THEORITICAL CONCEPT AND NURSING CARE CONCEPT OF BENIGN PROSTATIC HYPERPLASIA

THEORITICAL CONCEPT AND NURSING CARE CONCEPT OF BENIGN PROSTATIC HYPERPLASIA

A. THEORITICAL CONCEPT

1. Definition

Benign prostatic hyperplasia is enlargement of the prostate that constricts the urethra, causing urinary symptoms. One of four men who reach the age of 80 will require treatment for BPH (Nettina, 1996).

Benign prostatic hyperplasia (BPH) is a progressive adenomatous enlargement of the prostate gland that occurs with aging (White, 2002).

Benign prostatic hyperplasia (BPH), also known as benign prostatic hypertrophy, is a histologic diagnosis characterized by proliferation of the cellular elements of the prostate (Leveillee, 2009).

Benign prostatic hyperplasia (BPH) also known as benign prostatic hypertrophy, benign enlargement of the prostate (BEP), and adenofibromyomatous hyperplasia, refers to the increase in size of the prostate in middle-aged and elderly men (Wikipedia, 2010).

2. Etiology

The prostate grows larger due to an increase in the number of cells (hyperplasia). However, the precise reason for this increase is unknown. A variety of factors may be involved, including androgens (male hormones), estrogens, growth factors and other cell signaling pathways.

As the prostate grows larger and the urethra is squeezed more tightly, the bladder might not be able to fully compensate for the problem and completely empty. In some cases, blockage from prostate enlargement may cause repeated urinary tract infections and gradually result in bladder or kidney damage. It may also cause a sudden inability to urinate (acute urinary retention) (Stöppler, 2010).

3. Pathophysiology

a. The process of aging and the presence of circulating androgens are required for the development of BPH.

b. The prostatic tissue forms nodules as enlargement occurs.

c. The normally thin and fibrous outer capsule of the prostate becomes spongy and thick as enlargement progresses.

d. The prostatic urethra becomes compressed and narrowed, requiring the bladder musculature to work harder to empty urine.

e. Effects of prolonged obstruction cause trabeculation (formation of cords) of the bladder wall, decreasing its elasticity (Nettina, 1996).

4. Clinical Manifestation

The clinical manifestations of benign prostatic hyperplasia are:

a. In early or gradual prostatic enlargement, there may be no symptoms, because the detrusor musculature can initially compensate for increased urethral resistance.

b. Obstructive symptoms-hesitancy, diminution in size and force of urinary stream, terminal dribbling, sensation of incomplete emptying of the bladder, urinary retention.

c. Irritative voiding symptoms-urgency, frequency, and nocturia (Nettina, 1996).

5. Pathway

The process of aging and the presence of circulating androgens

The prostatic tissue forms nodules

The normally thin and fibrous outer capsule of the prostate becomes spongy and thick

The prostatic urethra becomes compressed and narrowed

Effects of prolonged obstruction

Trabeculation (formation of cords) of the bladder wall,

Decreasing its elasticity

(Nettina, 1996).

6. Complication

Complications of BPH are:

a. Urinary retention

b. Renal insufficiency

c. Recurrent urinary tract infections

d. Gross hematuria

e. Bladder calculi

f. Renal failure or uremia (rare in current practice) (Leveillee, 2009).

7. Diagnosis Evaluation

a. Rectal examination-smooth, firm, symmetric enlargement of the prostate

b. Urinalysis to rule out hematuria and infection

c. Serum creatinine and BUN to evaluate renal function

d. Serum PSA to rule out cancer, but may also be elevated in BPH

e. Optional diagnostic studies for further evaluation:

1) Urodynamics-measures peak urine flow rate, voiding time, and status of the bladder’s ability to effectively contract.

2) Measurement of post void residual urine; by ultrasound or catheterization

3) Cystourethroscopy to inspect urethra and bladder and to evaluate prostatic size

(Nettina, 1996).

8. Management

a. Patients with mild symptoms (in the absence of significant bladder or renal. impairment) are followed annually; BPH doesn’t necessarily worsen in all men.

b. Pharmacologic management

1) alpha-Adrenergic blockers such as doxazosin (Cardura), prazosin (Minipress), terazosin (Hytrin)-relax smooth muscle of bladder base and prostate to facilitate voiding.

2) Finasteride (proscar) – antiandrogen effect on prostatic cells, reverses or prevents hyperplasia.

c. Balloon dilatation of the prostatic urethra provides temporary relief of symptoms.

d. Surgery-TURP (Trans Urethral Resection), transurethral incision of the prostate (TUIP), or open prostatectomy for very large prostates, usually by suprapubic approach.

e. Newer approaches-laser surgery, insertion of prostatic stents or coils, microwave hyperthermia treatment (Nettina, 1996).

B. NURSING CARE CONCEPT

1. Assessment Nursing Diagnosis

a. Client Identity

It includes name, gender, age, address, religion, marital status, education, occupation, register number, admission time, and medical diagnosis.

b. History of Illness

1) Chief complain

Client complains retention of urine.

2) Present health illness

Obtain history of voiding symptoms, including onset, frequency of day and night time urination, presence of urgency, dysuria, sensation of incomplete bladder emptying and decreased force of stream. Use symptom index to determine severity of symptoms and impact on patient’s life style

3) Past health illness

It about client life style, habit, surgery, treatment and specific disease that contribute to occur BPH.

