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HYPERPLASIA (BPH)
10 DIN 0131
KPJIUC
LEARNING OBJECTIVE
LEARNING OBJECTIVES
PATIENT DATA
NURSING ASSESSMENT
PATIENT DATA
NAME: Mr.Z
I/C NO: XXX
R/N: 48XXX
AGE: 53 Years
SEX: Male
RACE: Malay
RELIGION: Islam
LANGUAGE SPOKEN: Malay
OCCUPATION: Retired from MARA
CONSULTANT: Dr.A
DATE:/TIME OF ADMISSION: 1/11/2011
@
1800 hours
REASON FOR ADMISSION: C/O back pain for 4/12,sense of unable to
empty the bladder
fully,frequent urination and
bladder
distanded for 1/12
MEDICAL HISTORY: Nil
SURGICAL HISTORY: Nil
FAMILY MEDICAL HISTORY: Nil
CURRENT MEDICATIONS: Nil
ALLERGIES: Nil
CONDITION ON ADMISSION
CONDITION ON ADMISSION
VITAL SIGN
TEMPERATURE
: 36.0 C
PULSE
: 80 bpm
RESPIRATION
: 20 bpm
BLOOD PRESSURE: 127/80 mmHg
WEIGHT
: 65 kg
HEIGHT
: 156 cm
MODE OF ADMISSION
WALK IN
LEVEL OF CONSCIOUSNESS
CONSCIOUS
MENTAL STATUS
ORIENTATED
EMOTIONAL STATUS
CALM
PHYSICAL EXAMINATION
PHYSICAL EXAMINATION
HAIR
Short hair
White colour
No dandruf
EYES
No jaundice
No redness
Both eyes are symmetry
NOSE
No bleeding
No discharge
No displacement of nasal bone
EARS
No bleeding
No discharge
Both ears are symmetry
MOUTH
No dryness
No discharge
No ulcer
NECK
No scar
No enlargement of lymph nodes
CHEST
Respiratory movement normal
Chest is symmetry
No scar
UPPER LIMBS
No scar
Joint is normal movement
Capillary refill is normal
ABDOMEN
Distended bladder
GENITILIA PART
No abnormalities detected
LOWER LIMBS
No edema
Joint is normal movement
Capillary refill is normal
BACK
No displacement of spinal
No scar
The alignment is normal (straight)
CBD
IV LINE
ANTERIOR
POSTERIOR
BREATHING
NO HAVE DIFFICULTIES IN BREATHING
NO HAVE ANY COUGH
NO SMOKE
EATING/DRINKING
NO ANY FOOD/DRINK THAT HE DO NOT TAKE
NO HAVE ANY PROBLEM WITH EATING/DRINKING
ELIMINATIONS-BOWEL
TWICE PER DAY OFTEN HE MOVE HIS BOWEL
NO CHANGES IN BOWEL HABITS LATELY
NO TAKE ANY MEDICATION FOR BOWEL MOVEMENT
BLADDER
BLADDER DISTANDED
SLEEPING
HAVE PROBLEM IN SLEEPING CAUSE 4 TIMES GET UP AT
NIGHT TO PASS URINE
NO REQUIRE MEDICATION TO SLEEP
MOBILITY
AMBULANT
PERSONAL HYGIENE
SELF
SAFE ENVIRONMENT
SIDERAIL
SPIRITUAL
NO REQUIRE ANY SPIRITUAL SUPPORT
HOBBIES
READING NEWS PAPER
COMMUNICATION
MALAY
SPEECH
NORMAL
VISION
VISUAL AIDS (SPECTACLES)
HEARING
NORMAL
SKIN CONDITION
NIL
OTHERS
NIL
TESTICLE -
URINARY SYSTEM
PROSTATE GLAND
DEFINITION
DEFINITIONS
In many patients older than 50 years,the
ETIOLOGY
ETIOLOGY
1) Unknown
2) Male Hormone Mechanism
A) Androgen Testosterone
- stimulate cell growth in the tissue line the prostate gland
B) Estrogen
- sometime in older, level of testosterone will drop and level of
estrogen increase with in the gland and promote cell growth possibly
triggering
prostate growth.
