruptions of frequent monitoring.

WBC 6.90 6.93 8.40RBC 3.24↓ 3.14↓ 3.14↓Hemoglobin 9.6↓ 9.7↓ 9.5↓Hematocrit 29.2↓ 28.9↓ 28.4↓Platelet 175 180 280

Blood IndicesMCV 90.0 92.0 90.0MCH 29.8 30.9 30.3MCHC 33.1 33.6 33.5RDW 13.1 16.2↑ 12.6PDW 15.3↑ 10.9 14.5↑MPV 8.1 9.8 9.4Relative Differential CountNeutrophil (%) 87.3↑ 74.5↑ 80.5↑Lymphocytes (%) 7.5↓ 12.1↓ 11.7↓Monocyte (%) 4.1 9.7↑ 5.5Eosinophils (%) 0.8 3.6 2.2Basophils (%) 0.3 0.1 0.1Absolute Differential CountNeutrophil (#) 6.06 5.16 6.73Lymphocytes (#) 0.52↓ 6.84↓ 0.98Monocytes (#) 0.28 0.67 0.46Eosinophils (#) 0.06 0.25 0.18Basophils (#) 0.02 0.01 0.01

HEMATOLOGY REPORT

Prothrombin Time Result Reference UnitPatient 16.0 Sec.Activity 68.0 >70% %

INR 1.30 <=1.21Control 13.0 Sec

Control activity 100.0 %

CLINICAL CHEMISTRY REPORTTest Result Reference unit

Creatinine 2.0↑ 0.6-1.5 Mg/uL

URINALYSISPhysical Characteristics Result

Color Brick redTransparency cloudypH 7.0Specific Gravity 1.010

Chemical Characteristics ResultProtein 30Glucose NegativeKetone NegativeUrobilinogen 4Leukocytes 0.03Blood PositiveBilirubin PositiveNitrite NegativeAscorbic Acid Negative

Microscopic Finding ResultRBC 16WBC 4Bacteria NoneMucus Threads 6

CUES NURSING DAIGNOSIS

SCIENTIFIC BASIS

GOALS & OUTCOME CRITERIA

NURSING OUTCOME &

NURSING ORDERS

RATIONALE EVALUATION

S-“sakit ang ako pus.on dapit” as verbalized by the patient.

O-Received patient lying on bed, conscious, coherent, a febrile, and responsive to questions asked with a grimaced face, guarding behaviour on the suprapubic area due to urinary obstruction. With a pain scale of 8,10 as the highest pain and 0 as no pain

Alteration in comfort: Pain related to urinary retention sec. to prostatic malignancy

Pain exists when the patient says it does. Pain may be either acute or chronic. Acute pain is sudden and of short duration it may be associated with a single event, such as surgery, or an acute exacerbation of a condition such as sickle cell crisis. The inflammatory response that follows the initial injury causes a sustained pained response.(Fuller, 2001, London p.12008)

Goals: after 8 hours of nursing intervention the patient will be able to verbalize decrease of pain and discomfort.

The pt. will:1. Verbalize a pain

scale of 4/10.2. Diminished or

absent of nonverbal indicators such as: grimace, irritable and guarding behavior.

3. Will appear relax and more fit and healthy.

4. Participate in desired activities at level of activity

5. Verbalize the reduction of pain

After 8 hours of nursing interventions, patient will be able to verbalize the relief of pain.

INDEPENDENT

Assess pain, noting location, characteristic, severity,(0-10 scale). Investigate and report changes in pain as appropriate.

Useful in monitoring effectiveness of medication, progression of healing. Changes in characteristic of pain may indicate developing abscess/ peritonitis, requiring prompt medical evaluation and intervention.

(Doenges 7th ed. P.354)

After 8 hours of nursing interventions, patient was able to verbalize the pain scale of 4. Demonstrate behaviours which are less pain.

Goal was partially met.

Provide accurate, honest information to client / SO.

Keep at rest in semi-Fowler’s position.

DEPENDENT

Encourage early ambulation.

Being informed about progress of situation provides emotional support, helping to decrease anxiety.


