In Partial Fulfillment Of the Requirements in RLE Hospital Exposure (Medical Ward)

CASE STUDY In

Benign Prostatic Hyperplasia

Submitted to:

Dean Celina G. Casis, RN, MSN Clinical Instructress

Submitted by:

Ms. Jinky A. Rosel SN4

August 1, 2006 Department of Nursing Holy Trinity College

INTRODUCTION

In BPH, the prostate gland grows in size. It may compress the urethra which courses through the center of the prostate. This can impede the flow of urine from the bladder through the urethra to the outside. It can cause urine to backup in the bladder (retention) and the need for frequent urination. If severe enough, complete blockage of the urethra can occur in which can injure the kidneys. Benign prostatic hypertrophy is one of the most common diseases affecting middle-aged and older men. Transurethral resection of the prostate (TURP) is the 10th most frequently performed operative procedure. Each year, an estimated 400,000 men undergo TURP for management of problems related to benign prostatic hypertrophy. [1] This article reviews current approaches to the management of patients with this disease. An age-related, nonmalignant enlargement of the prostate gland, benign prostatic hyperplasia (BPH) develops when the number of prostate cells increases. Although the cause is unknown, a prevailing theory implicates hormone changes related to aging. As a man's testosterone levels decline, his estrogen levels may rise and facilitate the action of other androgens to stimulate cell production. Half of men have BPH by the time they reach age 50, and more than 75% have it by age 80. This study was chosen to be studied because prostate enlargement is one with the highest prevelent rate nowadays. This study will help the student to; enhance the assessment skills,review the anatomy and function of the male reproductive system and the alteration in this field. This study woul also help the student to trace the disease process or the pathophysiology and the most important is for the studnt to detemine the different nursing responsibilities and intervention.

I - NURSING HISTORY Personal Profile Name: Mr. E Age: 54y/o Sex: Male Address: Brgy Irawan, Puerto Princesa City Religion: Roman Catholic Civil Status: Married/widow Educational Attainment: Elem. Grad. Date of Admission: July 17, 2006 Occupation: Fisherman Chief Complaint: Dysuria Medical Diagnosis: Benign Prostatic Hyperplasia Informed: patient and mother I FAMILY HISTORY Name of Father: Mr. AE Living Name of Mother: Mrs. LE Living Number of Children in the family: eight(8) Position in the family: 2nd child No history of hereditary diseases diarrhea II - Past Medical History Type of Delivery: Normal Vaginal Delivery Childhood Diseases: cough, cold, fever and chicken pox Immunization Status: none Previous Sickness/ Hospitalization Chief Complaint: Remedy Undertaken: III - History of Present Illness: 2 weeks prior to admission, patient experience polyuria, nocturia and dysuria with intermittent pain in the hypogastric region hat radiated on dorsolumbar region. Patient take OTC drugs for the other related symptoms like headache. 1 day prior to admission, pt experiences a more severe pain and worried about his elimination. He sought consultation and was diagnosed to have benign prostatic hyperplasia that prompts his admission. Deaths in the family: 1 Cause: severe

A. Perception and Expectation of present Illness/Hospitalization Patient perceive at first that his illness is UTI. He experience the symptoms for almost 2 months but he didnt sought medical attention for it. His check up gave him a clear viewpoint on the reason of having those symptoms. He expected that this hospitalization would help him regain his normal health status and will able him to get him back to work. He expected that the doctors and the nurses had enough knowledge in rendering care totheir patient. B. Comfort, Rest Needs and Safety Needs Before this health condition occurs, patient takes his rest for almost 11-12 in the evening because of his work and he wakeup early in the morning at around 4 o clock and prepare his materials for fishing. After fishing he wasnt able yet to get rest when he got home because he have to fixed first all his materials for the other day. He usually takes a bath in the morning or in the evening after doing his work. At home, upon existence of this health condition, patient was not able to work so he stays in their house. He usually sleeps at around 10 o clock in the evening until 6 o clock in the morning. His sleep was frequently disturbed of his voiding pattern because he urinates almost 7 times in the evening and also in the morning. Upon admission, the patient verbalized a more comfortable feeling because of the improvement in his health condition. He was able to rest from 8 o clock in the evening until 6 in the morning with some interruption because of medication. Before hospitalization, the patient was accompanied by is his son and his nephew in fishing. He feels comfortable doing those things because he is in this kind of work for 6 years. When this health problem existed, in their home, patient was in the care of his children and grand daughter. They were the one who perform task and accompanied their father in his ADL when he wasnt able to perform those things for himself. Upon admission and assessment, the patient was able to move and perform ADL with minimal assistance from his watcher. He was able to move out of bed but he complaints of the difficulty in moving because of generalized body weakness. The floor was kept dry and he provided with 3 pillows to support hid head and extremities when lying. Psychologically, patient feels safe with the presence of his mother who supports him morally. C. Fluid and Nutrition Before hospitalization, pt usually consumes 1 -2 cups of rice in every meal and a serve of viand which is usually fish. He can consume 3 cups of coffee in a day and water for 4-5(9601200ml) glasses. Upon existing of this health condition, in their home, patients eating were affected because he is experiencing loss of appetite, he can consumes only 1 cup of rice in every meal and 5-6 glasses(1200-1442ml). Upon admission, the patient can consume the meal serve in the hospital but because of the pain he is experiencing, and sometimes he can consume only half of the servings. He consumes the same of water in the hospital; he also refrains from drinking coffee. Patient was