3) Aging
- Begin at age around 40-45 years of age and continuous slowly,
25% by 50 years but 90% by 80 years
- About 10% are symptomatic.
-At age 70 years and 80 years,80% will experience urinary symptoms.
4) Prostatitis
- is an inflammation of the prostate gland that is caused by
infectious agents (bacteria,fungi,mycoplasma) or other condition
(prostatic hyperplasia)
5) Family History
- particularly involving first degree relatives.
6) Environment and diet.
- Although men from both Western and Eastern cultures
develop
BPH disease at about the same rates, men from western
cultures
are much more likely develop BPH. For diet, high in zinc,
butter
and margarine, where by the in individual who eat lot of
fruits are
though to have lower risk for BPH.
7) Race
- Highest in African Americans lowest in native Japanese.
PATOPHYSIOLOGY
PATOPHYSIOLOGY
Disturb the urinary flow from bladder towards urethra and cause
urinary retention.
Prostatic tissue enlarged by BPH,the bladder neck and urethra
obstructed and cause urinary flow slowed
STATISTIC
STATISTIC ON PATIENT WITH BPH IN SPECIALIST HOSPITAL FROM JAN UNTILL JUNE 2011
20-40 41-60
5
JANUARY
0
FEB
0
MARCH
APRIL
0
MAY
0
JUN
0
JULY
0
AUG
0
SEPT
0
OCT
0
INTERPRITATION OF STATISTIC
The above graph was show the STATISTIC ON PATIENT WITH
BPH IN SPECIALIST HOSPITAL FROM JAN TILL JUNE based on
the statistic from Jan have 1 patient at age of41-60.On Feb
have 2
patient at age of 41-60.On March have 5 patient but their
only 1
patient at age of 20-40 and the rest at age of 41-60. On April
have 2
patient at age of 41-60 and on May also have 2 patient at
age of 4160.Lastly, on June have 4 patient at age of 41-60.Majority
total of
case is 16 patient with BPH and it is above at age of 41-60
cause of
aging process and hormone imbalance (dihydrotestosterone).
20%
80%
INTERPRITATION OF STATISTIC
The pie chart above show that the statistic for the patient
with
Benign Prostate Hyperplasia which undergone medical and
surgical
management fro Jan untill June 2011. Based on the statistic
total of
patient who have BPH is 20 patient which are 16 of the
patient
undergone the cystoscopy procedure surgically.Whereas,the
balance of 4 patient was treat medically. Based on the pie
chart the
majority of the patient had undergone the surgical treatment
is
because the aging process and hormone imbalance
(dihydrotestosterone)
CLINICAL MANIFESTATION
CLINICAL MANIFESTATIONS
VOIDING SYMPTOMPS
Frequent and urgent need to urinate,especially at night
(Nocturia)
Dribbling or leaking after urination (Postvoid)
Diminished force of urinary stream
Straining to urinate
Pain or burning during urination
Sensation of incomplete bladder emptying
IRRITATIVE SYMPTOMS
Urinary retention
Frequency
Urgency
Urge incontinence
Dysuria (difficult or painful micturition)
Problems in ejaculation
Back pain
COMPLICATION
COMPLICATIONS
Increasing bladder distention- diverticula
(outpouchings) on the bladder wall.
Ureters obstruction.
Infection- retained urine or ascend from
bladder to kidneys due to diverticula.
Hydroureter- an accumulation of urine in a
ureter.
Hydronephrosis- an accumulation of urine in
the pelvis of the kidney.
Renal insufficiency.
INVESTIGATION
INVESTIGATIONS
Patient
Lab.No.
Sex
Age
Reported
00048
1411xx
M
53Y
Ward/Clinic: SURGICAL WARD
Examination
Result
Reference range
FULL BLOOD COUNT
Haemoglobin
13.1
Red cell count
5.1
***Haematocrit (PCV)
38
***MCV
75
***MCH
26
MCHC
34
RDW
13.0
Platelet Count
228
MPV
10.6
White blood cell count
7.1
Date Received
01/11/2011
Date
01/11/2011
unit
g/Dl
10^12/L
%
f/L
pg
g/Dl
%
10^3/Ul
f/L
10^3/Ul
13.0-18.0
4.5-5.9
41-53
76-103
26-34
31-36
8.0-14.6
150-450
5.8-12.0
4.3-10.5
40-
20-
%
%
%
0-6.0
1-11
0-2
mmol/L
2.0-
mmol/L
135-
mmol/L
3.5-
mmol/L
95-
Patient
Lab.No.
