SEMINAR PRESENTED TO
THE DEPARTMENT OF
NURSING SCIENCE
FACULTY OF HEALTH
SCIENCE AND TECHNOLOGY
COLLEGE OF HEALTH
SCIENCES
IN
PARTIAL FULFILLMENT OF THE
COURSE
NURSING SEMINAR (COURSE
CODE: NSC 514)
ABSTRACT
Benign
prostate hyperplasia or benign prostate hypertrophy is the enlargement of the prostate
gland in men due to increase in size and number of cells of the gland. Because
the prostate surround the male urethra at its junction with the bladder, its
enlargement occludes the urethra causing urine retention or stasis of urine
flow exposing the urinary tract to infections. Precipitation of the salts
contained in urine can cause bladder stones or kidney stones. Apart from the
above mentioned problems, other symptoms associated with prostate enlargement
include weak urinary stream, prolonged emptying of the bladder, abdominal
straining, hesistency, urgency, irregular need to urinate, incomplete bladder
emptying, post urination dribbling, nocturia,and many others. BPH has been shown by different studies to be
caused by testosterone, dihydrotestosterone synthesized from testosterone,
estrogen, dietary factors, smoking, heavy alcohol consumption, and diabetes.
The management of BPH involves relief of pain and pressure by catheterization
and suprapubic cystotomy to aid irrigation of urine. Other managements include
medications such as alpha blockers which relaxes the smooth muscles of the
bladder neck and prostate to enhance safe flow of urine from the bladder
through the urethra, prostatectomy, and saw palmetto herbal product which works
like finasteride, a 5-alpha reductase inhibitor that interferes with the conversion
of testosterone to dihydrotestosterone inhibiting prostate growth.
INTRODUCTION
Benign
prostate hypertrophy or Benign prostate hyperplasia is a non-cancerous increase
in the size and number of cells that make up the prostate. (Schmitz 2009).The
three(3) significant words will be explained thus: Benign is described as a non
invasive condition or illness that is not serious even though treatment may be
required for health or cosmetic reasons.(Bailleire’s nurses’ dictionary 2005).
Prostate is a gland surrounding the male urethra at its junction with the
bladder, during ejaculation it produces fluid which forms part of the
semen.(Balleire’s nurses dictionary 2005).Hypertrophy is the increase in size
of an organ or tissue due to increase in size of the cells while Hyperplasia is
the increase in size of an organ or tissue due to increase in number of the
cells.(Dorland’s medical dictionary 2003).To be accurate, the process is one of
hyperplasia than hypertrophy but the nomenclature is often interchangeable even
amongst urologists.
In
approximately one half of men 50 years and above, the prostate gland enlarges
extending upward into the bladder and obstructing the outflow of urine by
encroaching on the vesicle orifice. In United states, benign prostate
hyperplasia is responsible for 375,000 hospital stays each year (Gilchrist 2004).Prostate
growth is believed to begin at approximately age of 30years.An estimated 50% of
men have histological evidence of BPH by age 50years and 75% by age of
80years.In 40-50% of these patients BPH becomes clinically significant.
(Schmitz 2009).Prostate enlargement is only found in males since women do not
have prostate gland. Prostate enlargement is only seen in older adult men and
not in younger males. This is because prostate enlarges over the course of many
years of exposure to male hormones and young males have not had enough year of
exposure for symptoms of BPH to emerge.
Benign
prostate hyperplasia is caused by male hormones particularly testosterone. Men
that live western lifestyle have much higher incidence of symptomatic BPH than
men that live a traditional or rural lifestyle. This is confirmed by a research
in China showing that men in rural areas have very low rates of clinical BPH
while men living in cities adopting western life have a skyrocketing incidence
of this condition(Wikipedia 2009).The most common symptoms are increased
frequency of urination, urgency,
nocturia, dysuria, hesistency and many others.BPH can be diagnosed by
ultrasound examination, rectal examination, renal function test, prostate
specific antigen blood test among others(Brenda, Suzanne, Kerry, Janice 2008).
The
management of BPH include medical and surgical management. The relief of
pressure and pain is by catheterization and suprapubic cystostomy.It is
therefore very imperative that BPH should be detected early and when detected
strict intervention should be maintained using proper techniques to avoid
morbidity and loss of life. This study is discussed under the following
specific objectives:
1.
To describe the anatomy of the prostate gland.
2.
To describe the pathophysiology of prostate enlargement.
3.
To discuss the management of BPH.
4
.To discuss the importance of adequate Nursing management.
