NRNP 6540F Advanced Practice Care of Older Adults Managing Genitourinary Disorders, Exams of Nursing

Download NRNP 6540F Advanced Practice Care of Older Adults Managing Genitourinary Disorders and more Exams Nursing in PDF only on Docsity! 1 NRNP 6540F Advanced Practice Care of Older Adults Managing Genitourinary Disorders As people age, functional and structural changes occur in their bodies. Changes take place as a part of the normal aging process in the absence of systemic diseases. However, common disorders in old patients can significantly affect the normal aging urogenital organs of older adults. In this paper, the goal is to present a focused subjective, objective, assessment, and plan (SOAP) for an elderly male patient with hematuria complaints. The author also aims to discuss the differential diagnoses, diagnostic exams, treatment plans, and reflect on the learnings from reviewing the patient's condition. An advanced nurse practitioner must make an appropriate assessment and treatment plan to assist elderly patients as they face aging and comorbid conditions that affect their renal functions. Focused SOAP Note Subjective Patient Information: R.B. 95-year-old, White, Male Chief Complaint: RB came to the clinic accompanied by son, reporting his "urine is really red." History of Present Illness: RB is a 95-year-old white male who came to the clinic 2 days ago, accompanied by his son, and complained that his urine appeared to be bright red in color. No other symptoms were reported. No other characteristics of the urine were reported. Alleviating and aggravating factors 2 were not reported; however, the patient has a history of gross hematuria and malignant neoplasm of the prostate. Time of symptoms, the environment where symptom occurs, and severity of pain (if there's any) were also not reported. Current Medications: Tamsulosin 0.4 mcg, 2 capsules daily, Aspirin 325 mg daily Atorvastatin 10 mg 1 tablet daily Donepezil 10 mg 1 tablet PO QHS Metoprolol 25 mg 0.5 mg tablet every 12 hours Acetaminophen 500 mg 1 tablet BID Analyzing RB's home medications based on the BEERS criteria, the chronic use of Aspirin should be avoided in patients over 70 years old unless other alternatives are not effective, and the patient can use gastroprotective agents like proton pump inhibitors (American Geriatrics Society, 2019). Using aspirin will increase gastrointestinal bleeding risk and induce kidney injury (American Geriatrics Society, 2019). With RB's symptoms of hematuria, the use of Aspirin should be analyzed for potential risk of worsening of the current complaint. Allergies: Penicillin- hives 5 • Cardiovascular: No chest pain, irregular heartbeats, palpitations, heart murmurs, swelling to legs or feet, cramping to legs with ambulation, leg pain, or varicose veins. History of new- onset atrial fibrillation, diagnosed on 12/2019. History of DVT on the left lower extremity. • Gastrointestinal: No decreased appetite, nausea, vomiting, hemoptysis, heartburn, regurgitation, jaundice, diarrhea, constipation, blood in the stool, black tarry stool, or hemorrhoids. Regular diet consists of pureed food and honey thickened liquid. • Genitourinary: Reports bright red urine. No difficulty in urination, pain or burning with urination, cloudy urine, frequency or urgency in urination, nocturia, incontinence, penile discharge, kidney stones, rash or ulcers, or sexually transmitted diseases. Reported history of similar gross hematuria episodes in the past. History of malignant neoplasm of the prostate. • Musculoskeletal: No cramping pain, joint or muscle pain. No joint swelling, neck pain, back pain, or significant muscle injuries. Right-sided hemiplegia and hemiparesis noted related to post-ischemic CVA. • Neurologic: No headache, dizziness, syncope, muscle spasms, loss of consciousness, sensitivity, or pain in both hands and feet. History of moderate vascular dementia. History of ischemic stroke with right-sided hemiplegia and hemiparesis. Denies recent fall or trauma. • Psychiatric: No depression, suicidal ideation, or hallucinations. • Integumentary: No changes to skin, hair, and nails. Denies rashes or changes to moles. Denies easy bruising, skin redness, skin rash, hives, nodules or bumps, hair loss, changes in the hands or feet. 6 • Hematologic: No other bleeding tendencies were reported other than the active bleeding in the urine. • Allergic: No rhinitis, asthma, skin sensitivity, latex allergies, or sensitivity. Allergic to Penicillin and reported hives as his allergic response. Objective Physical exam: General: Awake, alert, and oriented to person, place, and time with lapses of memory. Cognitive communication deficits were noted related to history of ischemic stroke. Speech is clear and coherent. Good eye contact. Appears well-groomed and well-nourished. Vital Signs: BP: 122/70, HR 66, RR 18, Temp 98.0 degrees Fahrenheit, Pulse ox 98% HEENT: Head: Normocephalic and atraumatic. Intact facial sensation on the left. Right-sided facial hemiparesis noted related to the history of stroke. Eyes: Pupils equal, round, and reactive to light and accommodation. No AV nicking or exudates in fundoscopic exam. No abnormal discharge noted. No periorbital swelling noted. Eyebrows symmetrical. Ears: Symmetrical. Patent external auditory canal with no swelling noted. No abnormal ear discharges noted. Tympanic membranes intact with no erythema or effusion. 