CASE ANALYSIS FOR UNRINARY BLADDER MALIGNANCY, BENIGN

PROSTATE HYPERPLASIA, HYPENTENSION AND DIABETES 2

A. Pre-operative Preparations

Cystoscopy is a procedure that

allows your doctor (urologist) to examine the
lining of your bladder and the tube that
carries urine out of your body (urethra) using
a cystoscope which is a thin tube with camera
and lens at the end (Bergen, 2019). It is done
to diagnose and treat bladder disease and
conditions and diagnose and enlarged prostate. Preparations for cystoscopy includes
taking antibiotics before and after the procedure if patient has UTI or a weak immune
system. Also, the doctor might ask for a urine sample before the test. Before
cystoscopy, the nurse will assist the patient in going to the bathroom to empty his
bladder and in changing into surgical gown. If the doctor plans to give general
anesthesia advise the patient to fast for several hours ahead of time and take time to
rest after the procedure. The nurse should provide health teachings regarding potential
risk and side effect after cystoscopy such as swollen urethra (urethritis), infection in
rare cases only, bleeding from urethra, which can appear bright pink in urine and toilet
paper, burning sensation upon urinating and more frequent urination for the next day
or two. Recommend patient to take a rest, drink lots fluid to flush bladder and reduce
irritation and hold a warm, moist washcloth over the opening to your urethra to help
relieve pain.

Transurethral Resection of the Bladder Tumor (TURBT) is an “incision-less”

surgery, usually the most common treatment for early-stage or superficial (non-muscle
invasive) bladder cancers. The goal is to take out the cancer cells and nearby tissues
down to the muscle layer of the bladder wall (American Cancer Society, 2019). The
surgeon puts a thin rigid tube called a cystoscope into your urethra then passes small
instruments down the cystoscope to cut any tumors out of the bladder lining. It is
commonly done under general anesthesia, which means the patient is asleep or in
some cases under spinal anesthetic (epidural) where the patient cannot feel anything
below the waist. The treatment typically takes 15 to 90 minutes to finish.

Transurethral Incision of the Prostate (TUIP) is a minimally invasive

procedure used to treat patients with enlarged prostates, which are typically caused
by benign prostatic hyperplasia The goal of a TUIP is to relieve pressure on the urethra
to allow urine to flow from the bladder into the urethra and out of the body (Mercy
Health, 2020). The doctor will make two incisions into the prostate gland to open the
urinary channel and relieve pressure on the urethra, relaxing the opening to the bladder
and decreasing resistance to the flow of urine out of the bladder. No tissue is removed.
It is also done under either general or spinal anesthetic. If successfully done, TUIP
helps reduce urinary symptoms caused by benign prostatic hyperplasia (BPH)
including frequent and urgent need to urinate, difficulty starting urination, slow or
prolonged urination, increased frequency of urination at night and urinary tract
infections.
 Preoperative preparations for both Transurethral Resection of the Bladder
Tumor (TURBT) and Transurethral Incision of the Prostate (TUIP) starts with a pre-
assessment clinic a week or two before the surgery where history taking takes place
which includes medical history (previous surgery, serious illness or trauma), history of
familial diseases, allergies, support system, religious belief, lifestyle etc. Physical
assessment is also needed and done. On the day of your operation, the patient will
see the surgeon who will explain the procedure completely and thoroughly. It is
required to have an informed consent signed by the patient of legal age and mentally
capable or by the parent/guardian if the patient is minor, incompetent, unconscious.
This is to protect the patients from unsanctioned surgery and the surgeon from any
legal complications. Prior to the surgery, ensure that NPO is maintained, blood ordered
is available, dentures/false teeth and jewelries are removed and nails and surgery site
is cleaned. Since TURBT and TUIP may be done under general anesthesia, a blood
test, chest X-ray and ECG is necessary and instruct patient to stop eating at least 6
hours beforehand and can only drink sips of water up to two hours before. Several
days before surgery, advise patient to stop taking medications such as warfarin
(Coumadin) or clopidogrel (Plavix) as per doctor’s order because it can increase the
risk of bleeding. The nurse is also likely to give an antibiotic to prevent a urinary tract
infection either before or after surgery. The nurse assists the patient in full bath if able,
going to the hospital chapel (if there is any), in changing clothes into hospital gown and
in transporting patient from room/ward to operating room. It is also essential for nurses
to obtain vital signs for baseline data and reinforce teachings such as deep breathing
& coughing exercises, leg exercises, turning to sides, early ambulation, pain
management, cognitive coping strategies. Aside from that, preoperative checklist is
done by nurses before endorsing the patient to the operating nurse one hour prior to
the surgery filled with patient’s signature and vital signs data. The nurse should provide
health teachings about proper treatment and care after the surgery for possible side
effects (blood in urine, irritating urinary symptoms, difficulty holding urine, infections).
Overall, preoperative care involves preparation of the patient and patients’ family or
significant others physically, mentally, emotionally, and spiritually.

