What is a holistic patient care plan and how do you create it?

  

Create a wholistic care plan for disease prevention, health promotion, and acute care of the patient in the clinical case. Your care plan should be based on current evidence and nursing standards of care.Visit the online library and research for current scholarly evidence (no older than 5 years) to support your nursing actions. In addition, consider visiting government sites such as the CDC, WHO, AHRQ, Healthy People 2020. Provide a detailed scientific rationale justifying the inclusion of this evidence in your plan.Next determine the ICD-10 classification (diagnoses). The International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-10-CM) is the official system used in the United States to classify and assign codes to health conditions and related information.USE care plan template to help you design a holistic patient care plan. The care plan example provided here is just a reference for you to build your care plan. You are expected to develop a comprehensive care plan based on your assessment, diagnosis, and advanced nursing interventions. Reflect on what you have learned about care plans through independent research and peer discussions and incorporate the knowledge that you have gained into your patients care plan.Grading CriteriaMaximum PointsCare plan demonstrated involvement of the client in the process of recognition, planning, and resolution of the problem.15Care plan included effective nursing interventions that were customized for the client and appropriate to the goal.15Care plan included diagnostic workup, medications, conservative measures, and a follow-up plan.15Care plan provided rationale for choosing a particular treatment modality.15Care plan demonstrated logical diagnosis, which was substantiated with relevant evidence.10Care plan focused on patient education, maintained a fine balance between major and minor health issues of the patient.10Care plan included nursing interventions that are specific, appropriate, and free of essential omissions.10Used APA standards consistently and accurately.10Total100
Week 4: Genitourinary Clinical Case
HPI
A 60-year-old Hispanic male presents with the chief complaint of decreased urinary flow. The patient
has been experiencing this over the past two years, but for the past two weeks, the symptoms
have increased significantly. The current symptoms are similar to what he experienced in the past.
However, for the past two weeks, he has had increased nocturia, with decreased strength of urinary
flow and slight terminal dysuria. Patient has had no treatment in the past. The nocturia has been very
troublesome over the past two weeks. Yesterday he had significant difficulty in starting his urine flow
and this is interfering with daily activities. He needs to pass urine four to five times every night. He has
been urinating frequently and always needs to know if there are bathrooms around.
Patient does not complain of any other radiating pain. He has had no treatment or diagnostic work
up in the past, but now the symptoms have been increasing in severity. He believes he had a lowgrade fever yesterday. The patient is not sure what is going on but thinks he may have cancer. He had
significant obstructive symptoms two days ago. Gradual worsening of symptoms has compelled him
to seek medical help now.
PMH
Patient has not sought any medical care for this problem to date. He is being treated for hypertension
and hypercholesterolemia. There is no known history of heart disease, but he was hospitalized five
years ago as a suspected case of angina. He was diagnosed with chest wall syndrome for which he was
treated and then released. There are no recent hospitalizations and no surgeries.
ROS
Denies any other positive review of systems. Denies abdominal pain, nausea or vomiting. No blood in
the stool. No gross hematuria.
MEDICATIONS
Cardizem 240mg daily
Zocor 20mg daily
Patient is compliant with the prescribed regimen and knows why he is being treated.
ALLERGIES/REACTIONS
No known drug allergies
Page 1 of 3
NSG6001 Advanced Nursing Practice I
2015 South University
NSG6001 Advanced Nursing Practice I
Week 4: Gastroenterology Clinical Case
SOCIAL HISTORY
Patient has a masters degree in engineering and his income is $65,000.00 per year. Though
the patient is educated, he lacks an understanding of resources available to him. Patient
has no problems with finances. He has excellent access to healthcare, but most often does
not utilize the services to the extent that is expected. He has an excellent health insurance
coverage including a prescription plan.
Patient is married and his spouse has excellent general health. He has two grown-up sons
who live with their own families. They are 35 and 37 years old, both alive and well. Although
the patient has a masters in engineering, his knowledge of healthcare is inadequate. He
believes that he is generally healthy.
His perception of self-efficacy is adequate. He has very little stress. His support systems
include his wife and friends from work who provide him with the required emotional support.
There is no family dysfunction. The patient is high strung and an over achiever. He gets little
from social support outside the home or work.
Patient is originally from United States. He lives in a suburban setting. His resources include
his wife and the people he works with. Though there are other resources available to him, he
is not sure what they are.
HABITS
Smoking: Non smoker
Alcohol: Does not drink
Substance use: Denies substance abuse
DIET HABITS
His wife does most of the cooking. He believes that he gets adequate exercise, eats healthy,
and maintains a regular checkup regime with his physician.
WORK HABITS
He is an engineer and has always done the same work.
FAMILY HISTORY
He has one sister and one brother. Both are alive and well. There is a remote history of heart
disease among his aunts and uncles.
PHYSICAL EXAMINTAION
Vital Signs: BP right arm sitting 140/92; T: 99 po; P:80 and regular; R 18, non-labored; Wt: 200#;
Ht: 71
NSG6001 Advanced Nursing Practice I
Week 4: Gastroenterology Clinical Case
HEENT: WNL
Lymph Nodes: None
Lungs: Clear
Heart: RRR with Grade II/VI systolic murmur heard best at the right sternal border
Carotids: No bruits
Abdomen: Android obesity, non-tender
Rectum: Stool light brown, heme positive. Prostate enlarged, boggy and tender to palpation.
Genital/Pelvic: Circumcised, no penial lesions, masses, or discharge.Testes are descended
bilaterally, no tenderness or masses
Extremities, Including Pulses: 2+ pulse throughout, no edema in the lower legs.
Neurologic: Not examined
Lab Results/Radiological Studies/EKG Interpretation
Lab Results
PSA: 6.0
CBC: WNL
Chem panel: WNL
Radiological Studies: None
EKG: None

