Benign Prostate Hyperplasia (BPH)

Matrix : 1524

LEARNING OBJECTIVE After end of case study I will able to;  State the definition for benign prostate hyperplasia (BPH).  Explain the anatomy and physiology of prostate gland.  Explain the pathophysiology of BPH.  State the etiology of BPH.  State the clinical manifestation.  State the complication on BPH.  Describe the investigation done on patient with BPH.  How do show your understanding the implication for medication and treatment used in care patient in BPH.  Implement the nursing care plan.  Appreciate the importance of giving health teaching to patient in BPH to prevent further complication.

PATIENT BIODATA Name: Mr. X Consultant: Dr. L MRN: xxxxxx Date of birth: 13 June 1945 Age: 60 years old Gender: Male Marital status: Married I/c no: 450613 450613-xxxx-xxxx Race: Chinese

Religion: Buddha Occupation: Businessman Reason for admission: Complaint of difficulty passing urine for 1 weeks Diagnosis: Benign prostate hyperplasia Medical history: Nil Surgical: Nil Family medical history: Mother had stroke Current medication: Nil Allergies: Norfloxacin and crab

ADMISSION

Mr. X was admitted to 4th floor in Puteri Specialist Hospital (PSH) on 02 December 2007 at 1330 pm with complaint of difficulty to passing urine for 1 week.

Vita sign Blood pressure: 140/80mmHg Temperature:36.5 Pulse: 80 beat per minutes consciousness Respiration:23 breath per minutes Skin condition: Normal and clean

Mode of admission Wheel chair Level of conscious

ACTIVITY DAILY LIVING BREATHING Mr. X no complaint of difficulty in breathing, shortness of breath (SOB) during admission. COUGH Mr. X no complaint of cough. SMOKE Mr. X is not active smoke only 3stick/day. EATING AND DRINKING Mr. X allergic to antibiotic (norfloxacin, and crab) ELIMINATION Mr. X did not complaint of constipation.

BLADDER Mr. X had difficulty in passing urine in 1week. SLEEPING Mr. X has sleeping disturbance at night because nocturia. MOBILITY Ambulant PERSONAL HYGIENE Mr. X can do himself. SAFE ENVIRONMENT Put the side rails up all the time.

SPIRITUAL Not applicable. COMMUNICATION Mr. X cans speech normally. VISION AND HEARING No complaint of blurred vision and hearing sound. INTEREST Like to reads news paper.

PHYSICAL EXAMINATION Physical examination was done on patient from head toe. Below is the information: HEAD Hair grey and black hair. Clean head scalp and no swelling seen. EYES No conjunctivitis and no discharge. Eyes appeared symmetrical. NOSE Nose shape is symmetrical. Patient able to smell slight. No discharge seen.

EAR No discharge seen. Ear shape is symmetrical. NECK No lymph node swelling or thyroid enlargement detected. No redness and scarring seen. UPPER LIMB ARM No bruises, flexible joint. WRIST Have a vasocan at right hand.

FINGERS Normal digitalis. Can move normally. NAIL No clubbing seen. SKIN Clean and warm.

BODY CHEST Symmetrical in shape. No scarring. ABDOMEN Having slight distended, wound not detected. LOWER LIMB No swelling and redness. Flexible joints. No itchiness so is detected.

vasocan

ANATOMY AND PHYSIOLOGY

PROSTATE GLAND Lies on pelvic cavity in front of rectum and behind the symphysis pubis, surrounding the first part of the urethra. Consist of an outer fibrous covering , a layer of smooth muscle and glandular substances composed of columnar epithelial cells. The prostate makes a fluid that becomes part of semen. Semen is the white fluid that contains sperm.

