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CUYAHOGA COMMUNITY COLLEGE

DEPARTMENT OF NURSING EDUCATION


NURSING CARE PLAN

Students name: Brian L. Barnes LPN

General Information

Patient initials: Date of Care: 03/25/14

Source of Data:

Patient Health Care Team Chart Family Other:

Age: 80 Sex: Male Martial Status: SINGLE Admission Date: 03/23/14

Religion: Baptist Advanced Directives: DNRCCA

Reason for Admission: Patient admitted for hematuria.

1 Primary Medical Diagnosis
Hematuria
Hypertension

2 Secondary Medical Diagnosis
Dementia
Lumbago
Benign Prostate Hyperplasia
UTI

3 Surgical procedures & dates
No previous surgical procedures

4 Reported signs & symptoms (use patients own words)
Patient stated, I came here because I was pissing out blood. I dont know why
they kept me this long because this problem been like this for a long time. I also
keep having this lower back pain that I just cant get rid of.

5 Signs and Symptoms of diagnoses as given in your text
Hypertension
HTN itself usually does not have any signs or symptoms
Some things may occur: flushing, headache, dizzy
Hematuria
Visible blood, pink, red or cola colored urine
Abdominal Pain
Decreased urinary force
Fever
Frequent urination (polyuria)
Pain during urination (dysuria)
Pain in the flank or side

Brief description of basic pathophysiology of present condition(s)

HTN: Blood pressure is a measure of how hard the blood pushes against the walls of your
arteries as it moves through your body. Its normal for blood pressure to go up and down
throughout the day, but if it stays up, you have high blood pressure. Another name for high
blood pressure is hypertension. When blood pressure is high, it starts to damage the blood
vessels, heart and kidnes. This can lead to heart attack, stroke, and other problems.

Hematuria: Presence of blood in the urine, an indication of injury or disease of the kidney or
some other structure of the urinary tract. The blood may become apparent during urination or
only upon microscopic examination. Rarely, blood may appear in the urine in the absence of
genito-urinary disease. Such instances may result from transfusion of incompatible blood, from
severe burns, from abnormal blood conditions in which the red cells are broken down.

MEDICAITONS & TREATMENTS:
Vancomycin (Vancocin) HCL 1250 gram via IV BID
Flomax (Tamsulosin) 0.4 mg QHS
Norvasc (Amlodipine) 10 mg QD
Diflucan (Fluconazole) 100 mg QD
Hydrochlorothiazide (Microzide) 25mg QD
Zestril (Lisinopril) 20 mg QD
Apresoline (Hydralazine) 10 mg via IV Q4HR PRN
Tylenol (Acetaminophen) 650mg Q6HR PRN

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