ANATOMY
OF THE PROSTATE GLAND
Diagram:
Description:
The prostate gland lies in the pelvic cavity in front of the rectum and behind
symphysis pubis surrounding the first part of the urethra. It consists of an
outer fibrous covering, a layer of smooth muscle and glandular substance
composed of columnar epithelial cells. The prostate has a base, an apex and
four (4) surfaces, posterior, anterior and two (2) inferolateral surfaces. The
base of the prostate is closely related to the neck of the urinary bladder. The
prostatic urethra enters the middle of the base near its anterior surface. The
apex is inferior and is related to the superior fascia of urogenital diaphragm.
The posterior surface rests on the ampulla of the rectum thus this surface can
be palpated by a digit in the rectum. Anterior surface is convex and extends
from the apex to the base. The inferolateral surfaces of the prostate meet
anteriorly with the convex anterior surface and rests on the fascia covering
the levator ani muscles.
Functions:
The prostate gland secrets a thin, milky fluid appearance. It contains a
clotting enzyme which thickens in the vagina increasing the likelihood of semen
being retained close to the cervix. The fluid contains proteins which include
protoelytic enzyme, prostatic acid phosphate, and prostate specific antigen.
Another important prostate function is controlling the flow of urine during
ejaculation. A complex system of valves in the prostate sends the semen into
the urethra during ejaculatory process and a prostate muscle called the
sphincter seals the bladder, thereby preventing urine from entering into the
bladder.
Blood
supply: The prostate gland is supplied by the inferior vesical artery and
middle rectal artery.
Venous
supply: This is by the prostatic venous plexus around the sides and base of the
prostate which drains into the internal iliac artery.
Lymphatic
drainage: The lymph vessels terminate in the internal iliac and sacral lymph
nodes.
Nerve
Supply: Parasympathetic nerves arise
from the pelvic splanchnic nerves, S2, S3, and S4 and Sympathetic fibres from
inferior hypogastric plexuses.
PATHOPHYSIOLOGY OF BENIGN
PROSTATE HYPERPLASIA
Diagram
of Enlarged Prostate
Benign
prostate hyperplasia simply means prostate enlargement. It is a non-cancerous
increase in the size and number of cells that make up the prostate. BPH is a
progressive disease that undergoes rapid enlargement during puberty but the
growth is retarded once puberty is completed. At middle age, the prostate
begins growing again but very slowly this time. Testosterone which is a male
hormone is responsible for prostate growth, as men grow older, the prostate
grows slowly but continuous. Due to the slow progression of the growth, most
men do not notice any symptoms of BPH until they are older and prostate has
grown to such a size that it impinges on the outflow of urine from the
bladder.(Bostwick,Roerhbornch et al,2002).In addition, the circulating
testosterone is usually converted to dihydrotestosterone (DHT) which is a more
powerful enhancer of prostate enlargement, as men get older, DHT synthesis
takes place in the stromal cells of the prostate and enlarges the gland until
it blocks normal urinary flow causing urinary retention and pains. Estrogen, a
female hormone that aids in the development of ovaries can also adversely
affect the prostate. Some of the men suffering from BPH have being found to
have high level of estrogen and low level of testosterone, estrogen plays the
same role as testosterone in enlarging the prostate gland (Wikipedia
2009).Recent studies have also identified smoking both current and former
smoking, heavy alcohol consumption, diabetes and dietary factors to affect
prostate growth in African American men.
(Joseph, Harlow, Wei et al 2003).
The
enlargement of the prostate leads to symptoms; such as storage and voiding symptoms as classified by Bostwick
(2002).The storage symptoms include:
urinary frequency which is urinating much more often than normal, urgency
that is having a sensation that you need to urinate immediately, incontinence
that is involuntary leakage of urine, nocturia-getting up to urinate at night.
The voiding symptom include: weak urinary stream, hesistancy meaning difficulty
starting the urine stream, intermittency meaning the stream starts and stops
intermittently, straining to void, dribbling, dysuria (painful urination).
These storage and voiding symptoms are evaluated using the international
prostate symptom score(IPSS) questionnaire designed to assess the severity of
BPH. Other generalized symptoms of BPH include fatigue, anorexia, vomiting,
epigastric discomfort. Urinary retention results in stasis of urine which
harbor bacterias and increases the risk of urinary tract infections. Urinary
retention can be acute when there is inability to void and chronic when the
residual urinary volume gradually increases and bladder distends. Also urinary
bladder stones are formed from the crystallization of salts such as calcium
phosphate, magnesium phosphate, ammonium phosphate, uric acid and its
salts(urates) due to urine retention.(Barocas,Salem et al 2009).
