II.

NURSING ASSESSMENT

Personal Data

Name: A.C.A
Age: 70 y/o
Civil Status: Married
Nationality: Filipino
Address: Binangonan Rizal
Religion: Roman Catholic
Date of birth: November 15, 1940
Attending Physician: Dr. Bella
Date of Admission: November 28, 2010 (3:20 am)
Chief Complaint: Dysuria or Difficult urination
Impression of Dx: Benign Prostatic Hyperplasia

Personal History

Mr. A.C.A is a 70 year old male, who resides at Binangonan Rizal. His religious
affliation is Roman Catholic and married to Mrs. L.A and had eight children. Mr. A.C.A
works as a shoe maker when he was young and became a fisherman before. Since
then he never had a job and now just stays in their home with his wife and their
youngest child who was still a single. Mr. A.C.A usually sleeps at 10 in the evening and
wakes up at around 4 in the morning . Mr. A.C.A usually spend time watching t.v,
dawdled in front of their house, chatting with his neighbors and going the market via his
bicycle.

Mr. A.C.A usual viand includes fish, vegetables, chicken, meat and rice. He also
loves eating bread and milk. Before he used to eat tinapa, tocino, sardines, tocino and
bagoong. He also smokes and is able to consume 1 pack of cigarette a day. He drinks
alcohol beverages occasionally, Regarding the finances about health his daughter who
has good job as an OFW in Taiwan shoulders everything together with his other
children who ahs a stable job.

History of Past and Present Illness

It is not the first time of Mr. A.C.A to be confined in a hospital. He had PTB before
and has a compliance completing his antibiotic treatment, last year he was diagnose of
having a problem in his prostate. He was advised by the doctor to stop eating food high
in salt and rich in preservatives.
 As for his present condition, he was admitted to Angono Medics Hospital 3 days
before he was transferred to Rizal Provincial Hospital with a chief complaint of blood in
the urine and black stool and was diagnosed with Benign Prostatic Hyperplasia based
of the diagnostic procedure he had undergone. One week prior to his admission he
experiences pain during urination and find a tinge of blood in his urine. Last November
28, 2010 he was brought in the hospital around 3:20 in the morning due to his black
stool and hematuria.

Family History
According to the wife of Mr. A.C.A, the familial disease that they have in the
family is DiabetesMellitus. His mother has DM and died of natural cause while his father
died of stroke. He has seven siblings and one died due to stroke. He is also the only
member in the family who has BPH.
 Laboratory / Diagnostics

1. Complete Blood Count (CBC)

This is to determine blood components and the response to inflammatory process

or if there is a presence of infection.

Date Ordered: 11/28/10

Date Result In: v
Results:Hct- 20.3 %
Platelet- 22.6
WBC- 24.4 g/l
Granulocytes- 3
Lympho/Mono- 17
Hgb- 67

Conclusion: WBC is elevated based on the normal value of 4.3-10 g/l which

confirms the presence of infection

2. Fasting Blood Sugar

This is to measure the blood glucose levels

Date Ordered: 11/28/10
Date Result In: 11/28/10
Results:107 mg/dl

Conclusion: the result is within normal range based on the normal value of < 126

mg/dl.

3. BUN

This is an indicator of renal function and perfusion, dietary intake of CHON and
the level of protein metabolism.
Date Ordered: 11/28/10
Date Result In: 11/28/10
Results:17.4 mg/dl

Conclusion: the result is within normal range based on the normal value of 7-21

mg/dl.

4. Creatinine
In men with symptoms, blood tests are performed to measure a substance
called serum creatinine, which is a marker for kidney trouble. Kidney problems exist in
an average of13.6% of BPH patients. Studies have reported rates as high as 30% and
as low as 0.3%.

Date Ordered: 11/28/10

Date Result In: 11/28/10
Results:

1.0 mg/dl

Conclusions:

The result is within normal range based on the normal value of 0.60-1.7 mg/dl

5. Urinalysis
A urinalysis may be performed to detect signs of bleeding or infection.
Aurinalysis involves a physical and chemical examination of urine. In addition, the urine
isspun in a centrifuge to allow sediments containing blood cells, bacteria, and
otherparticles to collect. This sediment is then examined under a microscope. Although
urinaryinfection is uncommon in younger men, it occurs more frequently in older
men,particularly those with BPH. A urinalysis also helps rule out bladder cancer.

Date Ordered: 11/28/10

Date Result In:11/28/10

Results:
Color- yellow
Specific Gravity- 0.010
pH- 7.5
Appearance- turbid
Pus cells- 1-3 hpf
Red cells- 15-25 hpf

Conclusions:
The results are almost normal but there is a presence of pus cells in the
urinewhich indicates the presence of infection and presence of red cells that indicates
thepresence of blood in the urine.

6. Fecalysis

Aids in the evaluation of the digestive efficiency and the integrity of the stomach
and intestines.
Date Ordered: 11/28/10
Date Result In:11/28/10
Results:

Color- dark brown

Consistency- soft

Conclusions:

The results are normal.

7. KUB x-ray

diagnostic medical imaging technique of the abdomen[1] and stands

for Kidneys, Ureters, and Bladder.

Date ordered: 11-28-10

Date Result in: 11-29-10

Result:

There is gas filled bowel into the abdomen.

Renal shadows are obscured.

Flank strips Iips are intact.

Oval-shaped opaque density noted in the pelvic capacity.

Osseous structures are unremarkable.

Impression: To consider Cystolithiasis. Suggest, KUB Ultrasound.

8. Chest x-ray

This is to rule out respiratory cause of referred pain.May be obtained to detect

pulmonary disease and the status of respiratory problems or trauma

Date ordered: 11-28-10

Date Result in: 11-29-10

Hazed densities noted in the left lung and right upper lung field.

Midline structures are devastated to the left.

Heart size cannot be ascertained because it is obscured along with the hemidiaphragm

and sulci.

Osseous structures are unremarkable

Impression: PTB, BILATERAL WITH ATELECTASIS.

9. Immunochemistry

 is a branch of chemistry that involves the study of the reactions and components on
the immune system.

Various methods in immunochemistry have been developed and refined, and been used
in scientific study, from virology to molecular evolution.

Date ordered: 11-26-10

Date result in: 11-26-10

Result:

PSA: 19.0 ng/ml

NV: 0-1.0 ng/ml

Analysis:

The PSA result is elevated based on the normal value this indicates, PSA is present in
small quantities in the serum of men with healthy prostates, but is often elevated in the
presence of prostate cancer and in other prostate disorders.