THE DEPARTMENT OF NURSING SCIENCE
FACULTY OF HEALTH SCIENCE AND TECHNOLOGY
COLLEGE OF HEALTH SCIENCES
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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