MANAGEMENT OF BENIGN PROSTATE
HYPERTROPHY:
The
patient suffering from benign prostate hypertrophy usually present with acute
pain at the lower abdomen arising from the full bladder and pressure of
enlarged prostate on the urethra. Pain is relieved through catheterization to
empty the bladder and suprapubic cystotomy(an incision into the bladder through
the abdomen to provide drainage. After relieving pain using catheter or
suprapubic cystotomy, the patient is now diagnosed to estimate the severity and
extent of benign prostate hypertrophy. Diagnostic investigations the patient
can undergo include; Digital rectal examination, prostate specific antigen
blood test, renal function test, complete blood studies, and ultrasound examination.
Digital rectal examination reveals a large, rubbery and non tender prostate
gland. Prostate specific antigen is synthesized by tumor cells and released
into the circulation in abnormal amounts. The PSA level indicates the presence
of prostate tissue. Renal function tests include serum creatinine levels to
determine whether there is impairment from prostatic back pressure and evaluate
renal reserve. Complete blood studies are performed because hemmorrhage is a
major complication of prostate surgery, it helps in early detection of clotting
defects and treatment. Ultrasound examination of the testicles, prostates, and
kidney is often performed to rule out malignancy and hydronephrosis
(Thomas,Jones et al 2010).
The
diagnosis and the extent of the enlargement will determine the type of
treatment to be given which may be conservative management or surgical
intervention( Brenda, Suzanne, Kerry, Janice
2008).
CONSERVATIVE MANAGEMENT:
This is the nursing intervention given when the
patient’s problem do not need surgery.
·
Assessment
on Admission: After admission for treatment, the
nurse assesses how BPH has affected the patient’s lifestyle. During assessment
the nurse can ask the following questions; Has the patient’s activity level or
activity tolerance changed? What is the presenting urinary problems described
in the patient’s own words? Has he lost weight? Has the patient experience
erectile dysfunction? Does he appear pale? and others. This information helps
determine how soon the patient will be able to return to normal activities
after treatment.
·
Observation: The nurse observes the patient’s vital signs,
Temperature, blood pressure, Pulse, and Respiration to detect deviation from
normal. The nurse also observes his lower abdomen for distented bladder due to
urine retention.
·
Psychological
care: The nurse clarifies the nature of the
surgery and expected postoperative outcomes and their management. He is
encouraged to verbalize his feelings and concerns in order to reduce patient’s
fear. Divertional therapy, touching the patient and listening to his complains
can help maintain psychological stability.
·
Investigations:
The nurse assists the patient to go for prescribed tests and assembles them for
the physician to make diagnosis.
·
Hygiene: The nurse maintains personal and
environmental hygiene to prevent nosocomial infection and increase patient’s
morale. The nurse encourage the patient to take his bath at least twice a day, the nurse also assist the patient if he
cant help himself in bathing, shaving, mouth cleaning, combing and cleaning his
bedsides.
·
Catheter
care: Catheterization is for drainage of
urine from the bladder to relief pressure and pain. The nurse ensures that the
catheter is well lubricated before insertion to reduce pain. There should also
be maintenance of aseptic technique during insertion of the catheter to prevent
infection from catheter contamination. The nurse ensures that the catheter is
removed when due, the nurse also ensure proper emptying of the bladder to
enhance flow of urine and reducing risk of infections. During bowel
elimination, the nurse advices the patient not to apply much pressure to
prevent the catheter from falling off and to achieve this the nurse advices the
patient to be eating light and low residue meal to prevent constipation.
Prescribed Frusemide (lasix) may be given by the nurse to promote urination
thereby helping to keep the catheter patent. The nurse constantly observes the
lower abdomen, an over distended bladder manifests a distinct, rounded, swelling
above the pubis, to ensure that the catheter is not blocked or kinked, and that
the catheter is not compressed by the weight of the patient which can cause
retention of urine in the bladder leading to bleeding severe pain and shock.
·
Medication:
There are two(2) main medications, alpha adrenergic blockers and 5-alpha reductase inhibitors(Kirby,2004). Alpha
adrenergic blockers example
terazosin, doxazosin, tamsulosin relax the smooth muscle of the bladder neck,
prostate and urethra to improve urine flow and relieves benign prostate
hypertrophy symptoms. Side effects include orthostatic hypotension, ejaculation
changes, nasal congestion, and weakness while
5-alpha reductase inhibitors example finasteride have been effective in
preventing the conversion of testosterone to dihydrotestosterone to decrease
prostate size. Prescribed analgesics example ibuprofen can be given to reduce
pain.
There
is also a herbal medication known as Saw Palmeltto. This active element comes
from the fruit of the American dwarf palm tree. Research has shown that the
efficacy of Saw Palmetto is similar to that of 5-alpha redutase inhibitors like
finasteride and the herbal product may be better tolerated and less
expensive(Gordon and Shaughnessy,2003).Saw palmetto functions by interfering
with the conversion of testosterone to dihydrotestosterone. It should not be
used with finasteride, dutasteride or medications containing estrogen.