DEFINITION OF BENIGN PROSTATE HYPERPLASIA (BPH)

An age related , non malignant enlargement of the prostate gland , is a common disorder of the ageing male , the prostate , very small at birth , grows at puberty , reaches adult size around age 20. (Medical surgical page 1537)

Definition 2 Benign prostatic hyperplasia is nonmalignant (non cancerous)enlargement of the prostate gland, a common occurrence in older men. It is also known as benign prostatic hypertrophy and abbreviated as BPH

DEFINITION 3 The prostate gland starts to enlarge after middle age.When the prostate becomes enlarged, the condition is called benign prostatic hyperplasia (BPH), or benign prostatic hypertrophy.

ETIOLOGY
 Unknown.  The

aging process levels (DHT)

 Testosterone

 Dihydrotestosterone

PATHOPHYSIOLOGY Aging Androgen that mediates prostatic growth at all ages is Dihydrotestosterone (DHT) formed in prostate from testosterone Androgen reduce in aging men and more sensitive to DHT Estrogen produced in small amount in men, sensitive the prostate gland to effects of DHT

Increase estrogen level in aging related to testosterone level Its begins as small nodules in periurethral glands, inner layers prostate Prostate enlarge, formation and growth of nodules and enlargement of glandular cell Benign prostate hyperplasia (BPH)

CLINICAL MANIFESTATION More frequent urination Bladder irritability Nocturia Urge incontinence Dysuria Urinary retention

COMPLICATION OF BENIGN PROSTATE HYPERPLASIA (BPH) Vesicoureteric reflux Hydoureter Hydronephrosis

INVESTIGATION Chest xx-ray Blood test (pre operation) GP 78A or M19 Serology Prostate Specific Antigen (PSA) Electrocardiogram (ECG) Uroflowmetry

PRE-OPERATIVE PROFILE (GP78A) @ M1 PREDate order: 3 January 2007 Date done: 3 January 2007 HAEMATOLOGY Haemoglobin Platelet count BIOCHEMISTRY Glucose

14.7g/d

13.0 - 18.0

207 10/uL 150 450

5.7mmol/L

3.93.9-6.1

Reference range: Random blood sugar : <7.8 mmol/L (<140mg / dL)

Creatinine Urea Sodium Chloride 111

63 umol/L 5.8 mmol/L 141 mmol/L 103 mmol/L

51 133 2.0 6.8 135 155 95

SEROLOGY Prostate specific antigen (PSA) 4.97ng/mL BLOOD GROUP ABO group Rhesus group (D) VDRL (RPR) O positive non reactive

<4.0

non reactive non reactive

HIV I/II antigen /antibodies non reactive HBs antigen

CHEST X RAY RESULTS Date order: 3 January 2007 Date done: 3 January 2007 No focal lung lesion Heart size is normal No hilar or pleural abnormalities The mediastinum is not widened. No body abnormalities

ECG Date order: 3 January 2007 Date done: 3 January 2007 Vent. Rate 72 bpm PR int 196 ms QRS dur 118 ms QT / QTc intr 388 / 412 ms P QRS / T axis 60 / 3 / 46 RVS SV 1 amp 1.630 / 1.070 mv RVS + SV 1 amp 2.700 mv 1100 sinus rhythm 1102 sinus arrhythmia 2320 non specific intraventricular conduction delay 9130 ** borderline ECG**

Uroflowmetry
700 600 500 400 300 200 100 0 0 20 40 1:00 1:20 Flow ml/s vol.mL

Dev (male) Max flow: Averange flow: Voiding time: Flow time: Time to peak flow: Voided vol: Flow at 2 seconds: Acceleration: 8.6 ml/s 3.5ml/s 1: 09. 2 sec 58.6 sec 6.0sec 207.8ml 7.1 ml/s 1.2ml/s -42% -67% -219% 42%

Statistic of BPH BPH in Puteri Specialist Ho Hospital spital (PSH)