Introduction:
Holistic care is necessary for the prevention of diseases and promotion of health, as well as the provision of acute care for patients suffering from varying health conditions. To achieve this, healthcare providers must create effective care plans based on current evidence and nursing standards of care. In this clinical case, a 60-year-old Hispanic male presents with decreased urinary flow, along with other symptoms. The aim of this analysis is to generate a wholistic care plan for the prevention, promotion, and management of the patient’s health.

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Description:
In this case, the patient presents with decreased urinary flow and other urinary symptoms. The patient has experienced these symptoms for two years, with a significant increase in severity over the past two weeks. The patient complains of increased nocturia, decreased strength of urinary flow, and slight terminal dysuria. The patient has had no prior treatment or diagnostic workup for these symptoms. The patient believes he may have cancer and has had significant obstructive symptoms. The care plan should involve effective nursing interventions customized to the patient and appropriate to the intended goal. The plan should also include diagnostic workup, medications, conservative measures, and a follow-up plan. The care plan should be based on current evidence and nursing standards of care. The ICD-10 classification (diagnoses) should also be determined.

attention.

Solution 1:
The primary diagnosis for the patient is benign prostatic hyperplasia (BPH), which commonly occurs in older males. The following are the nursing interventions, diagnostic workup, medications, and a follow-up plan for the patient:
– Nursing Interventions: Perform a comprehensive assessment of the patient including physical examination, evaluation of vital signs, and analyze laboratory results. Initiate bladder training to help reduce urinary frequency, encourage the patient to avoid excessive fluid intake before bedtime, and advise the use of a bedside commode. Additionally, the patient should be advised to perform pelvic floor exercises to improve bladder control.
– Medications: Prescribe alpha-1 blockers such as tamsulosin to relax the smooth muscles of the prostate and improve urinary flow. 5-alpha reductase inhibitors such as finasteride can be prescribed to reduce the size of the prostate and relieve urinary tract symptoms.
– Diagnostic Workup: Conduct a prostate-specific antigen (PSA) test to rule out prostate cancer. Imaging studies such as ultrasound and cystoscopy can be done to identify any structural abnormalities in the urinary tract.
– Follow-up Plan: Schedule follow-up visits to adjust medication dosages as needed, monitor PSA levels, and assess the patient’s response to treatment.

