Benign Hypertrophy of Prostate
1.Mr.Ramu, a 60 year old man is admitted in the urological unit with the diagnosis of benign prostatic hypertrophy. Answer the following questions :
a) Define benign prostatic hypertrophy. (2)
b) Discuss the clinical manifestations (2)
c) Explain the surgical approaches for benign prostatic hypertrophy. (4)
d) Draw a nursing care for Mr.Ramu including health education. (7)
Definition
A condition in men of more 65 years where the prostate gland enlarges and causes an obstruction to the flow of urine. It is noncancerous and hence called benign
Clinical Manifestations
Hesitancy
Increased frequency of urination
Urgency
Obstruction to flow necessitating straining at micturition
Dribbling at the end of micturition
Nocturia
Overflow incontinence
Urinary retention
Repeated urinary tract infections causing frequent attacks of fever with chills & rigors
Uremia
Renal failure
Fatigue
Anorexia
Nausea
Surgical Approaches
TURP - Transurethral resection of Prostate - the adenoma is removed bit by bit via the urethra by cutting with the aid of a cystoscope
Transvesical prostectomy - Open Prostectomy : The adenoma is enucleated by a suprapubic incision and opening the bladder.
Nursing care and Education
Preoperative preparation : Assess renal function - Urine analysis, blood naurea, serum creatinint, urine culture and sensitivity, urodynamic studies, Bleeding and clotting time, assessment of clotting factors, blood sugar, cardiac assessment - ECG, Echocardiogram, assessment of respiratory function, X-ray Chest PA view
Postoperative Nursing Interventions:
Maintain fluid balance
Irrigation of the surgical site - The catheter is irrigated. Make sure that the same amount is recovered. Fluid may be absorbed - fluid retention, fluid imbalance, and water intoxication.
The urine output and the amount of fluid used for irrigation monitored
Ensure an adequate urine output.
Monitor for electrolyte imbalances (ie, hyponatremia),
Look for rising blood pressure, confusion, and respiratory distress.
Risk for fluid and electrolyte imbalance with preexisting cardiovascular or respiratory disease.
Relieving pain
The patient is assisted to sit and dangle his legs over the side of the bed on the day of surgery.
Ambulate next morning
Relieve pain due to the incision or at excoriation of the skin at the catheter site.
Look for bleeding from the urethra around the catheter.
Medications that relax the smooth muscles can help to ease the spasms : flavoxate (Urispas)
Warm compresses to the pubis or sitz baths may also relieve the spasms.
Secure the catheter drainage tubing to the leg or abdomen to decrease tension on the catheter and prevent bladder irritation.
Discomfort may be caused by dressings that are too snug, saturated with drainage, or improperly placed.
Analgesic agents are administered as prescribed.
Preventing Bleeding
Encourage to walk but not to sit for prolonged periods because this increases intra-abdominal pressure and the possibility of discomfort and bleeding.
Stool softeners provided to ease bowel movements and to prevent excessive straining.
Look for major complications : hemorrhage, infection, deep vein thrombosis, catheter obstruction, and sexual dysfunction.
Look for hemorrhagic shock.
Preventing Obstruction to urine outflow
Ensure patency of the drainage system. Clots may obstruct urine flow.
The drainage initially reddish-pink → light pink in 24 hours. Bright-red bleeding with increased viscosity and numerous clots usually indicates arterial bleeding - needs surgical intervention (eg, suturing of bleeders or transurethral coagulation of bleeding vessels)
Venous bleeding controlled by traction to the catheter & pressure to the prostatic fossa : by securely taping the catheter to the patient’s thigh.
If blood loss is extensive, fluids and blood component therapy may be administered.
Closely monitor vital signs;
Maintain I/O Chart
When harmorrhage occurs explain and reassure the patient and his family
Look for infection
Rectal thermometers, rectal tubes, and enemas are avoided
After the perineal sutures are removed, the perineum is cleansed
A heat lamp may be directed to the perineal area to promote healing. The scrotum is protected with a towel while the heat lamp is in use.
Sitz baths are also used to promote healing.
Education
Instructed to monitor for signs and symptoms of infection (fever, chills, sweats, myalgias, dysuria, urinary frequency, and urgency).
To prevent deep vein thrombosis (DVT) and pulmonary embolism by) low-dose heparin therapy and by applying compression stockings to legs
To avoid Obstructed Catheter
To promote urination with Furosemide (Lasix), thereby helping to keep the catheter patent.
To look for distended bladder.
The drainage bag, dressings, and incisional site are examined for bleeding. The color of the urine is noted and documented;
Blood pressure, pulse, and respirations are monitored and compared with baseline preoperative vital signs to detect hypotension.
Observe the patient for restlessness, cold sweats, pallor, any drop in blood pressure, and an increasing pulse rate.
Overdistention of the bladder is avoided
Explain the purpose of the catheter to the patient and assure him that the urge to void results from the presence of the catheter and from
bladder spasms.
Not to pull on the catheter : it causes bleeding and subsequent catheter blockage,
Some urinary incontinence may occur after catheter removal, and the patient is informed that this is likely to subside in time.
Sexual Dysfunction
Patient may experience sexual dysfunction related to erectile dysfunction, decreased libido, and fatigue.
Several options to restore erectile function are discussed with the patient by the surgeon or urologist.
Reassurance that the usual level of libido will return following recuperation.
A referral to a sex therapist may be indicated.
PROMOTING HOME AND COMMUNITY-BASED CARE
Teaching Patients Self-Care
Teach the patient and family management of the drainage system, complications.
Verbal and written instructions are provided .
Signs and symptoms to be reported to the physician (eg, blood in urine, decreased urine output, fever, change in wound drainage, calf tenderness).
Urinary frequency and burning may occur after the catheter is removed.
Exercises may help the patient regain urinary control:
• Tense the perineal muscles hold this position; relax. Performed 10 to 20 times each hour.
• Try to interrupt the urinary stream after starting to void; wait a few seconds and then continue to void.
The patient should urinate as soon as he feels the first urge to do so.
Inform that regaining urinary control is a gradual process; he may continue to “dribble” after being discharged from the hospital, but will gradually diminish (within up to 1 year).
Lining underwear with absorbent pads can help to minimize embarrassing stains on clothing.
The urine may be cloudy for several weeks after surgery but will clear as the prostate area heals.
While the prostatic fossa heals (6 to 8 weeks), the patient should avoid activities that produce Valsalva effects
Patient should avoid long motor trips and strenuous exercise,
Spicy foods, alcohol, and coffee may cause bladder discomfort.
Encourage to drink enough fluids to avoid dehydration,
Continuing Care
Referral for home care may be indicated
Ambulate and carry out perineal exercises as prescribed.
