J.D. is a 64-year-old man who presents to the family practice complaining of increased urination at night. The patient has a past medical history of hypertension, hyperlipidemia, and coronary artery disease (CAD). Vital signs are: T 97.5, P 85, R 16, and BP 120/60. What subjective information should the nurse obtain? What is the Rationale for obtaining that information ? Please respond to using no less than 100 words
When assessing a patient like J.D., it is important for the nurse to obtain subjective information related to the patient’s symptoms and medical history. In this case, the nurse should inquire about the frequency and severity of J.D.’s increased urination at night. Additionally, the nurse should ask about the duration of these symptoms, any associated pain or discomfort, and whether J.D. has noticed any changes in the color or odor of his urine.
The rationale for obtaining this information is to gain a comprehensive understanding of the patient’s condition and to gather baseline data that will aid in the assessment and diagnosis process. Asking about the frequency and severity of the symptoms helps to determine the impact on J.D.’s quality of life and whether the symptom is affecting his sleep patterns. Inquiring about the duration of the symptoms can provide insight into the chronicity of the condition and help differentiate between an acute or chronic issue. Asking about pain or discomfort can help in excluding other possible causes such as urinary tract infection or prostate issues. Finally, inquiring about changes in the color or odor of the urine can provide valuable information about potential underlying conditions such as diabetes or kidney dysfunction.
Gathering this subjective information will assist the nurse in developing a focused plan of care and will also provide valuable data for the healthcare provider to make an accurate diagnosis. Based on the patient’s medical history, it is possible that the increased urination at night could be related to his hypertension, hyperlipidemia, or CAD. However, it is important to rule out other potential causes such as urinary tract infection, prostate issues, or diabetes. By obtaining the subjective information mentioned above, the nurse can discern the need for further diagnostic tests or referrals to specialists, if necessary.
In summary, obtaining subjective information about J.D.’s increased urination at night will help in the assessment and diagnosis process. It will provide a comprehensive understanding of the patient’s symptoms, aid in ruling out other potential causes, and guide the development of an appropriate plan of care. This information is crucial for providing quality care and ensuring the best possible outcome for the patient.