Solution 2:
An alternative diagnosis for the patient’s symptoms could be a urinary tract infection (UTI). Here are the nursing interventions, diagnostic workup, medications, and a follow-up plan for the patient:
– Nursing Interventions: Perform a comprehensive assessment of the patient including physical examination, evaluation of vital signs, and analysis of laboratory results. Educate the patient on personal hygiene and the importance of wiping from front to back after bowel movements. Encourage the patient to drink plenty of fluids, especially water, to promote urinary flow and wash bacteria out of the urinary tract. Administer urinary analgesics such as phenazopyridine to alleviate discomfort during urination.
– Medications: Prescribe antibiotics such as trimethoprim-sulfamethoxazole or nitrofurantoin for the treatment of a UTI.
– Diagnostic Workup: Conduct a urine culture and sensitivity test to identify the type of bacteria causing the UTI and determine the appropriate antibiotic treatment.
– Follow-up Plan: Schedule follow-up visits to monitor the patient’s response to treatment, evaluate the effectiveness of antibiotics, and assess the patient’s progress in resolving the UTI.

ICD-10 Classification:
The ICD-10 classification for the patient’s symptoms could be N40.1 (Enlarged prostate with lower urinary tract symptoms).

Suggested Resources/Books:
1. “Urological Emergencies: A Practical Approach” by Ahmed F. Alhajeri
2. “Urinary Tract Infections: Detection, Prevention, and Management” by Jonathan I. Epstein and William G. Couser
3. “2019 Guidelines for the Early Management of Patients with Acute Ischemic Stroke” by the American Heart Association/American Stroke Association
4. “Clinical Nephrology: Principles and Practice” by Richard J. Johnson
5. “Urinary System (Quick Study Academic)” by Wayne R. Hedrick

Similar asked questions:
1. What are the causes of decreased urinary flow in men?
2. What is the appropriate diagnostic workup for urinary flow issues?
3. What are the potential complications of urinary flow issues?
4. What are the most effective treatments for urinary flow issues in men?
5. How can lifestyle changes prevent urinary flow issues in men?

ICD-10 classification:
1. R33.9 – Retention of urine, unspecified
2. N40.1 – Enlarged prostate with lower urinary tract symptoms
3. N13.3 – Hydronephrosis with renal and ureteral calculous obstruction
4. N30.0 – Acute cystitis
5. N39.0 – Urinary tract infection, site not specified

Care Plan:
1. Assessment: Collect data regarding the patient’s symptoms, medical history, current medications, and family history. Perform physical examination including digital rectal exam and urinalysis. Obtain ultrasound and urodynamic studies if necessary.
2. Diagnosis: Impaired urinary elimination related to urinary obstruction secondary to enlarged prostate.
3. Planning:
– Collaborate with urologist to discuss treatment options including medication or surgery to relieve urinary obstruction.
– Administer medication as prescribed and monitor for side effects.
– Implement bladder training program and encourage pelvic muscle exercises to improve urinary flow and reduce incontinence.
– Provide patient education regarding dietary changes to prevent worsening of symptoms, fluid intake recommendations, and prevention of urinary tract infections.
4. Implementation:
– Administer medication as prescribed and monitor for side effects.
– Teach the patient pelvic muscle exercises and implement bladder training program.
– Encourage the patient to drink at least 8-10 glasses of water per day.
– Monitor urine output, fluid intake, and document any changes in symptoms or response to treatment.
5. Evaluation:
– Assess the patient’s response to treatment and adjust interventions as needed.
– Monitor for any adverse effects of medications.
– Document any changes in symptoms and response to interventions.

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