B. Focused Physical Priority Assessment

The purpose of focused assessments is to do a physical priority assessment in

response with the patient’s specific health issues and problems which is recognized
by the nurse as needing further assessment of a body system or systems. Patient PAS
has been diagnosed of urinary bladder malignancy, benign prostate hyperplasia,
Hypertensive cardiovascular diseases, diabetes mellitus type 2, hypertension stage 2
– uncontrolled. Given his disease complications and based from his assessment and
history of present illness, the nurse should do a focused physical priority assessment
on genitourinary, respiratory, endocrine, and cardiovascular systems.

a. Focused Genitourinary System Assessment

The gastrointestinal and genitourinary system is responsible for the

ingestion of food, the absorption of nutrients, and the elimination of waste
products. An assessment of gastrointestinal system includes inspecting
abdomen for distention, striae, scars, contour and symmetry, observing any
abdominal movements associated with respiration, pulsations or peristaltic
waves, auscultating and palpitating abdomen for bowel sounds in all four
quadrants. An assessment of the renal system includes all aspects of urinary
 elimination. This includes objective data about urinary pattern, incontinence,
frequency, urgency and dysuria, hydration status (fluid balance, balance,
weight), diet or fluid restrictions, skin condition (temperature, turgor and
moisture), urine output, urinalysis (pH, ketones, protein, blood, leukocytes,
specific gravity) and reviewing laboratory results (blood chemistry, urea,
creatinine, electrolytes and albumin). For subjective data, it covers patient’s diet
and exercise routine, patient’s family history of gastrointestinal and
genitourinary disease and asking patients regarding any symptoms about
gastrointestinal and genitourinary disease (characteristics of feces and urine,
pain upon urination). Aside from that, history taking for feeding patterns and
difficulties, elimination pattern (frequency, consistency, color, any bleeding) and
pain, cramping, nausea, vomiting (frequency, color, bleeding, consistency), and
previous GI interventions and concerns (stoma, bowel obstruction etc.) is
required.

b. Focused Endocrine System Assessment

Every cell in our body is influenced by our endocrine system. The

endocrine system acts to maintain equilibrium at the cellular level and is a vital
link in homeostasis. A focused endocrine system assessment needs medical
history about any experienced signs and symptoms of endocrine diseases and
disorders of the patient and the family as well. Signs and symptoms of
endocrine disease may include fatigue or lethargy, weight gain or loss,
dizziness, feelings of depression, irritability, or anxiety, pain, decreased libido,
nausea and vomiting, changes in urinary or bowel habits, changes in vision,
intolerance to heat or cold, or change in appetite. In conducting a focused
endocrine assessment on a patient both subjective and objective data are
important, and it comprises a thorough history of their chief complaints,
psychological status, present health status, current lifestyle, laboratory test
(blood tests, FBS, A1C), and physical assessment. Physical exam may reveal
heart murmur, cardiac irregularities, abnormal breath or bowel sounds,
changes in skin color or turgor, bruises or rashes, or enlarged pancreas.
Endocrine disorders and diseases usually manifest according to which
endocrine hormone is being overproduced and secreted, or under-produced,
at any given age (Jarvis, 2016).

c. Focused Cardiovascular/Peripheral Vascular System Assessment

The cardiovascular and peripheral vascular system affects the entire

body. Assessment of the cardiovascular system evaluates the adequacy of
cardiac output and includes both subjective and objective data. Same with
gastrointestinal and genitourinary systems history of patient’s diet, elimination
pattern and stress levels is asked, family history of cardiovascular diseases is
collected and signs, symptoms and complain about peripheral edema,
shortness of breath (dyspnea), and irregular pulse rate is inquired. A focused
cardiovascular/peripheral vascular system assessment involves inspection of
patient’s face lips and ears for cyanosis, chest for deformities, bilateral arm,
hands and legs, calf size and pain; examination of circulatory status and
hydration status (skin turgor, oral mucosa) of upper and lower extremities;
checking capillary refill time and nail beds, blood pressure, and for presence of
edema (central and/or peripheral). Auscultating apical pulse for one minute and
 the chest for heart sounds and murmurs. Noting the rate and rhythm and
comparing peripheral pulse and apical pulse for consistency (the rate and
rhythm should be similar). Palpating the radial, brachial, dorsalis pedis, and
posterior tibialis pulses for rate, rhythm and volume.
d. Focused Respiratory System Assessment

The respiratory system allows us to breathe. The lungs bring oxygen

into our bodies (called inspiration, or inhalation) and send carbon dioxide out
(called expiration, or exhalation). A focused respiratory system assessment
includes conducting an interview related to history of respiratory disease,
smoking and environmental exposures. Medical history is taken upon
assessment such as family’s history of pulmonary diseases and onset plus
duration of signs and symptoms (cough, shortness of breath) and triggers (dust,
pollen, smoking, aerosol). This is to determine the severity of respiratory
conditions. Assessment of objective data involves: inspection for the use of
accessory muscles and work of breathing, configuration and symmetry of the
chest, respirations for rate (1 minute), depth, and rhythm pattern, skin color of
lips, face, hands, and feet, audible sounds such as vocalization, wheeze,
stridor, grunt, cough (productive/paroxysmal), and O2 saturation using a pulse
oximeter; listening for absence/equality of breath sounds and auscultating
(anterior and posterior) lungs for breath sounds and adventitious sounds; and
palpating bilateral symmetry of chest expansion, skin condition (temperature,
turgor and moisture), capillary refill (central/peripheral), Fremitus (tactile), and
subcutaneous emphysema.