Gravity localizes inflammatory exudates into lower abdomen or pelvis, relieving abdominal tension, which is accentuated by supine position.


Promotes normalization of organ function; e.g., stimulates peristalsis and passing of flatus, reducing

Provide diversional activities.

COLLABORATIVE

Keep NPO/ maintain NG suction initially

Administer analgesics as indicated.

abdominal discomfort.


Refocuses attention, promotes relaxation, and may enhance coping abilities.


Decreases discomfort of early intestinal peristalsis and gastric irritation/ vomiting.


Relief of pain facilitates cooperation with other therapeutic interventions; e.g., ambulation, pulmonary toilet.


Place ice bag on abdomen periodically during initial 24-48 hr as appropriate.

Soothes and relieves pain trough desentization of nerve endings. Note do not use heat because it may cause tissue congestion/ increase edema formation.


UNIVERSITY OF CEBU-BANILADCOLLEGE OF NURING

DRUG STUDY

Patient: A.P.D Age: 80 yr.old Hospital No.:11-002-266-70-75 Room No.: 7A-715

Impression/ Diagnosis: Acute Urinary Retention sec. to Prostatic Malignancy Attending Physician: Dr. W. Limquico

Allergy to: NONE

GENERIC / BRAND NAME &

CLASSIFICATION

DOSE, STRENGTH &

FORMULATION

INDICATION / MECHANISM

OF DRUG ACTION

ADVERSE/ SIDE EFFECTS &

DRUG INTERACTION

NURSING RESPONSIBILITIES

RATIONALE CLIENT TEACHING

GENERIC :

folic acid

BRAND:

Folart

CLASSIFICATION:

ORDERED:

5 mg (PO)

TIMING:

OD

DURATION:

Unknown

INDICATIONS:

To treat folic acid deficiency.

MECHANISM OF ACTION:

Act as a catalyst for

Adverse effect / Side effect: Allergic reaction (bronchospasm, erythema, fever, malaise, rash, pruritus)

Drug Interaction:

Analgesics, carbamazipine ,estrogens(including oral contraceptives), phenolbarbital,

Warning: Don’t give injection form containing benzyl alcohol to neonates or immature infants.

Give folic acid

Because a fatal toxic syndrome may occur with CNS, respiratory, circulatory, and renal impairment and metabolic acidosis.

(Jones & Barlett 10th ed. P. 460)

To prevent

Advise against taking folic acid supplements as a substitute for proper dietary intake. Explain that good sources of folic acid include green vegetables, potatoes, cereals, and

Nutritional supplement

OTHER FORMS:

Tablets, I.V. infusion, I.M or subcutaneous injection

normal production of red blood cells, helping to prevent megaloblastic anemia, and helps maintain normal homocysteine levels. After being converted to tetrahydrofolic acid in the intestines, folic acid promotes synthesis of several enzymes, including glycine and methathionine; and metabolism of histidine, all of which are essential for normal cell structure and growth.

primidone,:possibly increased folic acid requirement.

supplements at least 1 hour before or 4 hours after cholestyramine or sulfasalazine and don’t give antacids within 1 hour before or 2 hours after giving folic acid.

Know that folic acid will correct hematologic disorders in pernicious anemia, but neurologic problems will progressively worsen.

decreased absorption.


To prevent further complication.


organ meats. Recommend eating raw green vegetables because heat used during cooking destroys up to 99% of folic acid in food.

Explain to patients with pernicious anemia that folic acid won’t affect the neurologic symptoms associated with the disease.