70

60

50

40

31- 40YRS 41-50YRS 51- 60YRS

30

>=61YRS

20

10

0 YEAR 2003 YEAR 2004 YEAR 2005 YEAR 2006

Medication in ward Name of drug: Tab tramal 50mg TDS IV maxolon 10mg TDS/PRN Tab zinnat 250mg BD IV pethidine 50mg STAT IV phenergan 25mg STAT Proscar 5mg OM Date on: 3/1/2007 3/1/2007 3/1/2007 3/1/2007 3/1/2007 3/1/2007 Date off: 5/1/2007 3/1/2007 continue at home 3/1/2007 3/1/2007 continue at home

Medication when discharge Tab maxolon I/I TDS/PRN 3/7 Zinnat 250mg BD 3/7

Name Dose Freq

IM 50 pethidi mg ne STAT

Indct
Reduce pain

s/effct

D/on D/off
3/1

Dizziness,s 3/1 weating,n ause and vomiting,d ry mouth Tachycardi 3/1 a,dizziness ,constipati on Sweating, 3/1 dizziness, vomiting dry mouth

IM 25 phener mg gan Tab 50 tramal mg

STAT

TDS/P RN

control nausea and vomiting Release pain

3/1

5/1

Name Zinnat

Dose

Freq Indct.

s/effct

D/on D/off cntn. at home

250 mg BD

Prevent Headach 3/1 infection e, eosinopill ia Control Impoten 3/1 and ce,decre vomiting ase libido

Proscar 5mg

OM

Cntn.at home

TREATMENT CONSERVATIVE (usually for mild cases)  Antibiotic therapy  Hormone therapy  Health education SURGERY TURP (Transurethral Resection of Prostate)

This is an instrument thats used in TURP procedures.

This is the way TURP was done to patient and the end of the resectoscope have the electrode cutting wire to cut the enlargement of prostate.

Doctors inserts the resectoscope through the penis

This photos shows that doctors cutting the prostate by using the electrode wire loop

ZINNAT Group: Macrolides Name of drug: Cefuroxime axetil Indication: Broncholitis , pneumonia , upper respiratory tract , GUT , skin and soft tissue infection , pyelonephritis . Dosage: 250mg BD Contra indication: Hypersensitivity and cephalosporins. Special precaution: Anaphylactic reaction to penicillins Side effect:. I disturbances occasionally pseunomembranous colitis , hypersensitivity reactions . Eosinophillia .headache . super infection.

PROSCAR Group: Genito urinary system Name of drug: Finasteride Indication: treatments and control benign prostate hyperplasia to cause regression of enlarged prostate, improve urinary flow and symptom associated with benign prostate hyperplasia. Dosage: 5mg OM

Contra indication: women and peads patients Special precaution: Large residual urine volume and or severely diminished urinary flow (monitor for obstructive uropathy ) exclude prostate cancer . Generally baseline PSA further evaluation and consideration of biopsy. Decrease in serum PSA concentration even in the presence of prostate cancer. BPH patient treated with proscar with reduction of serum PSA level does not rules out concomitant prostate cancer. Side effect: Impotence, decrease libido and volume of ejaculate.

TRAMAL Group: Analgesic and antipyretic Name of drug: Tramdol HCL Indication: Moderate to severe acute chronic pain, painful diagnostic measures and surgical pain. Dosage: 50mg TDS Contraindication: Analgesic or psychotropic. Narcotic withdrawal treatments. Hypersensitivity

Special precaution: Reduce level of consciousness of unclear origin, respiration disorder, increase intracranial pressure. Patient knows to suffer from convulsion. Pregnancy and lactation. On long term use, possibility of tolerance, psychic and physical dependence .Capacity to drive or operate machines may be impaired, especially if taken with alcohol. Side effect: Sweating , dizziness , drowsiness , vomiting , dry mouth. In rare cases , influence on CVS regulation , especially after IV administration , headache , vomiting, constipation , GI irritation , skin reaction. In very cases, motorial weakness, appetite changes, micturation disorder . Psychic side effect e.g. mood. Perception and activity changes. In isolated cases, cerebral convulsion especially on co medication with neuroleptics . Allergies reaction and shocks cannot definity be ruled out. Drug interaction: Avoid concurrent administration of MOAIs. Co medication with other centrally acting depressants include alcohol may potentiate CNS effects.

