Nsg 3370 Week 4 Assignment 1

NSG 3370 WEEK 4 ASSIGNMENT 1 S-subjective data CC- “rectal bleeding with pain/soreness to rectum area when wiping with tissue” HPI: Onset: “unsure” Location: “observed blood on tissue during wiping” Duration: Intermittent Characteristics: “bright red” Aggravating factors: “during straining to have a bowel movement; and at times when I have constant bowel movements during the day” Relieving factors: N/A Treatment: N/A Severity: “unsure, non-noted” PMHx: Allergies: NKA. Current medications: Lisinopril 10 mg daily and Prilosec 40 mg daily. Medical history: HTN, GERD, Gallbladder disease, and Diverticulosis. Surgeries: Cholecystectomy. Hospitalization: None. Immunizations: received all childhood immunizations, recently received Flu vaccine (October 20016), and unsure of last Tetanus. Soc Hx: Marital status: Married for 3 ½ years with his wife. Living arrangements: lives with spouse and son. Occupation: Commercial manager for local auto parts store. History of drugs/alcohol/tobacco: Denies use of drugs and tobacco products, occasional beer couple times a week. Education level: High school graduate. Sexual History: active with his wife. Denies history of STI and only has had female sexual partners in past relationships. Fam Hx: Parents: both deceased. Father died of lung cancer; Mother died of heart attack. Siblings: 3 brothers and 1 sister, unsure of health status. Children: 1 living, no disease process known. ROS: (focus on male GU/GI) CONSTITUTIONAL: weight gain (+) “recently observed few pounds gain in the last few weeks” or loss (-), fever (-), chills (-), fatigability (-), night sweats (-), body aches (-) generalized pain (-); localized pain (+) “rectum area during bowel movements” HEENT: blurred vision (-), hearing loss (-), loss of vision (-), nasal congestion (-), sore throat (-), difficulty swallowing (-), sense of smell (-), change in taste (-), discharge (-), allergy symptoms (-), teeth and/or gum problems (-) SKIN: rash (-), itching (-) dry skin (+) CARDIOVASCULAR: Chest pain (-), palpitation (-), chest discomfort (-) RESPIRATORY: shortness of breath (-), cough (+), sputum production (-) GASTROINTESTINAL: nausea (-), diarrhea (+) and/or constipation (+) “bowel habits with loose stool to hard stool at times”, vomiting (-), abdominal pain (-), bleeding (+) “during wiping anus/rectum area after bowel movement”; dark tarry stool (-). GENTITOURINARY: urinary frequency (+), hesitation (-), dribbling (-), and burning (-); penis discharge (-); scrotal swelling (-); scrotal and/or penis pain (-); nocturia (+); difficulty controlling urine (-); history of kidney disease (-), kidney stones (-), UTI (-), or flank pain (-); history of STI (-); sexual active (+) “with my spouse”, erectile dysfunction (+) “has been this way for several years on/off”; NEUROLOGICAL: headache (-), seizures (-), dizziness (-), numbness (-), tingling (-) MUSCULOSKELETAL: body aches (-), muscle aches (+), joint pain (-) HEMATOLGIC: bleeding (+) “during wiping anus/rectum area after bowel movement”; bruising (-) LYMPHATICS: N/A PSYCHIATRIC: anxiety (-), depression (-) ENDOCRINOLOGIC: sweating (-), chills (-), heat and cold intolerance (-) ALLERGIES: asthma (-), seasonal allergies (+) Objective: ROS: performed PE on focused systems Constitutional: J.M. is A/O to person, place, time, and situation; he is calm and cooperative with care; observed no distress (noted patient concerned with bowel habits and blood from rectum). Vitals signs: B/P 152/90, HR 92, RR 18, Temp 98.2; WT198 lbs, HT 5’6, “patient reported increase of weight gain in the last few weeks, he reports approximately month ago weight 192 lbs”. Respiratory: All lung fields clear on auscultation with no acute respiratory distress observed; no wheezing, rhonchi, crackles, or rales noted during auscultation; sats 98% on RA; no SOB observed during assessment; patient reports no “SOB during activities and at rest”; No shallow breathing observed; No coughing noted. Chest symmetrical during inspiratory/expiratory breathing. Cardiovascular: Heart sounds S1/S2 without S3/S4, gallop, and murmur upon auscultation; no c/o chest pain during palpitation; radial and pedal pulses equal and strong; no generalized or localized edema observed; patient reports “no palpation, chest discomfort, or pressure”; cap refill 3sec; perfusion to extremities noted with skin warm to touch; observed no s/s of PVD, stasis, or DVT to extremities. GU: Positive for nocturia; patient reported “no burning sensation during urination”; positive for urinary frequency; Urine collected, noted yellow/clear urine with no sediment or foul odor; penis flaccid/wrinkled/pink in color; no lesions, warts, and masses observed on palpitation; urethra opening slightly pink with no discharge or redness noted; scrotum symmetrical with right slightly hanging lower than left; skin on scrotum loose with no lesions noted; testicles palpated with no nodes or masses; palpated for inguinal hernia (-) bilaterally; patient reported “sexually active with wife, in past has sexual encounters with females in previous relationships, and denies any history of STD’s”; patient reported “erectile dysfunction for some time” possible r/t low testosterone levels. GI: Bowel sounds present in all quadrants upon auscultation; no abdominal distention present; abdomen soft and flat on palpitation; no abdominal tenderness during palpation; patient reported “last bowel movement this morning with pinkish to light red blood noted on tissue paper after wiping”; rectum observed with no lesions noted; hemorrhoids small and protruding from rectum externally, no internal hemorrhoids palpable; noted blood at anus; stool for occult blood (-); sphincter tone normal; no fissure or masses palpable; prostate palpated and not enlarged; No varicosities noted. Skin: Pink in color with no rash, lesions, or open wound noted; warm to touch; turgor 3-5 secs; skin firm/tight. All other systems not pertinent to the CC at this time. In summary, J.M. chief complain is bleeding from rectum upon wiping with external hemorrhoids noted from rectum with c/o pain at rectal site. Negative for occult blood in stool. Patient reports urinary frequency at times especially during night. However, denies fever, fatigue, and pain. Hemorrhoids are related to “increased intra-abdominal pressure produces increased systemic and portal venous pressure, thus causing increased pressure in the anorectal veins” (Sommers & Fannin, 2015, p. 473). There are many contributing factors associated to causing hemorrhoids: “prolonged sitting; heart failure; anorectal infections; anal intercourse; alcoholism; pregnancy; colorectal cancer; and hepatic disease such as cirrhosis, amoebic abscesses, or hepatitis. Straining because of constipation, diarrhea, coughing, sneezing, or vomiting and loss of muscle tone because of aging, rectal surgery, or episiotomy can also cause hemorrhoids” (Sommers & Fannin, 2015, p. 474). J.M.’s possibility of causes for hemorrhoids are straining due to constipation/diarrhea. Educating him some different treatment options would be use of stool softener and avoid straining, use of medicated topical or Tucks pads, and cool compresses such as ice or cool sitz bath at least 15 mins twice daily (Sommers & Fannin, 2015). Sommers, M. S. & Fannin, E. (2015). Hemorrhoids. Diseases & Disorders: A Nursing Therapeutics Manual, 5th ed F.A. Davis Company, (Philadelphia, Pennsylvania). p473- 476