given also fluid therapy to maintain and restore nutrition while on treatment. Upon assessment, the patient has no IVF and on DAT diet. D. Elimination Before hospitalization, the patient urinates more that 10 times in the morning and almost 7 times in the evening, the amount of urine is not determine but according to the patient it is very little and sometimes he voided at least 5-6 cc and usually yellow in color, no foul odor. Difficulty in urinating was experience and also the hesitancy. He defecates once a day in normal consistency, soft and form yellow-light brown in color. Upon admission, the patient urinates 3-4 times a day with the amount of 240ml per urination, yellowish in color. He defecates once a day with the same consistency. He verbalized sometimes difficulty in initiating to urinate because of the pain but patient verbalizes improvement of health condition upon receiving medication. E. Oxygenation The patient has a history of smoking when he is only 25 y/o until this February 2006. He can consume 20 sticks of cigarette a day. Upon admission, the patient has a productive cough, expectorated sputum with the amount of 10-20 cc a day. No difficulty of breathing. RR of 19 breaths per minute. F. Sexuality: The patient is masculine in appearance, the way he act, and a father of his 5 children. Sexual activity was not able to assess but the patient is widowed for almost 3 years. G. Spirituality: Patient is a roman catholic but he wasnt able to worship in every Sunday activity. H. Communication: The patient speaks in tagalog, able to comprehend easily and answer to questions in an appropriate manner.

PHYSICAL ASSESSMENT A HEENT Head Eyes Ears Nose face and skull is symmetrical hair is black, with 3-4cm long, soft and well distributed, oily in texture there is no presents of head lice scalp has negative of flakes, lesions and abrasions no tenderness and deformities found during palpation eyebrows black in color, symmetrically aligned, well distributed eyelashes black in color, symmetrically aligned well distributed and slightly curve outward sclera white in color, clear, and moist pale palpebral conjunctiva pupils equally round reactive to light accommodation good vision no tenderness on globe upon palpation symmetrically aligned, same in shape and color as with facial skin (- ) cerumen on both ears (- ) lesions, swelling or signs of bleeding in the external canal both ears can hear well nose at the midline of the face with vibrissae and nasal vestibule noted pinkish mucosa (-) nasal discharges no lesions or swelling no significant changes in facial appearance that suggest inflammation of the sinuses

Throat and Mouth dry and pale lips noted tongue in the middle, in normal function no 2 molar on upper right side and lower left, yellowish - brown in color gums slightly purple in color, not bleeding no signs of inflamed tonsil (- ) dysphagia

 no palpated lymph node Chest and Lungs chest is symmetrical in shape and expansion with regular rhythm of breathing nipples both brown in color no mass palpated bronchovesicular sound auscultated no dob , RR 19 breaths/min Abdomen flat, symmetrical umbilicus at the midline, inverted, no discharges color is the same as of extremities no rashes noted, no mass palpated burborygmic sound auscultated dull sounds percussed on upper right quadrant Genito- Urinary (- ) enlargement of the genitals (+) dysuria voided freely 3-4 times a day, 240 cc/ urination Extremities brown complexion fine hair noted on both upper and lower extremities normal curvature of the nails slightly pale nail beds, slightly long capillary refill of <2 seconds (+1) edema on the R foot SPECIAL TREATMENT Treatment Date Ordered: July 19,2006 DAT Rationale - provide adequate nutrition to the patient while on treatment

IV PNNS 1 L

To provide adequate nutritional intake. Patient was not given other IV because of the presence of edema that will aggravate if pt will be given IV with high Na.