7 Nose: Symmetrical. No nasal deviation, flaring, or nasal polyps noted. Throat: No erythema or exudates noted. Gag reflex intact. Neck: Supple with a full range of motion. Carotid arteries with no bruits or jugular vein distention. No masses palpated. No tracheal deviation noted. Respiratory: Symmetrical chest wall. Breathing unlabored. Clear lung sounds in all lung fields to auscultation with inspiration and expiration. Equal rise and fall of chest bilaterally upon inspiration and expiration. No rhonchi or wheezing noted. Cardiovascular: Heart rate regular rate and rhythm. S1 and S2 noted. No murmurs, gallops, and rubs. Abdominal aorta with no bruits. Distal pulses are symmetrical bilaterally 2+. No peripheral edema noted. Gastrointestinal: Soft, non-distended. No organomegaly or masses. No guarding or rebound tenderness. Bowel sounds present and normoactive in all four quadrants. Genitourinary: External meatus of the urethral orifice with no erythema. No penile tenderness and induration noted. No tenderness, masses, lump, or nodules in testes on palpation. Hard, irregular nodule palpable on prostate examination. History of malignant prostate neoplasm. Straight catheterization done with bright red urine return with no clots noted with 100 ml in a specimen cup. Neurologic: Gait and balance disturbances noted to the right side due to the right-sided hemiparesis and hemiplegia post-ischemic stroke. Pain sensation intact to both arms and legs. Deep tendon reflexes to bilateral upper and lower extremities 2+. 10 signs and symptoms of urgency, back pain, flank pain, suprapubic pain, gross hematuria, and urinary incontinence (Ashraf et al., 2020). In the absence of fever and dysuria with no indwelling catheters, UTI diagnosis requires at least two of the above-mentioned accompanying symptoms (Ashraf et al., 2020). Patient RB in the case study only reported gross hematuria; thus, if the provider is only using AHRQ's diagnostic criteria, the provider can rule out UTI. Performing a comprehensive assessment asking related genitourinary symptoms will help confirm the diagnosis. The provider in the case ordered for laboratory tests such as urinalysis and urine culture and sensitivity. The AHRQ recommends urinalysis and urine cultures to be performed for residents only when they meet clinical criteria for UTI (Ashraf et al., 2020). There may be additional symptoms not stated in the case study or obtained during the objective assessment that prompted ordering laboratory tests to rule in UTI. Urinalysis is utilized as a screening test for UTI. The absence of leukocyte esterase and nitrites in urinalysis rules out UTI (Ashraf et al., 2020). RB's urinalysis showed small leukocytes and was positive for nitrites, which are pertinent positives to rule in UTI for this patient. Another study discussed that urine culture is the gold standard in determining UTI (Chu & Lowder, 2018). In the absence of the urine culture results, the patient's clinical symptoms and urinalysis results can help rule in UTI. The patient in the case study has a pertinent positive symptom of blood in the urine or hematuria, typical for cystitis. A large amount of blood in the urine showed in the urinalysis, which is a pertinent positive. Another pertinent positive includes the high RBC (>900/HPF) in the microscopic analysis of the urine. The presence of RBC in the urine shows microscopic hematuria (Kennedy-Malone et al., 2019). The presence of localized genitourinary symptom and pyuria are required for diagnosing cystitis (Kennedy-Malone et al., 2019). Patient RB has a high WBC (>42.HPF) in the microscopic urine analysis indicating pyuria. Pyuria, 11 which is defined as WBC>10/HPF, is indicative of infection or inflammation (Kennedy-Malone et al., 2019). The pertinent positives stated above confirms cystitis as RB's primary diagnosis. There are other criteria for UTI, like the McGeer criteria and the National Healthcare Safety Network definitions, which are sometimes used to guide the diagnosis of UTI, but they are not intended for that purpose and were developed for surveillance purposes (Ashraf et al., 2020). 2. Prostate Cancer Patient RB in the case study, has been diagnosed with a malignant neoplasm of the prostate and has a history of gross hematuria like his complaint in his current visit. According to Kennedy-Malone et al. (2019), the early disease is usually asymptomatic; however, obstructive symptoms include hesitancy, intermittent urinary stream, decreased force of stream reflect locally advanced tumors with growth advancing to the urethra and bladder neck resulting in hematuria and hematospermia. This differential diagnosis could be ruled in with hematuria as the pertinent positive for RB in prostate cancer. In the case study, it was not stated if the patient had a treatment performed when he was first diagnosed with the prostate neoplasm. If there was a surgical procedure done or other treatment modalities, a referral to his oncologist should be performed to evaluate the recurrence of prostate cancer. 