Sex
Reported
00048
1411xx
M
01/11/2011
Examination
Reference range
Urine FEME/Urinalysis (UFEME 1)
Urine FEME/Urinalysis (UFEME 2)
Appearance/urine
Yellow
Specific gravity,urine
1.025
Ph,urine
Protein,urine
Glucose,urine
Ketone,urine
Bilirubin screen,urine
Urobilinogen screen,urine
Nitrite,urine
Leukocytes esterase,urine
Blood,urine
Age
53Y
Result
Date Received
Date
01/11/2011
unit
Pale yellow
Yellow/Pale
1.025
1.005-
6.0
Negative
Negative
Negative
Negative
Normal
Negative
Negative
Negative
4.8-7.5
Negative
Negative
Negative
Negative
Normal
Negative
Negative
Negative
--Microscopic examination,urine
WBC,urine
5
RBC,urine
3
Epithelial cell,
Occasional
Cast,urine
Crystal,urine
*Bacteria,urine
Nil
Yeast cell,urine
*Others,urine
1/hpf
0-
1/hpf
0-
Not seen
Nil
Nil
Occasional
Nil
See below
Mucous strand occ
Nil
Nil
Nil
THE REPORT
CHEST X RAY
Radiological Report
Name : Mr.Z Sex
:M
MRN : 48XXX Room No
: 432
IC No : 58XX
DEPT
:
Age : 53 Y
DATE
: 02/11/2011
CHEST
(CXR)
Heart size normal. Both lung fields appear normal.
No hilar abnormality seen.
IMPRESSION
Normal examination.
MEDICATION
IV CEFTREX
Generic name
: Ceftriaxone Na
Group
: Anti-Infectives
Indication
: Intra-abdominal infections.
Route
: IV
Dosage
:2g
Contraindication : Hypersensitivity to cephalosporins.
Side efect
: GI disturbances,haematological changes,skin
reactions,anaphylactoid
reactions,phlebitis.
Date on
: 01/11/2011
Date of
: 04/11/2011
Nsg.Responsibilities:
Wash hands before and after.
Follow 7 R
Check medication for 3 times before administer to patient.
Observe IV line to prevent phlebitis.
Ensure no bubble inside the tubing.
T.LASIX
Generic name
: Furosemide
Group
: Diuretics
Indication
: Oedema (cardiac, hepatic,renal;oedema due to burns) HTN
Route
: Oral
Dosage
: 40 mg
Contraindication : Acute renal failure with anuria,hepatic coma and
precoma,hypokalemia,
hyponatremia,hypovolemia with or without hypotension or
dehydration.
Side efect
: Symptomatic
hypotension,dehydration,haemoconcentration,hypokalaemia
hyponatraemia,metabolic alkalosis;increase in blood lipid
levels,urea,uric
acid,reduced glucose tolerance.
Date on
: 03/11/2011
Date of
: 04/11/2011
Nsg.Responsibilities:
Wash hands before and after
Follow 7 R
Check medication for 3 times before administer to patient.
Monitor urine output of patient.
SLOW-K
Generic name
: KCI
Group
: Electrolytes
Indication
: K deficiency
Route
: Oral
Dosage
: 600 mg
Contraindication : Hyperkalaemia.Marked renal failure.Con-comitant
treatment with K-sparing
diuretics and patient in whom there is cause for
arrest or delay in tab passage
through the GI.
Side efect
: GI upsets.
Date on
: 03/11/2011
Date of
: 04/11/2011
Nsg.Responsibilities:
Wash hand before and after.
Follow 7 R
Check medication for 3 times before administer to patient.
Advice patient to take with food
Advice patient do not chew or crush
VESICARE
Generic name
Group
Indication
urinary
: Solifenacin succinate
: Drug for Bladder & Prostate Disorders
: Symptomatic treatment of urge incontinence &/or increased
frequency
& urgency in patients with overactive bladder syndrome.