Procedure

Results =63mg/dl (07-22-06) =145mg/dl (07-21-06) =54mg/dl (07-20-06) =83mg/dl) 07-19-06) 110 g/l (7-199-06) 74 g/l (07-17-06) 15.7 g/l (07-17-06) 90 (07-17-06) 10 (07-17-06) 160 x 10 9/L (07-17-06) 8.3 mmol/L (07-18-06)

Laboratory Diagnosis Normal Interpretation Values The result from the first day of monitoring until the last day suggest that there is no significant changes in the blood glucose that would reveal DM.

Rationale To determine rise in the circulating blood glucose; to ruled out DM.

RBS

80100mg/dl

Hgb

WBC

Neutrophils Lymphocyte Platelet

The result is within 135-180g/l normal range that indicates sufficient amount of circulating blood carrying oxygen to tissues. 5-10 x10 g/l The result is above normal that may indicate presence of infection. The result is above 35-65vol % normal that indicates infection. 2-35 The result is within range 150-500 The result is normal range.

To determine the amount of bloodcarrying oxygen to tissues and find out presence of anemia, in any form. To determine presence of infection in the circulation. To determine variation in the WBCs differential count that may signifies infection or suppress immune response. above To determine risk for bleeding FBS has been taken to determine level of blood glucose in postprandial. Creatinine is needed to diagnose any abnormality in renal function. The BUN level is an indicator of any

FBS

4.206.40mmol/L

Creatinine

145 umol/L (07-18-06) 4.3 mmol/L (07-18-06)

5397umol/L 0.803.87mmol/L

The result is above normal range that indicates increase in blood glucose in the circulation. The result is above normal that indicates renal dysfunction The result is elevated that indicates renal

BUN

dysfunction Cholesterol 4.0 mmol/L (07-18-06) Up to 5.70mmol/L The result is within normal range that indicates normal level of cholesterol in circulation.

Triglycerides

1.1mmol/L (07-18-06)

1.71mmol/L

The result is within normal.

HDL

1.68mmol/ 0.65mmol/L L

The result is below normal that is possible in the patients who are smoking. The result is within normal.

LDL

2.9mmo/L (07-18-06)

Up to 3.90mmol/L

Urinalysis Color:

Transparency

Light yellow (07-19-06) Dark Yellow (07-17-06) Hazy (07-19-06) Hazy (07-17-06)

Amber

Clear

Albumin:

(+) (07-19-06) (+) (07-17-06)

(-)

The first UA result the color of urine suggests abnormality that suggests either bleeding or dysfunction in the kidney. The result is hazy that indicates infection because its hazy appearance is the presence of pus or other substances not normally found in urine. The result indicates presence of albumin in the urine. Its appearance in the urine suggest in dysfunction in the nephrons because of the

insufficiency of dysfunction in renal function. The cholesterol needs to determine presence of CAD and to evaluate dysfunction in the hormone synthesis and cell membrane formation. Triglycerides are levels is being taken to evaluate presence of CAD and DM. HDL level determines dysfunction in the transport of cholesterol and triglycerides from cell to tissues. To determine dysfunction in the transport of cholesterol and triglycerides in the cells. It determines also CAD. The color of urine suggests dysfunction in the kidney that may either bleeding or hyper pigmentation. The transparency of urine determines presence of infection in urinary tract or dysfunction in the nephrons. The albumin determines malfunction in the filtration process I the kidney.

dysfunction in filtration. Glucose: (-) (07-19-06) (-) (07-17-06) 6.5 (07-19-06) 6.0 (07-17-06) The presence of glucose in the urine determines increase level in the circulation. It may also suggest DM. The result of the first test The ph of urine 5-6 is within normal range determines the acidthat indicates imbalanced base balance. in the acid-base. The second result indicates acidic environment of urine this may be because pt is taking furosemide in the excretion of the sodium and other substance. The result is within SG determines the 1.005-1.015 normal range that capability of the indicates normal kidney to concentrate concentration of urine. urine. There is presence of pus To determine presence in the urine that indicates of infection either in infection. the urinary tract or in the kidney. There are presences of To determine bacteria in the urine. infection. (-) The result is normal. Result Enlarged R kidney Interpretation and Rationale - because of infection in the ureters in that exudates through the kidney it causes enlargement of the calyses.