·
Nutrition:
Protenious meal is given to increase immunity. Also soft and light meal is
encouraged to prevent constipation that cause straining during bowel
elimination that can displace indwelling catheter.
·
Rehabilitation:
Because the patient have been on catheter, he might have partially lost control of micturition, the nurse helps the
patient to regain control by calling on the patient to empty his bladder when
the urge to urinate comes. Observe the patient’s ability to control the urge
further after removing catheter to ensure that the patient is not still
suffering from the symptoms of BPH example incontinence, urgency among others.
·
Advice
on discharge: The nurse advices the patient to take
his drugs accordingly involving the family during advice because they will help
the patient adhere to advices if he forgets. The nurse reviews the anatomy of affected
gland again to increase understanding and for the patient to further appreciate
management. The nurse advices the patient to keep to all follow up appointments
and report to the hospital for any unusual symptoms.
SURGICAL
MANAGEMENT:
Prostatectomy
is the surgical removal of part or the whole prostate. It is indicated in BPH
and also for patients with prostate cancer. The surgical procedure include:
Transurethral resection of the prostate, suprapubic prostatectomy, perineal
prostatectomy, retropubic prostatectomy, Trasurethral incision of the prostate,
laparasopic radical prostatectomy (Brenda, Suzanne, Kerry, Janice 2008)
Transurethral
Resection of the Prostate (TURP): This is the
most common procedure used. It is carried out through endoscopy. The surgical
and optical instrument is introduced directly through the urethra to the
prostate which can be viewed directly. The gland is removed in small chips with
an electrical cutting loops. TURP can cause retrograde ejaculation because
removal of prostatic tissue at the bladder neck can cause the seminal fluid to
flow backward into the bladder rather than forward through the urethra during
ejaculation. After surgery, flushing with infusion follows.
Suprapubic prostatectomy: Is
one method of removing the gland through an abdominal incision. An incision is
made into the bladder, the prostate gland is removed from above. Suprapubic
infusion of intravenous fluid example sodium chloride is given to flush the
particles of the prostate and arrest bleeding(Nthumba,Bird 2006).
Perineal Prostatectomy:
This involves removal of the gland through an incision in the perineum. This
approach is practical when other approaches are not possible. The incision may
easily be contaminated because the wound is near the rectum. Therefore, proper
wound dressing is required to prevent infection.
Retropubic prostatectomy:
An incision is made in the lower abdomen and prostate is removed by going
behind the pubic bone without entering the bladder.
Laparascopic radical
prostatectomy: This is a laparoscopic procedure
involving four small incisions made in the abdomen used to remove the entire
prostate for treatment of prostate cancer.
PREOPERATIVE
NURSING MANAGEMENT:
·
This is nursing intervention
given from the period of time from when the decision for surgical intervention
is made and the patient is admitted for preparation of the surgery to when the
patient is transferred to the operating room.
·
Assessment:
The nurse check and record vital signs. The nurse takes history on how BPH has
affected the patient’s lifestyle. During assessment the nurse can ask the
following questions; Has the patient’s activity level or activity tolerance
changed? What is the presenting urinary problems described in the patient’s own
words? Has he lost weight? Has the patient experience erectile dysfunction?
Does he appear pale? among other questions. This information helps to determine
how soon the patient will be able to return to normal activities after
prostatectomy.
·
Care
of bladder and drainage of urine: The nurse catheterizes the patient to empty
the bladder. The nurse ensures that the catheter is well lubricated before
insertion to reduce pain. There should also be maintenance of aseptic technique
during insertion of the catheter to prevent infection from catheter
contamination. The nurse observes the catheter for blockage and kink to prevent
urine retention.
·
Investigations:
The nurse fills forms and sends for the following investigations as ordered:
Digital rectal examination which reveals a large, rubbery and non tender
prostate gland. Prostate specific antigen is synthesized by tumor cells and
released into the circulation in abnormal amounts. The PSA level indicates the
presence of prostate tissue. Renal function tests include serum creatinine
levels to determine whether there is impairment from prostatic back pressure
and evaluate renal reserve. Complete blood studies are performed because
hemmorrhage is a major complication of prostate surgery, it helps in early
detection of clotting defects and treatment. Ultrasound examination of the
testicles, prostates, and kidney is often performed to rule out malignancy and
hydronephrosis (Thomas, Jones et al 2010).Fasting blood sugar to rule out
diabetes mellitus. The nurse then assembles these laboratory results.