Route
: Oral
Dosage
: 5 mg
Contraindication : Urinary retention,severe GI condition (including toxic
megacolon)
myasthenia gravis,narrow-angle glaucoma.
Haemodialysis.Severe renal
impairment or moderate hepatic impairment.
Side efect
: Dry mouth.
Date on
: 01/11/2011
Date of
: 02/11/2011
Nsg.Responsibilities:
Wash hands before and after
Follow 7 R
Check medication for 3 times before administer to patient.
Advice patient take with or without food.
T.DORMICUM
Generic name
: Midazolam
Group
: Hypnotics & Sedative
Indication
: Tab Short-term treatment of insomnia, premed prior to
surgery or diagnostic procedures. Amp Conscious sedation before
diagnostic or therapeutic procedures, premed before induction of anaesth,
ataralgesia in combination w/ ketamine in childn, long-term sedation in ICU.
Route
: Oral
Dosage
: 7.5 mg
Contraindication : Hypersensitivity to benzodiazepines.
Side efect
:Drowsiness, numbed emotions, reduced alertness,
confusion, fatigue, headache, dizziness, muscle weakness, ataxia, double
vision; GI disturbances, changes in libido, skin reactions; amnesia;
depression; paradoxical reactions; local efect on inj site.
Date on
: 01/11/2011
Date of
: 03/11/2011
Nsg.Responsibilities:
Wash hands before and after
Follow 7 R
Check medication for 3 times before administer to patient and administer
on night.
MANAGEMENT
CYSTOSCOPY
SURGICAL MANAGEMENT
CYSTOSCOPY
Cystoscopy is a test that allows the doctor to look at
the inside of bladder and the urethra using a thin,
lighted instrument called a cystoscope .
The cystoscope is inserted into the urethra and
slowly advanced into the bladder. Cystoscopy allows
the doctor to look at areas of the bladder and
urethra that usually do not show up well on X-rays.
Tiny surgical instruments can be inserted through
the cystoscope that allow the doctor to remove
samples of tissue (biopsy)or samples of urine.
Small bladder stones and some small growths can
be removed during cystoscopy. This may eliminate
the need for more extensive surgery.
Why It Is Done
Cystoscopy may be done to:
Find the cause of symptoms such as blood in
the urine (hematuria), painful urination
(dysuria), urinary incontinence urinary
frequency or hesitancy, an inability to pass
urine (retention), or a sudden and
overwhelming need to urinate (urgency).
Find the cause of problems of the urinary
tract, such as frequent, repeated urinary tract
infections or urinary tract infections that do
not respond to treatment
What is a cystoscopy?
A cystoscopy is an examination of the inside of the
bladder and urethra, the tube that carries urine
from the bladder to the outside of the body. In
men, the urethra is the tube that runs through the
penis. The doctor performing the examination uses
a cystoscope -- a long, thin instrument with an
eyepiece on the external end and a tiny lens and a
light on the end that is inserted into the bladder.
The doctor inserts the cystoscope into the patient's
urethra, and the small lens magnifies the inner
lining of the urethra and bladder, allowing the
doctor to see inside the hollow bladder. Many
cystoscopes have extra channels within the sheath
to insert other small instruments that can be used
to treat or diagnose urinary problems.
TRANSURETHRAL RESECTION
OF PROSTATE (TURP)
SURGICAL MANAGEMENT
TURP COMPLICATION
1) Bleeding
2) Clot retention
3) Urinary tract infection
4) Inability to void
5) Incontinence
6) Retrograde ejaculation (semen entering
bladder)
7) TURP syndrome
8) Impotence
TURP SYNDROME
Sometimes during CBI in progress, TURP
syndrome may appear due to absorption of
large amount of isotonic irrigation fluids
Early sign detection of TURP syndrome :1) Restlessness
2) Headache
3) Tachypnea
4) Respiratory distress
5) Hypoxia
6) Vomiting
7) Confusion and coma
CONTINUOUS BLADDER
IRRIGATION (CBI)
MANAGEMENT
CONTINUOUS BLADDER IRRIGATION (CBI)
Is a procedure to cleanse the urinary bladder
from blood clots following bladder operation
or injuries, prostate operation or after
Transurethral Resection of Prostate (TURP)
A three-way Foleys catheter with a 30-45 ml
retention balloon is inserted.