Mrs. Pergeline Cabahug Jhanine F. Bulalaque

Printed name and signature Printed name and signature Clinical instructor student

UNIVERSITY OF CEBU-BANILAD COLLEGE OF NURING

DRUG STUDY

Patient: A.P.D Age: 80 yr.old Hospital No.:11-002-266-70-75 Room No.: 7A-715Impression/ Diagnosis: Acute Urinary Retention sec. to Prostatic Malignancy Attending Physician: Dr. W. LimquicoAllergy to: NONE


CLASSIFICATION

DOSE, STRENGTH &

FORMULATION

INDICATION / MECHANISM OF DRUG ACTION

ADVERSE/ SIDE EFFECTS & DRUG

INTERACTION



GENERIC :

cefixime

BRAND:

Targecef

CLASSIFICATION:

antibiotic

ORDERED:

500 mg (PO)

TIMING:

TID

DURATION:

unknown

OTHER FORMS:

Oral suspension,

INDICATIONS:

To treat uncomplicated UTI caused by Escherichia coli and Proteus mirabilis; otitis media caused by Haemophilis influezae, Moraxella catarrhalis, or Strptococcus pyogenes; pharyngitis and tonsillitis caused by S. pyogenes; acute bronchitis and acute acute exacerbations of

Adverse effect / Side effect:

CNS: chills, fever, headache, seizures.CV: EdemaEENT: hearing lossGI: abdominal cramps, diarrhea, elevated, liver function test results, hepatic, failure, hepatitis, hepatomegaly, jaundice, nausea, oral candidiasis, pseudomembranous colitis, vomiting.GU: elevated BUN

Use cefixime cautiously in patients with impaired renal function or a history of GI disease, especially colitis.

If possible, obtain culture and sensitivity test results, as ordered, before giving the drug.

To prevent further complication.


To know if the patient is allergic to that medication or not.

(Jones & Barlett 10th ed.

Instruct patient to complete the prescribed course of therapy.

Advise patient to shake oral suspension well before pouring dose and to use a calibrated device to obtain an accurate dose.

Instruct patient to store

tablets, capsules. chronic bronchitis caused by H. influenza and Streptococcus pneumonia.


Interferes with bacterial cell wall synthesis by inhibiting the final step in the in the cross linking of peptidoglycan makes cell membranes rigid and protective. Without it, bacterial cells rupture and die.

level, nephrotoxicity, renal failure, vaginal candidiasisHEME: eosinophilia, haemolytic anemia, hypoprothrombinemia, neutropenia, thrombocytopenia, unusual bleedingMS: arthralgiaRESP: dyspneaSKIN: ecchymosis, erythema, pruritus, rash, Stevens-Johnsons syndrome.

Tablets shouldn’t be substituted for oral suspension to treat otitis media.

Monitor BUN and serum creatinine for early signs of nephrotoxicity. also monitor fluid intake and output.

Be aware that an allergic reaction may occur a few days after therapy starts.

Assess bowel pattern daily.

P. 192)

Cefexime suspension produces higher peak blood level than do tablets when administered at the same dose.


Decreasing urine output may indicate nephrotoxicity.


Normal reaction when the therapy starts.


Severe diarrhea may indicate pseudomembranous colitis.

suspension at room temperature and to discard unused portion after 14 days.

Tell patient to immediately report severe diarrhea to prescriber.

Inform patient that yogurt and buttermilk can help maintain intestinal flora and decrease diarrhea.

Teach patient to recognize and report signs of superinfection, such as furry tongue, perineal itching, and loose, foul smelling stools.

Assess for pharyngitis, ecchymosis, bleeding, and arthralgia.


They may indicate a blood dyscrasia.




UNIVERSITY OF CEBU-BANILAD COLLEGE OF NURING

DRUG STUDY



CLASSIFICATION

DOSE, STRENGTH & FORMULATION



DRUG INTERACTION



GENERIC :

ofloxacin

BRAND:

Inoflox

CLASSIFICATION:

ORDERED:

200 mg (PO)

TIMING:

OD

DURATION:

unknown

OTHER FORMS:

INDICATIONS:

To treat pelvic inflammatory disease caused by susceptible organism.


Inhibits synthesis of the bacterial enzyme DNA gyrase by

ADVERSE/ SIDE EFFECTS:

CNS: aggressiveness, agitation, ataxia, dizziness, drowsiness, emotional lability, exacerbation, of extrapyramidal disorders, and myasthenia gravis, fever, headache, incoordination, insomnia, light headedness, mania, peripheral neuropathy,

Monitor elderly patients closely for prolonged interval QT.

