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Risk for complication of stroke.
The patient has a history of coronary artery disease, hyperlipidemia, hypertension, and diabetes mellitus type 2.

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Erosion of the tubing in the inflatable penile prosthesis.

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Disturbed Body Image
R/T: Alteration in body function and surgical procedure.
M/B: Alteration in body function, alteration in view of one's body.
S/T: Erectile dysfunction and inflatable penile prosthesis.
Patient Goal: The patient will demonstrate adaptations to body functions within 6 weeks of discharge.
Achievement: This goal was not achieved during my shift. I set the timing to six weeks to allow the penis to heal. Ideally, the patient would report to their healthcare provider if he has an increase in sexual functioning.
Patient Teaching: If body image difficulties continue, see the urologist or try therapy.

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Risk for Infection
R/T: Invasive procedure and Diabetes Mellitus Type 2
Patient Goal: The patient will demonstrate appropriate care of infection-prone site (penis) within 24 hours of instruction.
Achievement: This goal was achieved. The patient demonstrated and understood why and where to put the bacitracin.
Patient Teaching: Teach the patient signs of infection such as fever, redness, warmth, and discharge

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Acetaminophen (Tylenol)
-Dose: 1,000 mg
-Route: PO
-Times of administration: Q 6 hrs
-Patient Teaching: Do not exceed 4,000 mg per day when taking this medication at home.
-Intended Effect: Treats minor pain and fever.
Atorvastatin (Lipitor)
-Dose: 40 mg
-Route: PO
-Times of Administration: Bedtime
-Patient teaching: Avoid drinking more than 200mL/day of grapefruit juice.
-Intended Effect: Atorvastatin lowers total and LDL cholesterol and triglycerides. Atorvastatin is also used to prevent cardiovascular disease.
Bacitracin Zinc Packet
-Dose: 500 unit/gram
-Route: Topical
-Times of Administration: 3 times/day
-Patient Teaching: The bacitracin should be applied to the tip of his penis.
-Intended Effect: Bacitracin is an antibiotic used to prevent infection.
Cefdinir (Omnicef)
-Dose: 300 mg
-Route: PO
-Times of Administration: Q 12 hrs
-Patient Teaching: Continue to take the medication, even if feeling better.
-Intended Effect: Cefdinir treats skin infections.
Fentanyl (Sublimaze)
-Dose: 25 mcg
-Route: IV
-Times of Administration: Q 2 hr, PRN
-Patient Teaching: This medication may cause dizziness or drowsiness. It is important to ask for assistance before ambulating.
-Intended Effect: Fentanyl is used to decrease moderate to severe pain.

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This patient had a circumcision in February 2018 due to phimosis.

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Full Set of Vital Signs/How Often Vital Signs are Ordered

-Ordered: Q1hr x4hrs, Q4hrs x 24 hrs
- Temperature: 36.4 C
- Pulse: 70
- Respirations: 16
- Blood Pressure: 97/61
- O2 Sat: 98%
- Pain: 0

Trending Vital Signs

- Temperature: 36.4
- Pulse: 72
- Respirations: 16
- Blood Pressure: 100/70
- O2 Sat: 98%
- Pain: 0

Specialties/Services Collaborating:

Urology

Tests

No test results available.

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Subjective
-Zero pain
-Recently tried PDE5 Inhibitors to help with erectile dysfunction, but became unresponsive to medications.
-Said he had a tough time trying to urinate
Objective
-Erectile dysfunction
-Oriented and Alert x3
-Penis circumcised
-Lower blood pressure when first arrived to unit (97/61)
PMH
-Coronary Artery Disease (believed to be the cause of his erectile dysfunction)
-Diabetes Mellitus Type 2
-Hypertension
-Hyperlipidemia

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Male, 72
Diagnosis: Erectile Dysfunction
Procedure: Implantation Inflatable Penis

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Evening shift, 3/26/2019