·
Psychotherapy:
The nurse establishes communication with the patient to assess his
understanding of the diagnosis and of the surgical procedure. The nurse
clarifies the nature of the surgery and expected postoperative outcomes and
their management. He is encouraged to verbalize his feelings and concerns and
ask questions in order to reduce patient’s anxiety. The nurse encourages bed rest
to calm the patient. Before surgery the nurse reviews the patient on the
anatomy of the affected structures and their function in relation to the
urinary and reproductive system using diagrams and other teaching aids to
increase understanding and relief fears. The nurse involves the family of the
patient to help him emotionally.
·
Consent:
The nurse presents consent form for the patient’s approval and acceptance of
surgery, to give legal backing to the surgeon, anaesthetists, nurses, and
protect patient from unauthorized procedure.
·
Other
Cares:
- The nurse ensures that the patient
maintained nil per oral atleast
12hours before surgery.
- The
nurse prepares the surgical site by cleaning and shaving.
- Elastic
compression stockings are applied before surgery for prevention of deep vein thrombosis, if the
patient will be placed in a lithotomy position during surgery.
- An
enema is usually administered on the morning of the surgery to empty the bowel.
- Other
medications is given as prescribed, example prophylactic antibiotics.
- The
nurse accompanies the patient to the theatre with case note, laboratory results
and ultra sound film.
- The
nurse finally prepares postoperative bed with resuscitation tray, vital signs
tray, oxygen, and suction machine.
POSTOPERATIVE
NURSING MANAGEMENT:
·
This is the nursing intervention
given from the period the patient is admitted to post surgical ward till after
follow up evaluation.
·
Reception:
The nurse receives the patient in the post operative bed.
·
Position:
Keep patient in a dorsal position with the head turned to one side to prevent
aspiration until he regains consciousness.
·
Clear
airway maintenance: The nurse does this by ensuring
adequate ventilation and suctioning when necessary. Observe the rate,
rhythm,and symmetry of chest movement, breath sound.
·
Observations:
The nurse observes patient’s vital signs, at frequent interval of 15minutes. Thereafter
they may be taken less frequently if it remain stable.
- The nurse observes the drainage bag,
dressings, and incision site for evidence of bleeding.
·
Maintenance
of patency of the catheter: The nurse ensures that the
catheter is removed when due, the
nurse also ensures proper emptying of the bladder to enhance flow of urine and
reducing risk of infections. During bowel elimination, the nurse advices the
patient not to apply much pressure to prevent the catheter from falling off and
to achieve this the nurse advices the patient to be eating light and low
residue meal to prevent constipation. Prescribed Frusemide (lasix) may be given
by the nurse to promote urination thereby helping to keep the catheter patent.
The nurse constantly observes the lower abdomen, an over distended bladder
manifests a distinct, rounded, swelling above the pubis, to ensure that the
catheter is not blocked or kinked, and that the catheter is not compressed by
the weight of the patient to prevent retention of urine in the bladder and
preventing bleeding, severe pain and shock.
·
Maintaining
fluid balance: The nurse monitor fluid output through
the catheter. Amount of fluid used for irrigation must be closely monitored to
determine whether it is being retained. She monitors signs of electrolyte
imbalances example low blood pressure, confusion, hyponatraemia, documents and
reports to the surgeon.
·
Relieving
Pain: The nurse assesses the cause, location
and the severity of pain. The nurse administers medications example flavoxate, a
smooth muscle relaxant which can help relax the bladder muscle that usually
undergoes spasms continuously or intermittently increasing pain. The nurse also
administer analgesics example ibuprofen which reduces pain by inhibiting
prostaglandin synthesis, she can also change the patient to his favourable
position.
·
Administer
prescribed drugs: The nurse administers analgesics
for relief of pain, antibiotics for combating infection, haematenics and
vitamins to aid body building and repair.
·
Wound
care: Maintain cleanliness, asepsis, and
dryness of surgical wound to aid healing. –Remove alternate stitches on seventh
day after surgery and remaining next day.
·
Feeding:
The nurse advices the patient to eat soft meal example fruit juice, after 24
hours of surgery - Protenious meal is given to aid healing and increase
immunity. –Soft and light meal will also prevent constipation that cause
straining during bowel elimination, this can displace indwelling catheter.
·
Advice on discharge: The nurse
gives advise on the followings:
- To report to his doctor if bleeding
occurs.
- To avoid straining, heavy lifting, vigorous
exercise for about one month to prevent
bleeding due to increased abnormal pressure.
- To take his drugs as required.
- To report to his doctor for any signs
of infection, example, fever, chills, severe
pain.
- The nurse stress on the importance of
perineal exercise example kegel exercise which is tightening the perineum and
speed the return of sphincter control.
- To avoid sexual intercourse, long car
trips, and driving a car until the doctor permits.
