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Benign Prostatic Hyperplasia-1.pptx

  1. Benign Prostatic Hyperplasia
  2. Pathophysiology There is a slow increase in the number of cells in the prostate gland, generally the results of aging and the male hormone dihydrotestosterone. As the size of the prostate gland increases, it begins to compress or squeeze the urethra shut. The narrowing of the urethra means the bladder must work harder to expel the urine. More effort and a longer time is required to empty the bladder. Eventually the narrow-ing causes an obstruction and may lead to urinary retention or eventually distention of the kidney with urine (hydronephrosis). It is the location of the enlargement, not the amount, that causes the problem. A small growth in the prostate gland closest to the urethra may cause more problems with urination than a growth the size of an orange in the outer portion of the gland
  3. • Obstructive symptoms associated with BPH have not only a static component (enlarged prostate gland) but also a dynamic component that reflects increased prostatic stromal and urethral smooth muscle tone. • Increased tone of this smooth muscle is dependent upon stimulation of a1- adrenoreceptors by noradrenaline released from adrenergic nerves. • α1-adrenoreceptors affecting the lower urinary tract are found in prostatic stroma, bladder detrusor and trigone, urethra, ganglia, and spinal and supraspinal structures. • The beneficial effects of α1-adrenoreceptor antagonists on symptoms of BPH may come from action on receptors in any of these areas.
  4. Clinical Manifestations • The prostate is large, rubbery, and nontender. Prostatism (obstructive and irritative symptom complex) is noted. • Hesitancy in starting urination, increased frequency of urination, nocturia, urgency, abdominal straining. • Decrease in volume and force of urinary stream, interruption of urinary stream, dribbling. • Sensation of incomplete emptying of the bladder, acute urinary retention (more than 60 mL), and recurrent UTIs. • Fatigue, anorexia, nausea and vomiting, and pelvic discomfort are also reported, and ultimately azotemia and renal failure result with chronic urinary retention and large residual volumes
  5. Assessment and Diagnostic Methods • Physical examination, including digital rectal examination (DRE), and health history. • Urinalysis to screen for hematuria and UTI. • Prostate-specific antigen (PSA) level is obtained if the patient has at least a 10-year life expectancy and for whom knowledge of the presence of prostate cancer would change management. • Urinary flow-rate recording and the measurement of postvoid residual (PVR) urine. • Urodynamic studies, urethrocystoscopy, and ultrasound may be performed. • Complete blood studies, including clotting studies.
  6. Medical Management • Immediate catheterization if patient cannot void. A suprapubic cystostomy is sometimes necessary. • “Watchful waiting” to monitor disease progression. Pharmacologic Management • Alpha-adrenergic blockers (eg, alfuzosin, terazosin), which relax the smooth muscle of the bladder neck and prostate .This improves urine flow and relieves symptoms of BPH. • Hormonal manipulation with antiandrogen agents (5-alpha-reductase inhibitors) (finasteride [Proscar]) decreases the size of the prostate by preventing the conversion of testosterone to dihydrotestosterone (DHT).
  7. Surgical Management • Minimally invasive therapy 1. Transurethral microwave heat treatment (TUMT; application of heat to prostatic tissue) 2. Transurethral needle ablation (TUNA; via thin needles placed in prostate gland) 3. Prostatic stents (but only for patients with urinary retention and in patients who are poor surgical risks) • Surgical resection Transurethral resection of the prostate (TURP; benchmark for surgical treatment(formerly the most common procedure) is done without an incision by means of endoscopic instrument.) Transurethral incision of the prostate (TUIP) Transurethral electro vaporization - (TUVP) or Photo vaporization of the prostate (PVP) is starting to replace TURP; done thro’ a cystoscope , using a laser to vaporize diseased prostatic tissue. • Open prostatectomy - Open prostatectomy is the surgical removal of the prostate gland. It is done under a general or spinal anesthetic.
  8. Nursing management THE PATIENT UNDERGOING PROSTATECTOMY Assessment • Take a complete history, with emphasis on urinary function and the effect of the underlying disorder on patient’s lifestyle. •Note reports of urgency, frequency, nocturia, dysuria, urinary retention, hematuria, or decreased ability to initiate voiding. •Note family history of cancer, heart disease, or kidney disease, including hypertension.