C. Laboratory Finding and Interpretations

Laboratory Test Laboratory Results Reference

RBC 2.92 L 3.69 – 5.90 x10E12/L
Hemoglobin 8.30 g/dl 13.50 – 17.50 g/dL
Hematocrit 33.40 % 41.00 – 53.00%
WBC 9.33 L 4.50 – 11.00 x10E9/L
Platelet Count 320 L 150.00 – 390.00 x10E9/L
Bleeding Time Minutes – 2; Seconds - 20 less than 10 min
Clotting Time Minutes – 4; Seconds – 2-8 minutes
29
Cholesterol 5.72 mmol/L 3.88-5.15 mmol/L
Triglycerides 1.89 mmol/L 1.69 mmol/L
HDL .77 mmol/L 1.04 mmol/L
LDL 4.23 mmol/L 3.36 mmol/L
Uric Acid 583 umol/L 200–430 µmol/l (men)
Minimal Fibrosis, Both Bony structures appear
Chest X-ray Lung Apices with residual white on the film. Hollow
Atherosclerotic Aorta structures containing
mostly air, appear dark.
Glycosylated hemoglobin 7.9% 5.7% - 6.4%
Concentric left ventricular The ventricular wall is
hypertrophy with thickest near the cardiac
Color flow doppler study segmental wall motion base and thins to 1–2
abnormality. mm at the apex.
Segmental wall motion is
kinetic.
 Ultrasound of the prostate Weight of the prostate is Average weight of 11
20 grams, with 35 cm3 in grams (1-16 grams), with
size. 20 cm3 in size

Interpretation:
A low level of hemoglobin in the blood relates directly to a low level of oxygen. Based
from the laboratory findings, patient PAS has low RBC, hematocrit and hemoglobin levels.
Low hemoglobin levels usually indicate that a person has anemia it is linked with a disease or
condition that causes your body to have too few red blood cells. In addition, low hematocrit
levels may be a sign of bone marrow diseases, hemolytic anemia and kidney failure. In the
case of Patient PAS, it is associated with his Urinary Bladder Malignancy and Benign Prostatic
Hyperplasia. Since kidney disorders and cancer can affect the body’s ability to produce red
blood cells.
Patient PAS has high cholesterol and HDL levels and low LDL levels which indicates
that fatty deposits are developing in his blood vessels that can eventually lead to heart attack
and stroke if these fatty deposits break and form a clot. Although high cholesterol levels can
be inherited, based from the patient’s record, it is clearly because of his sedentary lifestyle
and diet and non-compliance to medications.
High uric acid level or hyperuricemia is a sign that patient PAS may have gout. A gout
is a form of arthritis where crystals from uric acid form in your joints and cause intense pain.
This is supported by his assessment data where it is documented that he experiences pain
and has swelling in his lower extremities. It is also linked with his bladder cancer where he
undergoes chemotherapy treatments and these treatments kill a lot of cells in his body, which
can raise the level of uric acid leaving high levels of purines inside his body.
The chest X-ray results shows that patient PAS has pulmonary fibrosis. His lung
tissues are damaged and scarred making it more difficult for the lungs to work properly and to
function twice as needed. Along with minimal fibrosis, patient PAS also has atherosclerosis in
both lungs which is caused by his high cholesterol and HDL levels resulting in build-up of fats
in the artery walls. Shortness of breath, wheezing and dyspnea upon exertion are all
symptoms of both illness which is manifested by the patient as well. Yet Again, this is because
he is a smoker and lives a sedentary lifestyle with poor diet choices.
Patient PAS is already diagnosed with Type 2 Diabetes Mellitus, it is understandable
that he has high glycosylated hemoglobin (HbA1c) level. This condition leads him to have
cardiovascular problems and kidney disease. As shown in his color flow doppler study results,
while treating his long-term hypertension to decrease the risk of stroke, renal failure, and
myocardial infarction, patient PAS developed a left ventricular hypertrophy with segmental
wall motion abnormality; as a result of controlling arterial pressure, sodium restriction, and
weight.
The results of the ultrasound of his prostate reveals that his prostate is bigger in size
and weight and so he is diagnosed with benign prostatic hyperplasia or prostate enlargement.
This is cause and a complication of his urinary bladder malignancy which is evidenced by his
increase in urine frequency of at least 10-15 times a day. Other laboratory findings/results of
patient PAS like WBC, platelet count, bleeding and clotting time fall within normal range values
which implies that he has no current infection, no bleeding problems and clotting disorder.