The catheter is pulled down into the prostatic
fossa to help provide hemostasis.
Usually discontinued 24-48 hours after TURP.
PURPOSE
To prevent blood clot formation.
To keep the catheter free of obstruction.
To facilitate detection of obstruction or
other complications.
Allow free flow of urine.
Maintain indwelling catheter (IDC)
patency,by continously irrigating the
bladder with Normal Saline.
EXPECTED OUTCOME
The
NCP 1
Date/Time:
02.11.2011/1000 am
Nursing Diagnosis: Alteration in emotional status: anxiety
related
to surgical procedure (cystoscopy)
Supporting Data:
Verbal: Patients asking a lot of questions regarding the
surgery
(cystoscopy)
Non- Verbal: Patients expression look anxious before the
surgery
(cystoscopy)
Goal: Patients anxiety will be reduced within 1 hours before
surgery after interventions given during
hospitalization.
Nursing Interventions:
1.Assess patients general condition such as facial
expression look anxious and level of anxiety such as
asking a lot of questions regarding the surgery.
R-As a base line data for further interventions.
I:Before giving any information and explanation
regarding surgery to patients,I observe patients
facial expression and he looks anxious and I let be
patients express his feeling to reduce his anxious.
2.Reinforce doctor explanations regarding nature of
the surgery such as purpose doing surgery.
R-Ensure patients understand and reduce his anxiety.
I:I explain to patients about surgery base on what
doctor had inform before such as purpose of the
surgery,how the surgery will be performed and how
long the surgery will performed.
NCP 2
Date/Time:
03.11.2011/1100 am
Nursing Diagnosis: Alteration in comfort: pain related to
surgical
intervention (cystoscopy)
Supporting Data:
Verbal: Patients verbalized that he having pain at the
surgery site.
Non- Verbal: Patient facial expression look pale,anxious and
restless.
Goal: Patients pain will be reduced within 2 hours after
nursing
interventions given during hospitalization.
Nursing Intervention:
1.Assess patients general condition such as patients
facial expression look pale,anxious and also
restless.
R-As a base line data for further interventions.
I:After patient return to ward,I observed ptients
facial expression look pale,anxious and restless.
2.Assess patients level of pain by using pain score
and asking patients whether the pain is mild (13),moderate (4-6),severe (7-10) and observe site of
pain.
R-As a references for detect any abnormalities.
I:After patients return to ward I observed site of
surgery and asking patients level of pain using
pain score and patients verbalized he having
moderate pain (4-6)
Date/Time:
03.11.2011/1300 pm
Evaluation:
Patients pain was reduced after 2 hours nursing
intervention given
during hospitalization.
Supporting Data:
Verbal:Patients verbalized his pain is reduced and he felt
comfortable.
Non-Verbal:He looks more relax and comfort than before.
Sign:
STN NOOR AZIMAH BINTI MISWAN
NCP 3
Date/Time:
03.11.2011/1230 pm
Nursing Diagnosis: Potential bleeding related to
surgical intervention (Cystoscopy)
Supporting Data:
Verbal: Patients verbalized he felt not comfortable.
Non-Verbal: Patients urine color is bright blood
stain.
Goal:Patients bleeding will be minimal and no sign
and symptom of excessive bleeding will be
detected within 24 hours after nursing
intervention given during hospitalization
Nursing Interventions:
1. Assess sign and symptom of bleeding such as bloody
urine output, presence of large blood clot and decrease
urine output.
R- As a early detection of bleeding to plan for further
interventions.
I: I assess sign and symptoms of bleeding, there is bright
red color appears in urine.
2. Monitor patients vital sign every hourly for 6 hours
and followed by every 4 hours after surgery especially
blood pressure and pulse rate.
R- Dropping blood pressure below the normal range
(100-140 systolic) (60-90 diastolic) and tachycardia
indicate patients having bleeding.
I: I monitor patients vital sign every hourly for 6 hours
and record in observation chart, and his condition
stable.