For I.V infusion, dilute drug in normal saline solution or D5W to at least mg/ml ,and infuse over 60 minutes to minimize the risk of

Prolonged QT interval has an uncorrected electrolyte disorder.


To dilute the solution.


Encourage patient to take each oral dose with a full glass of water.

Advise patient to avoid hazardous activity until CNS effects of drug are known.

Tell patient to limit exposure to sun and ultraviolet light to prevent

antiboitic Tablets, I.V infusion counteracting excessive supercoiling of DNA during replication or transcription. Inhibition of DNA gyrase causes rapid-and –slow growing bacterial cells to die.

psychotic, reactions, restlessness, stroke, suicidal ideation ,syncope. CV: arrhythmias, prolonged QT interval, severe hypotension, torsades de pointes, vasculitis.

EENT: blurred vision, diplpoia, disturbances in taste, smell, hearing, and equilibrium.

ENDO: hypergycemia, hypoglycemia,

GI: abdominal cramps or pain, acute hepatic necrosis or failure, diarrhea, hepatitis, jaundice, nausea, pseudomembranous colitis and vomiting.

GU: acute renal insufficiency or failure,interstitial nephritis, renal calculi, vaginal candidiasis.

RESP: arthralgia,

hypotension. Discard un used portion.

Monitor patient closely for hypersensitivity, which may occur as early as firstdose.

Maintain adequate hydration.

If diarrhea develops, notify prescriber.

Notify the prescriber immediately and expect to discontinue the drug.


To prevent development of highly concentrated urine and crystalluria.


It may indicate pseudomembranous colitis.


phototoxicity. Advise patient

to notify prescriber immediately about burning skin, hives, itching, rash, rapid heart rate, abnormal motor or sensory function, and tendon pain.

Urge patient to seek medical care immediately for trouble breathing or swallowing, which may signal an allergic reaction.

myalgia, tendon inflammation.

SKIN: blisters, diaphoresis, erythema, photosensitivity, pruritus,rash.




DRUG STUDY



CLASSIFICATION




DRUG INTERACTION



GENERIC :

tranexamic acid

BRAND:

hemostan

CLASSIFICATION:

Antifibrinolytic

ORDERED:

500 mg (PO)

TIMING:

OD

DURATION:

unknown

OTHER FORMS:

INDICATIONS:

To treat cyclic heavy menstrual bleeding.


Displaces plasminogen from surface of fibrin by binding to high affinity lysine site of plasminogen. This

ADVERSE / SIDE EFFECTS:CNS: cerebral thrombosis, dizziness, fatigue,headache, migraine.

CV: deep vein thrombosis

EENT: Central retinal artery and vein obstruction, feeling of throat tightness,impaired color vision, ligneous

Tranexamic acid therapy isn’t recommended for women who use hormonal contraceptives.

Use tranexamic acid cautiously in patients with acute promyelocytic leukemia taking oral tretrinoin

It may increased risk of thromboembolism.


Because of possible exacerbation of the pro-coagulant effect of tretinoin.

(Jones & Barlett 10th ed.

Instruct patient to swallow tranexamic acid tablets whole, without chewing or breaking them.

Tell patient to seek emergency care immediately if she has any signs of allergic

tabletsdiminishes the solution of hemostatic fibrin, which decreases bleeding.

conjunctivitis, nasal and sinus congestion sinusitis, visual abnormalities

GI: Abdominal pain, diarrhea, nausea vomiting

GU: Acute renal cortical necrosis

HEME: Anemia

MS: Arthralgia, back pain, muscle cramps,and spasms, myalgia

RESP:Dyspnea, pulmonary embolism, respiratory congestion

SKIN: Allergic skin reaction, facial flushing

Other: Anaphlaxis, multiple allergies including seasonal.

for remission induction.

P. 1046) reaction, especially dyspnea, a feeling of throat tightness, and facial flushing, and to stop taking drugs.

Advise patient to report any changes in vision or ocular discomfort.