Ph

Specific Gravity Pus Cells

Bacteria

1.010 (07-19-06) 1.010 (07-17-06) 15-30 (07-19-06) 0-3 (07-17-06) few (07-18-06)

Diagnostic Procedure UTZ of KUB

PHARMACOLOGIC INTERVENTION Drugs Generic Name: Cefuroxime Brand Name: Panaxime Classification:2nd Generation Cephalosporin Actual Dose:750 mg IV q8 hrs. Action - inhibits bacterial cell wall synthesis causing cell death Indication - UTI caused by E. Coli, K Pneumoniae Side Effects and Adverse SE: GI: N and V, diarrhea, abd cramps, pain, dyspepsia, flatulence, Derma: urticaria, fever, chills, myalgia, edema, itching, numbness. CNS: headache, malaise, fatigue, vertigo, dizziness, lethargy. AE: Aplatic Anemia., Seizure Nursing Consideration 1. Monitor for allergic reactions. 2. Assess for bowel function( if severe diarrhea occur, di=scontinue drug) 3. May cause ghypoprothom binemea ( monitor bleeding, easily bruising and blood in urine or stool) 4. Monitor I and O. 5. Monitor V/S. 1. Identify indication for therapy and expected outcome. 2. If for long therapy, monitor cbc, renal, and liver function. 3. Check urine for occult blood, and albumin. 4. Not to combine with other drugs. 5. Monitor S/S of toxicity. Report immediately

-Effective analgesic. -Decrease Brand Name: fever by a Tempra hypothalamic Classification: effect Non narcoleptic leading to analgesic sweating and Actual Dose: 300 vasodilation. mg IV PRN for May cause fever analgesia by inhibiting prostaglandin synthesis, has no NSAID effect.

Generic Name: Paracetamol

-control pain due to headache, earache,arthralgia , myalgia. - Reduce fever in bacterial and viral infection

SE: Methemoglobenemia, neutropenia, thrombocytopenia, pancytopenia. Allergic: urticaria, erythematos, skin reaction, skin eruption AE: Hemolytic Anemia

Generic Name: Furosemide Brand Name: Lasix Classification: Diuretic Actual Dose: 1 amp

-inhibits the reabsorption of sodium and chloride in the proximal and distl tubule as well as the ascending loop of henle; this result in the excretion of sodium, chloride to a lesser degree, potaasium and bicarbonate ions. The resulting urine is more acidic

- edema associated with CHF, nephotic syndrome, hepatic cirrhosis, and ascites, IV for acute pulmonary edema.

SE: Fluid and electrolyte effects: Fluid and electrolyte depletion leading to hypovolemia and hypokalemia, hypochloremia, cause metabolic alkalosis, hyponatremia.GI: nausea, oral gastic irritation, vomiting, anorexia, diarrhea. CNS: vertigo, headache, dizziness, blurring of vision, restlessness, paresthesis.CV: orthostatic hypotension,anemia.

1.

2.

3.

4.

5.

6.

including N and V. Do not mix with other solution with below level of Ph. A precipitate may formif mixed with gentamycim, netimicin, or milirone, in either D5W or NSS. Assess closely for signs of vascular thrombosis, and embolism, particularly in the elderly Observe for any signs of toxicity for pts with renal impairment. Monitor electrolytes; observe for signs and symptoms of hypokalemia. Observe foe dehydration because of its rapid diuretic effect.

The Prostate Gland The prostate is a walnut-sized gland that forms part of the male reproductive system. The gland is made of two lobes, or regions, enclosed by an outer layer of tissue. As the diagrams show, the prostate is located in front of the rectum and just below the bladder, where urine is stored. The prostate also surrounds the urethra, the canal through which urine passes out of the body. Benign Prostatic Hyperplasia: A Common Part of Aging It is common for the prostate gland to become enlarged as a man ages. Doctors call this condition benign prostatic hyperplasia (BPH), or benign prostatic hypertrophy. As a man matures, the prostate goes through two main periods of growth. The first occurs early in puberty, when the prostate doubles in size. At around age 25, the gland begins to grow again. This second growth phase often results, years later, in BPH. Though the prostate continues to grow during most of a man's life, the enlargement doesn't usually cause problems until late in life. BPH rarely causes symptoms before age 40, but more than half of men in their sixties and as many as 90 percent in their seventies and eighties have some symptoms of BPH. As the prostate enlarges, the layer of tissue surrounding it stops it from expanding, causing the gland to press against the urethra like a clamp on a garden hose. The bladder wall becomes thicker and irritable. The bladder begins to contract even when it contains small amounts of urine, causing more frequent urination. Eventually, the bladder weakens and loses the ability to empty itself, so some of the urine remains in the bladder. The narrowing of the urethra and partial emptying of the bladder cause many of the problems associated with BPH. Many people feel uncomfortable talking about the prostate, since the gland plays a role in both sex and urination. Still, prostate enlargement is as common a part of aging as gray hair. As life expectancy rises, so does the occurrence of BPH. In the United States in 2000, there were 4.5 million visits to physicians for BPH.