Time : 2030 pm
Date : 03/11/2011
Blood pressure : 128/73 mmHg
Pulse : 83 bpm
Temperature : 37.3C
Respiration :20 bpm
3. Observe for the continuous bladder drainage such as color of
urine.
R- Color of urine will changed from bright blood stain to the slight
blood stain and clear urine (light pinkish)
I:I observed the urine color and found that the color had change
from bright red to the slight blood stain during the CBI progress.
4.Position patients to supine position for 24 hours.
R- To prevent pressure on the hypogastric region that can triggers
bleeding by increase intra-abdominal pressure towards surgical
incision.
I: I position patients to supine position and ensure that he
maintain the position by remind his wife as well.
Date/Time:
04.11.2011/1200pm
Re-evaluation:
There is no sign of excessive bleeding detected, patients
urine
color from bright blood stain to slight blood stain and
followed by
slight red urine color until CBD remove.
Supporting Data:
Verbal: Patients verbalized that he felt comfortable and no
complain.
Non-Verbal: Patients urine output appears slightly
hematuria.
Sign:
STN NOOR AZIMAH BINTI MISWAN
NCP 4
Date/Time:
03.11.2011/1230 pm
Nursing Diagnosis: Potential of infection related to insertion of
indwelling Foleys catheter.
Supporting Data:
Verbal: Patients verbalized that he feel itchiness at private
part.
Non-Verbal: Patients have indwelling Foleys catheter
inserted
after surgiacal procedure.
Goal: Patients will be free from signs and symptoms of
infection while catheter insitu after interventions given during
hospitalization.
Nursing Interventions:
1.Assess for any signs and symptoms of infection such
as color of urine,fever and itchiness at private part.
R-As a base line data for further inteventions.
I:I assess the site of catheter insertion for any redness
and also observed urine output for any cloudiness or
foul smell when empty the urine bag.
2.Monitor patients vital signs especially body
temperature.
R-Hyperthermia may indicate early sign of infection.
I:I had monitor patients vital sign especially patients
body temperature 4 hourly to detect any abnormalities
during my shift.
1230
36.4C
1630
36.6C
2030
37.3C
NCP 5
Date/Time:
04.11.11/1300 pm
Nursing Diagnosis: Knowledge deficit related to home care
management.
Supporting Data:
Verbal: Patients asked a lot of question regarding self care
at home
after discharged.
Non-Verbal: Patients look confused and not understand
regarding
self care at home after discharge.
Goal: Patients will be understand regarding health
education given
to him and able to take care of him self after discharged.
Nursing Interventions:
1.Assess patients level of understanding and knowledge regarding
self care management.
R-As a base line data to plan further health educations to patients.
I:I asked patients whether he knew about self care after discharged
and he verbalized that he is not very clear about it and hope that I
can help in giving informations regarding self care.
2.Advice patients in physical activity that suitable for him after
discharged which is light exercise and avoid heavy exercise such
as lift heavy things.
R-Heavy exercise may cause increase in intra-abdominal pressure
and lead to bleeding.
I:I advice patients not to do heavy work such as lifting and tell him
the purpose.
3.Inform patients that slide blood stained an urine are normal.
R-Reduce anxiety that may feel by patients if urine color are slide
pinkish.
I:I explained to patients that he may has slide bleeding in urine and
tell that it will stop within few days.
Date/Time:
04.11.2011/1300 pm
Evaluation:
Patients understand regarding health education given to
him and able to take care of him self after discharged.
Supporting Data:
Verbal: Patients verbalized that he was more clear about
self care after health educations given.
Non-Verbal: He look more understanding and cheerful.
Sign:
STN NOOR AZIMAH BINTI MISWAN
HEALTH EDUCATION
HEALTH EDUCATION
1) ACTIVITY
- Explain to patients that the process of healing may take: 4 - 8
weeks.
- Advise patients to have good rest.
- No strenuous activity and heavy lifting.
- Cycling are not allowed (bleeding).
- Should avoid long motor trip within 2 weeks.
2) ELIMINATION
- Keep bowel movement regular.
- Possibility sign & symptom of urgency, passing out small blood
clot in
urine, burning sensation.
