Question I. Data CollectionHistory of Present Problem: Mr. Jones is

Question I. Data CollectionHistory of Present Problem: Mr. Jones is a 75 year old male who comes to the Urgent Care complaining of frequency and urgency. “It seems like I am up 4-5 times in any given night and am now tired. The problem is that when I go it is only a very little urine and in a few hours I have to get up again. Once or twice I did not make it to the bathroom and I was at Walmart. This is getting too embarrassing for me. I don’t want to go anywhere.” Personal/Social History: Medical Issues: Takes thyroid medication for his hypothyroidism (diagnosed over 25 years ago)                       Had varicocele above his left testicle which was treated surgically 15 years ago.                        He reports being hospitalized for acute pyelonephritis three times in the last two years (3-4 days each time and treated with antibiotics) Medications: Levothyroxine 100 mcg po daily                        Ibuprofen 800 mg po twice a day for pain PRN Allergies: Penicillin and Sulfa drugs cause a severe rash Social: He has been married for 45 years. He was a contractor and worked on heavy equipment for 50             years.             He denies any religious affiliation. He smoked 2 packs a day for 40 years but quit when he retired 8 years ago.            Normally has 2 cups of coffee in the morning. While listening to the ball games on TV he drinks 3 – 4 cans of beer.            His only exercise is taking out trash nightly and mowing the lawn when needed.                            Family History: Father died age at 69 from a motor vehicle accident.                             Mother had diabetes mellitus type 2 for 15 years and died age at 84 due to renal failure                            Two sisters both healthy, ages 70 and 68                            Wife is 73 and has hypertension which is controlled on medications.                            No children Pertinent Review of Systems:Mr. Jones denies fever or chills. He states urine has no odor and is colorless most of the time. He has to strain to urinate usually so he can feel like his bladder is empty. He also has some dribbling for the past year or so. He reports some vague pain in his back which he says is arthritis. No other remarks of significance.  What data from the histories is important & RELEVANT; therefore it has clinical significance to the nurse?RELEVANT Data from Present Problem:Clinical Significance:       RELEVANT Data from Social History:Clinical Significance:      II. Patient Care Begin:Patient is well dressed and in no acute distress. Alert and oriented x4 Height 6 feet, weight 255 Current VS:    Pain Scale-FLACC, FACES, NUMERIC. Identify pain scale used and provide ratingT: 98.68/10 pain scale. The pain is in his back and left side of back. Denis pain in pelvic area. P: 80R:18BP:135/80O2 sat:97% What VS data is RELEVANT that must be recognized as clinically significant?RELEVANT VS Data:Clinical Significance:         Current Assessment:GENERAL APPEARANCE:Clean shaven, no lesions on his face, obese with a protruding abdomen RESP:Clear to auscultations with unlabored breathingCARDIAC:Regular rate and rhythm no murmur  pulses +2 bilaterallyNEURO/ MS:No tremors, Tender over the left flankAll reflexes +2 bilaterallyGI:Abdomen soft, bowel sounds heard in all 4 quadrants, some diffuse tenderness over bladder areaGU:Urine cloudy, no blood or leukocytes on urine dip, anal exam reveals an enlarged prostate, smooth and rubberySKIN:Skin clear, scrotal area shows some increase swelling of the left testicle    What assessment data is RELEVANT that must be recognized as clinically significant?RELEVANT Assessment Data:Clinical Significance:        III. Clinical Reasoning Begins…1. What is the primary problem that your patient is most likely presenting with?                2. What is the underlying cause/pathophysiology of this concern?      3. What imaging and lab tests are needed to thoroughly assess the primary problem?     4. What nursing priority(s) will guide your plan of care? (if more than one-list in order of PRIORITY)      5. What educational priorities will be needed to develop a teaching plan for this patient and /or family?       It’s due tonight, please answer as soon as positive Health Science Science Nursing HEALTH ASS 304 Share QuestionEmailCopy link Comments (0)

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