PETHIDINE Group: Analgesic and antipyretics Indication: Pain relief of moderate to severe pains. As anaesthetic adjust and for obstetric analgesia. Dosage:50mg STAT Contra Indication: Respiratory distress head injury increases ICP brain tumor cardiac arrthymia eclampsia Special Precautions: May impair ability to drive or operate machinery. Elderly. Reduced renal and liver function. Side Effect: Respiration depression dizziness, sedation, sweating, nausea and vomiting,Tachycardian bradycardia, gangrene. Drug Interaction: Barbituration CNS depresses increase the CNS effects.

MAXOLON Group: Antacids. Name of drug: Metoclopramide. Indication: Dyspepsia, flatulence, digestive disorders associated with hiatus hernia, peptic ulcer ulceration, reflux oesophagitis, gastritis, duodenitis. Dosage: IV 10mg TDS. Special precaution: Neuroleptics, anticholinergics, phyroplasty pregnancy. Side effect: rarely, extra pyramidal reaction, tacdive dry skinesia. Drug interaction: Phenothiazines, anti cholinergic, narcotic analgesics.

Special care
 Catheter

bladder drainage (CBD) bladder irrigation (CBI)

 Continues

CBD
          

Wash hand before and after handling the CBD. Ensure the urine is low with gravity. Maintain urine free flow all the time. Urine bag not touching the floor Ensure the catheter not kinking or blocked. Empty the urine bag 8hourly or PRN. Avoid patient to touch the urine catheter. Do not take the urine specimen from urine bag. Do the perineal care and ensure it is clean and dry. Do not pull out the catheter Urine bag must be attach to the frame and must be hanging at the bed.

CBI
        

Solution as prescribed is normal saline Run the solution at rate prescribed fast in 1st 5hours. Check and record pulse and blood pressure. Reduce the rate when blood stained is reduce. Change the normal saline when empty immediately to prevent air embolism. Ensure it is not blocked or kinking. Frequently observe the urine bag and empty if full Urine bag must be lower from bladder and not touch the floor. Inform doctor if bleeding still persists.

NURSING CARE PLAN (NCP) PRE OPERATION 1)Alteration in emotional status: anxiety related to pre operation. 2) Alteration in emotional status: pain(dysuria) related to constriction of urethre. POST OPERATION 3)Alteration in comfort: pain related to post operation. 4)Potential hypovolemic shock related to excessive bleeding. 5)Potential infection related to poor care of CBD.

NCP 1 Date:3 January 2007 Time:0730 Alteration in emotional status: anxiety related to pre operation. Supporting data: 1)Patient facial expression look anxious. 2) Patient keep in asking question about the operation. Goal: Patient will be reduce anxiety 11-2 hours after nursing intervention given and during hospitalization. Nursing intervention: 1) Assess patient general condition such as facial expression. Act as baseline data and plan appropriate nursing care. I- I assess patient general condition during admission and patient look anxious.

2) Monitor patient vital sign such as blood pressure, pulse , temperature and respiration. Patient anxious may indicated in high blood pressure. I- I check patient vital sign and my patient blood pressure is 160/90 mmHg. 3) Re inforce doctors explaination about the procedure will done to him. To reducing the anxiety level. I- I re inforce doctors explaination to patient to him get a picture about the operation. 4) Encourage patient to asking the question regarding the operation. To ensure patient understand about the operation and reducing anxiety. I- I encourage him to asking question and give answer in simple language.