- Bladder may take up to 2 month to return to its normal capacity.
- Retrain the bladder, because previously patient is on catheter so
the
bladder unable to hold the urine.
3) DIET
- Instruct patients to increase intake of fluid
more than 1-2 L/day to flush out the blood clot
that may persist.
- Encourage patients to take high protein diet
(promote wound healing) and also high fiber
diet (prevent constipation)
4) MEDICATION
- Reinforce patients regarding taking medication,
to make sure there is no skip doses and
complete the medications.
- Emphasize patients to taking medication with
full stomach.
5) FOLLOW UP
- Remain patients to come for the follow up
on 10/11/11 @ 10.00 am at doctor clinic.
- I also inform patients and his wife to bring
him to seek for the doctor if there is any
complication occur within day before for
the follow up date.
DISCHARGE
DISCHARGE
Mr.Z discharged on 04/11/2011 by Dr A. Condition Mr.Z during
discharge is stable and no complain of pain and difficul to pass urine.
His vital
signs on discharged:
Temperature
: 36.8C
Pulse
: 71 bpm
Blood Pressure : 112/72 mmhg
Respiration
: 20 bpm
Medication for discharged as Dr P ordered is :
Ural 11/11 BD
T.Mobic 7.5mg BD
Before discharged, I ensured the branula and ID band had been
removed
and reminded him about the follow up and take the medications as
prescribed.
FOLLOW UP
FOLLOW UP
On 10/11/2011, Mr. Z and his wife came to the
hospital and go to
the Dr A clinic for the follow up. Her condition
looks stable and
more comfortable and cheerful.
He also did not complained any pain or difficulty
to pass urine and
Dr.A decide want to see him another follow up
after 4/12.
SUMMARY
SUMMARY
Mr.Z, 53 years old admitted to Specialist Hospital on 01/11/2011at 1800
pm.He had back pain,difficult to pass urine and bladder distanded for 4/12. On
admission, he was accompanied by his wife and staf reception to admitted in Surgical
ward at 4th floor. His bed no is 432.
During hospitalization, Dr A had ordered some investigations such as FBC, BUSE,Urine
FEME for lab investigations on 01/11/2011. CXR and ECG on 02/11/2011.Dr A also
do special orders such as Cystoscopy at SPD on 02/11/2011 and Cystoscopy + diode
laser vaporisation of prostate surgery at OT on 03/11/2011.Patients NBM at 12 MN
before surgery.
In ward Dr A ordered medication such as IV Cefrex 2g Daily,Dormicum 7.5mg
NOCTE,T.Lasix 40mg TDS and T.Slow K Daily.
Mr.Z discharged on 04/11/2011 by Dr.A. Dr. A has prescribed medications such as Ural
11/11 BD and T.Mobic 7.5mg BD.
His follow up is on 10/11/2011 at 1000 am in Dr A Clinic. During follow up patients
look more comfortable and cheerful.He also did not complained any pain or difficulty to
pass urine and Dr.A decide want to see him another follow up after 4/12.
REFERENCE
REFERENCES
1. Lemone Burke, Medical Surgical Nursing Critical Thinking in Client
Care (2nd Edition) page (1972-1999)
2. Suzanne C.Smeltzer & Brenda G Bare,Brunner & Suddarths Textbook
of Medical Surgical Nursing (10th Edition) page (1486-1513)
3. Berman &Synder &Kozier Erb, Fundamentals of Nursing
(Concepts,Process and Practice) (8th Edition) page (1285-1319)
4. Anne Waugh & Allison Grant,Ross and Wilson Anatomy and
Physiology in Health and Illness (10th Edition) page (441-462)
5. Barbara F. Weller, Baillire Tindall (2009), Baillieres Nurses
Dictionary for Nurse and Health Care Workers (25 th Edition)
6. MIMS MALAYSIA DIMS (2011), (126th Edition) page (50,185,240,290)
Available: www.cancer.gov/dictionary?cdrid=44372
www.medterms.com/script/main/art.asp?articlekey=8946
www.kidney.niddk.nih.gov/statistics/uda/Benign.Prostatic.HyperplasiaChapter 02.pdf