- To keep to all follow up
appointments.
NURSING CARE PLAN OF A PATIENT
UNDERGOING PROSTATECTOMY
PREOPERATIVE NURSING CARE PLAN
|
Nursing
diagnosis
|
Nursing
objectives
|
Nursing
intervention
|
Scientific
Principle/rationale
|
Evaluation
|
|
1.Anxiety about surgery and its outcome
|
The
patient will demonstrate reduced anxiety within 2hours of nursing
intervention.
|
1.Establishing communication with the patient.
2.Clarify nature and reason of surgery and
outcomes.
3.Encourage the patient to verbalize his feelings
and concerns.
4.Diversional therapy like discussing other issues
or watching television.
5.Invite patient’s relative to stay around him.
|
1.To assess his understanding of the disorder and
where to help him.
2.To increase understanding and reduce fear.
3.This reduces fear and help the nurse to clear
him more.
4.This will partly remove his mind from his
problem
and surgery.
5.This makes him feel he is not alone and calm his
anxiety.
|
The patient demonstrated reduced anxiety after 2
hours of nursing intervention.
|
|
2.Pain(acute) related to bladder distention.
3.Knowledge (deficit) about factors related to the
disorder and treatment protocol.
|
The patient 24hours before surgery will relate
understanding of disorder and treatment regimen.
|
1.Catheterise the patient.
2.Ensure that the catheter is well lubricated
before insertion
3.Maitain catheter patency.
4.Maintain an unobstructed gravity flow, example
kinking.
1.Review the patient on the anatomy of affected
structures and their function using a diagram.
2.Involve the wife and family during the review.
3.Provide the patient with postoperative outcomes
and its management.
4.Explain reason for every procedure.
5.Explain the function of prescribed drugs given.
|
1.To empty the bladder and relief pressure nd
pain.
2.In order not to increase pain.
3.To
prevent urine retention and relief pain.
4. To prevent back flow of urine and retention.
1.To enable him have full understanding of his
problem.
2.They will help him understand more.
3.To increase knowledge and understanding of postoperative outcomes and its management.
4.To involve patient in management and this
happens only if he understands his problem.
5.To help the patient understand treatment regimen
and comply to medication.
|
The patient reported relief of pain after 2hours
of nursing intervention.
The patient 24hours before surgery related full
knowledge of his problem.
|
POST OPERATIVE NURSING CARE PLAN
OF A PATIENT UNDERGOING PROSTATECTOMY
|
Nursing
diagnosis
|
Nursing
objectives
|
Nursing
intervention
|
Scientific
Principle/rationale
|
Evaluation
|
|
|
1.Pain(acute)
related to surgical incision, catheter placement and bladder spasm.
|
Patient will complain less of pain within
48hours post operatively.
|
1.Keep patient quiet and comfortable during
immediate post operative period.
2.Reduce unnecessary movement.
3.Give prescribed analgesic example ibuprofen
800mg per day.
4.Give
smooth musle relaxant to relief spasm of bladder example flavoxate.
|
1. This prevents episodes of spasms and bleeding.
2.To reduce pain from surgical incision.
3. Ibuprofen inhibits prostaglandin synthesis
thereby relieving pain.
4.To calm
bladder spasm and reduce pain.
|
Patient did not complain of pain 36hours of
intervention as evidenced by his relaxation and calmness.
|
|
|
2.Fluid
volume,deficient,high risk for related to trauma to highly vascular area with
excessive blood loss.
|
Patient will not exhibit signs of hypovolaemia
throughout the period of hospitalization.
|
1.Monitor
vital signs every 15minutes until stable.
2.Check the
drainage bag, dressing, and incision site for evidence of bleeding.
3.Keep
accurate intake and output records and account for irrigating fluid.
4.Watch and
monitor blood transfusion.
|
1.Vital
signs monitoring afford early detection of deviation from the normal
functioning of the body.
2.Early
detection of bleeding prevents further blood loss.
3. To
regulate fluid balance as venous sinusoids of the bladder may absorb the
irrigating fluid.
4.Observation
ensures that the specified and prescribed dosage is being transfused.
|
Patient did
not exhibit signs of hypovolaemic shock as evidenced by normal blood pressure
and pulse rates.
|
|
|
3.Urinary
elimination, impaired related to indwelling catheter.
|
Patient will
have adequate bladder drainage throughout hospitalization.
|
1.Irrigate
the bladder with sterile normal saline,frequency based on amount of bleeding.
2.Maintain
patency of catheter.
3.Palpate
the lower abdomen.
4.Irrigate
catheter gently,rotate catheter gently to move drainage opening away from
bladder wall or clot.
|
1.Irrigation
removes blood clot from the bladder.