  9. Diagnosis Preoperative Nursing Diagnoses •Anxiety related to inability to void •Acute pain related to bladder distention •Deficient knowledge of the problem and treatment protocol Postoperative Nursing Diagnoses •Acute pain related to surgical incision, catheter placement, and bladder spasms •Deficient knowledge about postoperative care
  10. Potential Complications •Hemorrhage and shock •Infection •Deep vein thrombosis •Catheter obstruction •Sexual dysfunction
  11. Preoperative Nursing Interventions Reducing Anxiety •Clarify the nature of the surgery and expected postoperative outcomes. •Provide privacy, and establish a trusting and professional relationship. •Encourage patient to discuss feelings and concerns. Relieving Discomfort •While patient is on bed rest, administer analgesic agents; initiate measures to relieve anxiety. •Monitor voiding patterns; watch for bladder distention. •Insert indwelling catheter if urinary retention is present or if laboratory test results indicate azotemia. •Prepare patient for a cystostomy if urinary catheter is not tolerated.
  12. Providing Instruction •Review with the patient the anatomy of the affected structures and their function in relation to the urinary and reproductive systems, using diagrams and other teaching aids if indicated. •Explain what will take place while the patient is prepared for diagnostic tests and then for surgery (depending on the type of prostatectomy planned). •Reinforce information given by the surgeon. •Explain procedures expected to occur during the immediate perioperative period, answer questions the patient or family may have, and provide emotional support. •Provide information about postoperative pain management.
  13. Preparing Patient for Treatment •Apply graduated compression stockings. •Administer enema, if ordered.
  14. Postoperative Nursing Interventions Maintaining Fluid Balance •Closely monitor urine output and the amount of fluid used for irrigation; maintain intake/output record. •Monitor for electrolyte imbalances (eg, hyponatremia), increasing blood pressure, confusion, and respiratory distress. Relieving Pain •Distinguish cause and location of pain, including bladder spasms. •Give analgesic agents for incisional pain and smooth muscle relaxants for bladder spasm. •Monitor drainage tubing and irrigate drainage system to correct any obstruction. •Secure catheter to leg or abdomen. •Monitor dressings, and adjust to ensure they are not too snug or not too saturated or are improperly placed. •Provide stool softener, prune juice, or an enema, if prescribed.
  15. Monitoring and Managing Complications •Hemorrhage: Observe catheter drainage; note bright red bleeding with increased viscosity and clots; closely monitor vital signs; administer medications, IV fluids, and blood component therapy as prescribed; maintain accurate record of intake and output; and carefully monitor drainage to ensure adequate urine flow and patency of the drainage system. Provide explanations and reassurance to patient and family. •Infection: Use aseptic technique with dressing changes; avoid rectal thermometers, tubes, and enemas; provide sitz bath and heat lamps to promote healing after sutures are removed; assess for urinary tract infection (UTI) and epididymitis; administer antibiotics as prescribed. •Thrombosis: Assess for deep vein thrombosis and pulmonary embolism; apply compression stockings. Assist patient to progress from dangling the day of surgery to ambulating the next morning; encourage patient to walk but not sit for long periods of time. Monitor the patient receiving heparin for excessive bleeding.
  16. • Obstructed catheter: Observe lower abdomen for bladder distention; examine drainage bag, dressings, and surgical incision for bleeding; monitor vital signs to detect hypotension; observe patient for restlessness, diaphoresis, pallor, any drop in blood pressure, and an increasing pulse rate. Provide for patent drainage system; perform gentle irrigation as prescribed to remove blood clots. •Urinary incontinence: Encourage patient to take steps to prevent incontinence, improve continence, anticipate leakage, and cope with lack of complete control. •Sexual dysfunction: Erectile dysfunction, decreased libido, and fatigue may be a concern soon or months after surgery. Medications, surgically placed implants, or negative-pressure devices may help restore function. Reassurance that libido usually returns and fatigue diminishes after recuperation may help. Providing privacy, confidentiality, and time to discuss issues of sexuality is important. Referral to a sex therapist may be indicated
  17. Promoting Home- and Community-Based Care TEACHING PATIENTS SELF-CARE •Teach patient and family how to manage drainage system, monitor urinary output, perform wound care, and use strategies to prevent complications. •Inform patient about signs and symptoms that should be reported to the physician (eg, blood in the urine, decreased urine output, fever, change in wound drainage, or calf tenderness). •Teach perineal exercises to help regain urinary control. •As indicated, discuss possible sexual dysfunction (provide a private environment) and refer for counseling. •Instruct patient not to perform Valsalva maneuver for 6 to 8 weeks because it increases venous pressure and may produce hematuria.
  18. • Urge patient to avoid long car trips and strenuous exercise, which increases tendency to bleed. •Inform patient that spicy foods, alcohol, and coffee can cause bladder discomfort. •Encourage fluids to avoid dehydration and clot formation. CONTINUING CARE •Refer for home care as indicated. •Remind patient that return of bladder control may take time.