3. Metastatic Prostate Cancer/Bladder Cancer Patient RB has a malignant neoplasm of the prostate. Because of this condition, the advanced practice nurse can consider metastasis of cancer to the bladder as a differential diagnosis. Painless hematuria is the most common presentation of bladder cancer (Kennedy- 12 Malone et al., 2019). Other symptoms include urinary frequency, UTI, flank pain, mild suprapubic pain; however, it is often asymptomatic (Kennedy-Malone et al., 2019). Pertinent positives for RB are painless hematuria and the presence of UTI using the positive urinalysis results (large blood in UA, + WBC and RBC in the microanalysis, presence of leukocytes and + nitrites). In bladder cancer, the median age of diagnosis is 69 in males, the incidence is high in men, and Caucasian males are considered the highest risk (Kennedy-Malone et al., 2019). Age (95 years), gender (male), and ethnicity (white) are the pertinent positives for RB in this differential diagnosis. The diagnosis can be confirmed through cystoscopy. The National Comprehensive Cancer Network stated that cystoscopy is the gold standard for the initial diagnosis and staging of cancer of the bladder (Kennedy-Malone et al., 2019). Plan Treatment Depending on the diagnosis, there are different considerations in the treatment of older adults. Empiric pharmacologic treatment for UTI includes fluoroquinolone or trimethoprim- sulfamethoxazole (TMP-SMX) DS; however, older men like RB may require therapy up to 10- 14 days (Kennedy-Malone et al., 2019). Patient RB will be started on sulfamethoxazole- trimethoprim DS 160/800 mg twice a day for 14 days. Fluoroquinolones must be reserved for special circumstances related to microbial sensitivity (Kennedy-Malone et al., 2019). However, special consideration should be performed in administering TMP-SMX. The BEERS criteria recommend the use of TMP-SMX with caution in patients with decreased creatinine clearance. There is an increased worsening of kidney functions and hyperkalemia; hence, the dose must be reduced if creatinine clearance is between 15 and 29 and avoid if less than 15 (American 15 If the recurrence of prostate cancer is the nurse practitioner's concern, follow-up will depend on the current treatment and patient risk factors. PSA every 6 months for the next 5 years is recommended, and if the result is elevated, referral to the oncologist should be done (Kennedy-Malone et al., 2019). Digital rectal exam is usually done annually if radiation was done but discontinued after radical prostatectomy with undetectable PSA levels (Kennedy- Malone et al., 2019). Routine history and physical examinations, depression screenings, and annual quality of life assessment must be made. For bladder cancer, a bladder ultrasound will be ordered to determine the presence of a tumor that may indicate the metastatic spread of prostate cancer. Referral Consultation with a urologist will be done if cystitis progresses to pyelonephritis or urosepsis and recommend ordering cystoscopy for the bladder cancer differential diagnosis. If the recurrence of prostate cancer or bladder cancer is determined, the patient will be referred to an oncologist and radiologist. Imaging studies may be ordered by the oncologist like CT scan and MRI to stage invasive or locally advanced disease. Reflection In performing this SOAP, there was a realization of the importance of obtaining adequate patient history and performing synthesis of available information. The patient only presented with hematuria and no other symptoms. However, the medications, the past medical history, and the laboratory values were all relevant and vital in determining the differential diagnoses. 16 The author also noted that the patient was recently diagnosed with a new onset of atrial fibrillation. Patients are usually given anticoagulants with this condition. No blood thinners, other than the aspirin, were in the patient's home medications. Probing for this information is necessary because the blood in the urine may be related to anticoagulants. In preparing for the treatment plan, it was interesting to know that the pharmacologic treatment differs for symptomatic and asymptomatic UTI and catheter or non-catheter-related UTI. The length of pharmacologic therapy is also dependent on the severity of the condition. Moreover, nurse practitioners should also be aware of the different diagnostic criteria available in determining the correct diagnosis. Each medical condition has its gold standard to confirm the diagnosis. The provider must be familiar with those to prevent ordering unnecessary tests that waste the patient's time and money and exposes the patient to possible risks associated with some diagnostic tests. Summary Aging is a physiologic process that causes changes in the genitourinary system with subsequent functional and structural changes. Due to that, geriatric patients may present with hematuria, which may be a symptom of a specific genitourinary disease or an underlying condition that may be benign or malignant. It is crucial for the nurse practitioner to investigate thoroughly and order appropriate diagnostic tests to determine the cause of the presenting symptom. Advanced nurse practitioners must critically assess all pertinent systems, analyze data, synthesize the data into relevant problem focus, and create a treatment plan based upon this synthesis. 17 References American Geriatrics Society. (2019). American Geriatrics Society 2019 updated AGS Beers criteria for potentially inappropriate medication use in older adults. Journal of the American Geriatrics Society. https://doi.org/10.1111/jgs.15767 Ashraf, M. S., Bushen, O. Y., Chung, P., Hames, E., Mahajan, D., Nalls, V., Schweon, S. V., Trivedi, K. K., & Jump, R. L. (2020). Diagnosis, treatment, and prevention of urinary tract infections in post-acute and long-term care settings: A consensus statement from AMDA's infection advisory subcommittee. The Journal of Post-Acute and Long-Term Care Medicine, 21, 12-24. https://doi.org/10.1016/j.jamda.2019.11.004 Buowari, Y. D. (2019). Hematuria in the elderly: A review. Journal of Aging Research and Healthcare, 2(4), 7-10. https://doi.org/10.14302/issn.2474-7785.jarh-19-2932 Chu, C. M., & Lowder, J. L. (2018). Diagnosis and treatment of urinary tract infections across age groups. 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