2.Free flow
catheter maintains flow of urine and eliminates clots.
3.Palpation
ensures that there is no blockage of catheter as an over distented bladder
presents a rounded swelling above the pubis.
4.Irrigation
and rotation of the catheter encourage the free flow of irrigation fluid and
urine.
|
Patient had
adequate bladder drainage throughout hospitalization evidenced by
unobstructed flow of urine.
|
|
|
4.Infection,
high risk for, related to invasive procedures.
|
Patient will
not show signs and symptoms of infection, such as pyrexia t and purulent
drainage from drains and catheter.
|
1.Maintain
aseptic technique.
2.Frequently
check the incision site for signs of infection.
3.Change dressings when soiled.
4.Give high
protein diet.
|
1.To prevent
the invasion of infection.
2.Early
detection of infection prevents excalation.
3.Micro
organisms survive more in wet medium.
4.High
protein increases antibody production and provides adequate resources for tissue
repair.
|
Patient did
not show any sign of infection as evidenced by the wound healing by first
intention.
|
|
|
5.Skin
integrity, impaired related to surgery.
|
Patient’s
wound will heal by first intention within 7days post operatively.
|
1.Monitor
the incision for signs of infection.
2.Check the
vital signs 4 hourly and record.
3.Dress
wound under aseptic technique.
4.Give
prescribed antibiotic example Ampicillin.
|
1.Prompt
monitoring of incision detects wound infection.
2.An
increase in vital signs indicates infection,thus the 4 hourly checking.
3.Asepsis
promote wound healing.
4.Ampicillin
has a bacteriostatic and bacteriocidal effect.
|
Patient’s
wound healed by first intention within 7 days as evidenced by no wound
infection.
|
|
IMPORTANCE OF ADEQUATE NURSING MANAGEMENT
OF BPH
Men
with benign prostate hypertrophy experience serious complication when not
properly managed. These complications may be as a result of late diagnosis and
improper management. Adequate surgical, medical and nursing management of benign prostate
hyperplasia is important to prevent these complications which include:
Hemorrhage, catheter obstruction, infections, sexual dysfunction, deep vein
thrombosis, Renal failure, and prostate cancer.
Hemorrhage:
The immediate dangers after prostatectomy are bleeding and hemorrhagic shock.
This risk is increased with prostate hyperplasia because hyperplastic prostate
gland is very vascular. Bleeding may occur from the prostatic bed or also as a
result of clot formation which then obstruct urine flow. Bright red bleeding
with increased viscosity and numerous clots usually indicate arterial bleeding.
Venous blood appears darker and less viscous. Arterial hemorrhage usually
requires surgical intervention example Suturing or transurethral coagulation of
bleeding vessels, whereas venous bleeding may be controlled by applying
prescribed traction to the catheter so that the balloon holding the catheter in
place applies pressure to the prostatic fossa. The nurse gives high proteinous
meal to replace lost blood. It has been reported that bleeding is the major
cause of loss of life postoperatively, therefore adequate management, which
include close and careful observation of the patient to dictate early bleeding
signs and early adequate intervention given to save the life of the patient is
very important.
Catheter obstruction:
An obstructed catheter pre and postoperatively produces distension of the
prostatic capsule and resultant hemorrhage. After surgery like transurethral
resection, the catheter must be drained well to prevent obstruction and the
nurse ensures the irrigation fluid is maintained. Prescribed Frusemide (lasix)
may be given by the nurse to promote urination and initiate postoperative
diuresis thereby helping to keep the catheter patent. The nurse constantly
observes the lower abdomen, an over distended bladder manifests a distinct,
rounded, swelling above the pubis to ensure that the catheter is not blocked
causing retention, preventing bleeding, severe pain and shock.
Infection:
Urinary tract infections like cystitis and epididymitis are possible
complications after prostatectomy. The nurse works hard to prevent infection
from occurring by doing the following:
Care
of the catheter: This is very important to limit infection occurrence; the nurse ensures
that the catheter is removed when due, the nurse also ensure proper emptying of
the bladder to enhance flow of urine and reducing risk of infections. There
should also be maintenance of aseptic technique during insertion of the
catheter to prevent infection from catheter contamination.
Care
of surgical wound: Is also necessary to prevent
infection from occurring. The nurse maintains aseptic technique during wound
dressing to prevent infecting the wound leading to more complication and high
cost of treatment. Adequate diet is given to boost immunity and reduces the
rate by which the body is invaded by organisms.
Personal
hygiene
is also highly important, the nurse encourage
assisted bath which reduces source of infection and boost patient’s morale.