Pathophysiology The prostate gland sits on top of the urogenital diaphragm and beneath the bladder . It produces a portion of the seminal fluid and accounts for about 15 percent of the volume of ejaculate. The prostate is primarily involved in reproduction, but it may also provide some protection against urinary tract infection. The prostate enlarges rapidly at puberty and then remains a constant size until about age. At that time, the gland undergoes benign enlargement, or it atrophies. Hyperplasia of both epithelial and stromal elements produces the changes of benign prostatic hypertrophy. Although the etiology of the hyperplasia in benign prostatic hypertrophy is unknown, it is clear that the testes and the aging process both play some role. However, their exact roles (such as changes in the testosterone and estrogen balance) have not yet been defined. The testes must be present for the prostate to enlarge. Benign prostatic hypertrophy does not occur in men who were castrated before puberty, and established disease may regress following castration. Benign prostatic hypertrophy does not occur before age 45; however, by 80 years of age, approximately 75 percent of men have the disease. By age 75, between 10 and 25 percent of men require some form of intervention for one of the complications of benign prostatic hypertorphy. An enlarged prostate does not cause problems unless it obstructs the outflow of urine from the bladder. As the gland enlarges, it may encroach on the urethral lumen, causing resistance to the outflow of urine from the bladder. In response to increased resistance, the detrusor muscle undergoes hypertrophy. Urinary retention occurs when the bladder muscle can no longer generate enough pressure to overcome the increased outlet resistance. The prostate gland is a walnut-sized organ that surrounds the beginning of the urethra in males. At birth, the prostate is pea-sized and it grows slowly until puberty when it grows rapidly and doubles in size. Then, around age 25, the prostate begins to grow again. As the prostate enlarges, it places pressure on the urethra. Dihydrotestosterone (DHT), a male hormone, is required for normal prostate growth, however how it affects BPH is unknown.1,6,10,11 As the prostate enlarges, the layer of tissue surrounding it stops it from expanding, causing the gland to press against the urethra like a clamp on a garden hose.3 When the prostate has grown sufficiently to impinge on the urethra, the man begins to develop symptoms of BPH. The exact pathophysiology of BPH is unknown, but may involve hormonal changes associated with aging. Men produce both testosterone and estrogen. One hypothesis is that as testosterone levels decrease, there is a larger proportion of estrogen and the activity of cell growth in the prostate gland increases. A second hypothesis states that older men continue to produce and accumulate DHT, and this may encourage the growth of prostate gland cells. Scientists also note that men who do not produce DHT do not develop BPH.3 A third hypothesis is that BPH may result from genetic commands given to prostate cells early in life that reawaken later and produce signals instructing prostatic cells to grow or become more sensitive to hormones and then grow. Other scientists believe 5-alpha-reductase (an androgen metabolizing enzyme) and DHT levels decrease in the epithelium tissue of the prostate causing the increased growth of the prostate.

Summary and Conclusion As the summary of this case study, the patient was assessed properly as well as the entire diagnostic test done to him. It was found out that the major complication of this disease was greatly affecting the kidney of the patient. In the ultrasound I was diagnose that the kidney has enlarged, particularly the right kidney that may be due to the infection that exudates from the bladder up to the ureter and now also invade the kidney. The medical intervention focuses on the treatment of the symptoms manifested by the patient since admission. One of the major manifestations in the patient of the damage in the urinary tract is the edema in the lower extremities because of the water retention. In relation to the endocrine, although it was not included in the pathophysiology of the pt, endocrine system is quite related to the disease because of the over stimulation of the androgen that produces estrogen. The medical management is the administration of the drug that acts on the suppression of the androgen or the estrogen administration in order to suppress its release by the negative feedback mechanism. But that medical intervention was not given to the patient because of the insufficient diagnostic criteria that would suggest the etiology of having BPH. Benign Prostatic Hyperplasia if not treated could lead into renal failure that also affect the endocrine. It has an effect on the regulation of insulin that is the reason why the RBS and the FBS was taken and monitored. The adrenal gland function may also be altered because it is the major regulator of water in the kidney and the androgens. Therefore it is concluded that this BPH is a disease that needed a full treatment and a good assessment because if it can affect in the number of glands that can also affect in the hormone regulation.