Mrs.Pergeline Cabahug Jhanine F. Bulalaque



DRUG STUDY



CLASSIFICATION



ADVERSE/ SIDE EFFECTS & DRUG

INTERACTION



GENERIC :

metoprolol succinate

BRAND:

Betaloc Durules

CLASSIFICATION:

Antianginal, antihypertensive, MI prophylaxis and treatment

ORDERED:

50 mg (PO)

TIMING:

PRN

DURATION:

Unknown

OTHER FORMS:

Tablets , I.V injection

INDICATIONS:

To manage hypertension, alone or with other antihypertensive.

To treat angina pectoris and chronic stable angina.

MECHANISM OF ACTION

Inhibits stimulation of beta1-receptor sites, located mainly in the

ADVERSE/ SIDE EFFECTS:CNS: anxiety, confusion, depression, dizziness, drowsiness, fatigue, hallucinations, headache, insomnia, weakness.CV: angina arrhythmias,(including AV block and bradycardia), chest pain, decreased HDL level, increased triglyceride levels, gangrene of extremity heart failure, hypertension , and orthostatic hypotension.

Use cautiously in patients with hypertensionor angina who have congestive heart failure.

Before starting therapy for heart failure, expect to give diuretic, an ACE inhibitor,

Because beta blockers such as metoprolol can further depress myocardial contractility. Worsening heart failure.


To stabilize the patient.


Instruct patient to take metoprolol with food at the same time each day – once daily for E.R. tablets. Explain that he may halve tablets but not chew or crush them.

Advise patient to notify prescriber if pulse rate falls

heart, resulting in decreased cardiac excitability, cardiac output, and myocardial oxygen demand. These effects help relieve angina. Metoprolol also helps reduce in blood pressure by decreasing renal release of renin .

EENT: nasal cingestion, rhinitis, taste disturbanceGI: constipation, diarrhea. Hepatitis, nausea, vomitingGU: impotenceHEME: leukopenia, thrombocytopenia, MS: arthralgia, back pain, myalgia, RESP: bronchospasm, dyspnea, SKIN:diaphoresis, photosensitivity, rash, urticaria, worsening of psoriasis.

and digoxin. If patient has

pheochromocytoma, alpha blocker therapy should start first, followed by metoprolol.

If patient with heart failure develops symptomatic bradycardia , expect to decrease the metoprolol dosage.

To prevent paradoxical increase in blood pressure from attenuation of beta-mediated vasodilation in skeletal muscle.


To prevent further complications.


below 60 beats/ minute or is significantly lower than usual.

Urge diabetic patient to check blood glucose level often during the therapy.

Caution patient not to stop drug abruptly.



IVF STUDY

Type of Solution

Classification Content Mechanism of Action

Indication Contraindication How Supplied Dose Nursing Responsibility

PNSS Isotonic Na- 154 mEq/L

Cl – 154mEq/L

Osmolarity – 30gmomsm/L

It is a type of solution that causes no change in cell volume. Capable of diluting and gives sufficient supply of hydration in the body. Source of water and electrolyte, for fluid replacement.

(Mosby, 2006:743)

*Patients who are dehydrated

*Hypovolemic patients.

*Alkalosis

*For fluid loss in the body.

*Sodium depletion.

*Saline is also helpful for irrigation.

*It can be used to wash the wound.

*Congestive Heart Failure.

*Severely impaired renal function.

*Hypernatremia

*Fluid retention.

*Patients who are hypersensitive to the solution.

Baxter:

500cc

As directed by the physician.

1. Check the pt. Chart.

2. Check the 5 rights of giving medication.

3. Note reason for therapy; monitor pt’s electrolyte.

4. Monitor pt’s vital signs, intake and output.

5. Open only the solution when ready to use.

6. Use sterile infusion set.

7. Use only if solution is clean and container is not leaking.

8. Store at temperature not exceeding 30’C

APPENDIX B

APPENDIX C

APPENDIX D

prostatic ncp

Documents

assessment patient

associated signs

patient skin

vital signs temperature

chief complaints patient

degrees celsius blood

degrees celcius blood

acute urinary retention