4) Family history

Is the client’s family has inherit disease? (Nettina, 1996).

c. Functional Health Design (Gordon)

1) Health Perception/Health Management

Client's perceived pattern of health and well-being and how health is managed.

2) Nutritional-Metabolic

Pattern of food and fluid consumption relative to metabolic need and pattern; indicators of localnutrient supply.

3) Elimination

Patterns of excretory function (bowel, bladder, and skin). Includes client's perception of “normal"function.

4) Activity – Exercise

Patterns of exercise, activity, leisure, and recreation.

5) Cognitive-Perceptual

Sensory-perceptual and cognitive patterns.

6) Sleep-Rest

Patterns of sleep, rest, and relaxation.

7) Self-Perception/Self Concept

Client's self-concept pattern and perceptions of self.

8) Role-Relationship

Client's pattern of role engagements and relationships.

9) Sexuality-Reproductive

Patterns of satisfaction and dissatisfaction with sexuality pattern; reproductive pattern.

10) Coping / Stress Tolerance

General coping pattern and effective of the pattern in terms of stress tolerance.

11) Value – Belief

Patterns of values, beliefs (including spiritual), and goals that guide client's choices or decisions.

d. Physical Examination

Perform rectal (palpate size, shape, and consistency) and abdominal examination to detect distended bladder, degree of prostatic enlargement.

e. Diagnostic Evaluation

a. Urinalysis to rule out hematuria and infection

b. Serum creatinine and BUN to evaluate renal function

2. Nursing Diagnosis and Nursing Interventions

a. Pre-operative

Altered urinary elimination related to obstruction of urethra

Goals: the client will urinate adequately without residual urine

Interventions:

1) Provide privacy and time for patient to void.

2) Assist with catheter introduction with guidewire or via suprapubic cystotomy as indicated.

a) Monitor intake and output

b) Maintain patency of catheter

3) Administer medications as ordered and monitor for and teach patient about side effects.

a) Alpha-Adrenergic blockers-hypotension, orthostatic hypotension, syncope (especially after first dose); impotence; blurred vision; rebound hypertension if discontinued abruptly.

b) Finasteride (proscar)-hepatic dysfunction; importance; interference with PSA testing

4) Assess for and teach patient to report hematuria, signs of infection

(Nettina, 1996).

b. Post-operative

1) Acute urinary retention related to obstruction secondary to TURP

Goals: The client will avoid urinary retention

Interventions:

a) Monitor the client’s urinary output, noting the amount, color, and presence of clots. After 24 hours, the urine should be a light pink color.

b) Increase rate of flow of the bladder irrigant if the urine has clot; a darker color or decreased output.

c) Monitor the client’s intake; encourage a fluid intake of 2500to 3000 ml/day.

2) Acute pain related to bladder spasms or incision

Goals: The client will state that pain has decreased

a) Assess for pain using a pain scale every 2 to 4 hours.

b) Maintain traction on the urethral catheter by anchoring the catheter to the leg with tape, taking care that accidental additional traction will not occur with leg movement.

c) Monitor for signs of bladder spasm pain such us facial grimacing, nonflow of irrigating solution into bladder, and urinating around the catheter. Administer analgesics and antispasmodics as ordered.

d) Teach deep breathing, relaxation techniques.

3) Risk for excess fluid volume related to post-operative irrigation

Goals: The client will not experience water intoxication.

Interventions:

a) Accurately record input and output including irrigation fluid.

b) Monitor for changes in the client’s behavior, especially confusion and agitation, which may be the first signs of cerebral edema.

c) Monitor for hypertension, bradycardia, weakness, and seizures.

4) Stress urinary incontinence related to poor sphincter control after catheter removal after surgery

Goals: The client will achieve urinary control after removal of the catheter.

Interventions:

a) Advice the client that temporary urinary incontinence frequently occurs after surgery and reassure him that this is normal.

b) Teach the client perineal exercises that will help him regain urinary control. These exercises consist of tightening and relaxing gluteal muscles and are to be used each time the client urinates.

5) Sexual dysfunction related to surgery

Goals: The client will regain sexual function postoperatively.

Interventions:

a) Monitor the client’s statements to determine if he has any misunderstanding of the surgery and sexual function.

b) Instruct the client to void sexual intercourse until physician approval is given and that it may take time for his previous level of sexual expression such us kissing, stroking, and cuddling.

c) Provide the client with opportunities to voice his feeling and ask questions.

d) Advise the client that it is normal and not harmful if his urine has a milky appearance due to retrograde ejaculation

(Nettina, 1996).

3. Evaluation

Each goal must be evaluated to determine how it has been met by the client.

REFERENCES

Nettina, Sandra M. 1996. The Lippincott; Manual of Nursing Practice. Lippincott-Raven Publishers: Philadelphia.

Leveillee, Raymond J. 2009. Benign Prostate Hyperplasia. Provide at http://www.emedicine.medscape.com. Access on February 21, 2010.

White, Lois. 2002. Medical-surgical Nursing; An Integrated Approach 2^nd Edition. Delmar: New York.

Wikipedia staff. 2010. Benign Prostate Hyperplasia. Provide at http://www.wikipedia.com. Access on February 21, 2010.