Sexual dysfunction: Inadequate
surgery exposes the patient to sexual dysfunction related to erectile
dysfunction, decreased libido and fatigue. The patient may report these issues
weeks or months after surgery. The surgeon discusses relieve and treatment with
the patient. To restore erectile dysfunction medications or surgically placed
implants can be used. Reassurance that the usual level of libido will return
after recuperation from surgery is often helpful for the patient and his
partner. If the patient is finding it difficult to demonstrate significant
adjustment to sexual dysfunction, a referral to sex therapist may be indicated.
The nurse counsels the patient and encourages him to report problem early for
proper and early intervention.
Deep
vein thrombosis: During management, the patient
can be placed on heparin, elastic compression stockings can be worn to prevent
deep vein thrombosis. This is because patients undergoing prostatectomy have a
high incidence of deep vein thrombosis and pulmonary embolism. The nurse encourages
passive limb exercise to enhance venous return and prevent deep vein
thrombosis.
Renal
failure: This can occur as a result of bladder
stones and kidney stones development which is due to stasis or accumulation of
urine. The nurse cares and monitor the catheter steadily to prevent stasis or
accumulation of urine. The nurse administers smooth muscle relaxants to relax
the bladder neck, the prostate, and the urethra to enhance flow of urine
preventing accumulation of urine,precipitation of salts, and formation of
bladder stones and kidney stones.
Prostate
cancer: Improper management of benign prostate
hyperplasia can lead to cancer of the prostate which can metastasize to other
surrounding organs leading to high cost of treatment and may be loss of life.
Therefore, the nurse and the surgeon should endeavour to perform their duties
accurately and appropriately.The nurse should carefully observe the patient
while in the hospital , listen to his complains, ensure he goes for blood tests
as prescribed, monitor his vial signs and report deviations from normal, in
order to prevent and diagnose cancer early,and also for early intervention.
SUMMARY
Benign
prostate hypertrophy or benign prostate hyperplasia is the enlargement of the
male gland prostate due to increase in size and number of cells that make up
the gland. Because the prostate surround the male urethra at its junction with
the bladder, its enlargement occludes the urethra causing urine retention or
stasis of urine flow exposing the urinary tract to infections. Precipitation of
the salts contained in urine can cause bladder stones or kidney stones,
nitrogenous waste can also be accumulated causing azotemia. Apart from the
above mentioned problems, other symptoms associated with prostate enlargement
include weak urinary stream, prolonged emptying of the bladder, abdominal
straining, hesistency, urgency, irregular need to urinate, incomplete bladder
emptying, post urination dribbling, nocturia, irritation during urination,
frequency, incontinence, bladder pain, dysuria, problem in ejaculation.
BPH has been shown by different studies
to be caused by testosterone, dihydrotestosterone synthesized from
testosterone, estrogen, dietary factors, smoking, heavy alcohol consumption,
and diabetes. The management of BPH involves relief of pain and pressure by
catheterization and suprapubic cystotomy to aid irrigation of urine. Other
managements include medications such as alpha blockers which relaxes the smooth
muscles of the bladder neck and prostate to enhance safe flow of urine from the
bladder through the urethra, prostatectomy, and saw palmetto herbal product
which works like finasteride, a 5-alpha reductase inhibitor that interferes
with the conversion of testosterone to dihydrotestosterone inhibiting prostate
growth. I finally recommend awareness campaign among elderly men for early
diagnosis and proper treatment.
CONCLUSION
This
study showed that men of 50years and above of all race have the potential to
suffer from prostate enlargement because the male hormone that causes it is in
all men, as these hormones are gradually secreted in all men, the prostate
enlarges gradually as well and at a time starts to exert pressure on the
bladder neck and urethra to block or reduce flow of urine from the bladder to
the exterior. Complications of BPH and prostatectomy is costly, therefore the
nurses and urologists should adequately and carefully manage the patients,
preventing high morbidity, high treatment cost due to complications and most
importantly preventing loss of life.
RECOMMENDATION:
Having discussed benign prostate
hyperplasia as a common condition among the elderly men, the following
recommendations will aid to reduce occurrence of BPH:
1. Awareness campaign by health
institutions will help to bring the elderly men to the hospitals for early
diagnosis and treatment without complications.
2. The
public health nurse should inculcate on their programme, health education on
BPH.
3. Medical
practitioners should encourage the elderly that comes for check up to go for
urologic tests since BPH is almost a must-occur problem due to the presence and
secretion of androgens in men.
4. Seminars
and health talk should be prepared and given by urologists on the problem of BPH among the elderly and
make them see the importance of early diagnosis.
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G.B, Suzanne, C.S, Kerry H.C, Janice L.H (2008)
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textbook of medical
and surgical nursing
11th edition. Lippincott Williams and Wilkins
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