5) Teach patient to do deep breathing exercise (DBE) For relaxation and divert patient mind. I- I teach him to do DBE , inhaled and hold in 10 seconds then exhale do in 5 to 10 minutes. 6) Encourage patient to rest in bed (RIB) To reduce anxiety and relaxation. I- I advice him to rest and relax it is also can divert patient mind. 7) Encourage family member to be with patient. To give moral support to him. I- I encourage his wife to spend time with him.

8) Inform doctors if patient still anxious. To further treatment and intervention. I- I not inform doctor because the anxiety is reducing and blood pressure back to normal level. Evaluation: Patient reduce the anxiety level in 1hours after nursing intervention given and during hospitalization. Supporting data: Patient look more calm and relax. Patient blood pressure back to normal range 140140-80 mmHg. Date:3 January 2007 Time:0830

NCP 2 Date: 3 January 2007 Time:0930 Alteration in comfort: pain dysuria related to constriction of the urether. Supporting data: 1. Patient verbalize pain during passing urine. 2. Patient facial expression look pale. Goal: Patient will be reduce the pain within 33-4 hours after nursing intervention given during hospitalization. Nursing intervention: 1) Assess patient general condition such as severity of pain by using pain scale. Act as baseline data and plan appropriate nursing care. I- I assess severity of pain by asking him how the pain it is.

2) Monitor patient vital sign such as blood pressure, pulse, temperature and respiration. To detect any changes in vital sign especially in blood pressure reading. I- I do observation 4 hourly and blood pressure is 150/80 mmHg. 3) Encourage patient to do deep breathing exercise (DBE). To reduce the pain and relaxation. I-I demonstrate to him how to do the DBE and ask patient to demonstrate back to me. 4) Ensure patient in rest in bed (RIB) To reduce pain and minimize movement. I- I ensure him to rest in bed for reduce pain it is also can divert patient mind.

5) Serve medication as prescribed by doctors such as antipyretic tramal 250 mg. To decreasing and stop the pain. I- I serve tramal 250mg to him with supervise of staff nurse. 6) provide divertional therapy TO divert patient mind and not thing of the pain. I- I provide new strait time and switch on the televison. 7) inform dortors if the pain is not reduce. For futher treatment and investigation. I- I did not inform to doctors because the pain is reduce.

Evaluation : Patient reduce the pain after 3 hours after nursing intervention given and during hospitalization. Supporting data: Patient verbalize the pain is reducing. Patient blood pressure is normal range 140/70mmHg. Date: 3 January 2007 Time:1230

NCP 3 Date:3 January 2007 Time:1715 Alteration in comfort: pain related to post operation. Supporting data: Patient verbalize pain at the operation site. Patient look pale. Goal: Pain will reduce pain in 33-4hours after intervention given and during hospitalization. Nursing intervention: 1) Asses patient pain by using pain scale 11-10, 10 consider is severe pain. Act as baseline data and plan appropriate nursing care.

2) Monitor patient vital sign especially blood pressure. Increase blood pressure indicated patient in pain. I- I do observation 4hourly and blood pressure is 150/80mmHg. 3) Position patient in patient desired (recumbent) To reduce pain and relaxation. I- I position him in recumbent position as him desired. 4)Encourage patient to rest in bed (RIB) To minimize patient movement and relaxation. I- I encourage him to RIB and explain to him it is also can reducing the pain. 5) Encourage patient to do double breathing exercise (DBE) For release the pain and muscle relaxation. I-I teach patient to do DBE , inhale and hold in 10second than release.

6) Serve antipyretic drugs such as tramal 50mg TDS. To reduce and stop pain I- I serve antipyretic drug tramal to patient with supervise of staff nurse. Evaluation: Patient reduce the pain in 3hours after nursing intervention given during hospitalization. Supporting data: Patient verbalize the pain is reducing Patient look more relax compare than before intervention given. Date: 3 January 2007 Time: 2015

NCP 4 Date: 3 January 2007 Time: 2030 Potential hypovolemic shock related to excessive bleeding. Supporting data: 1. Patient post surgery ( TURP ) 2. Patient back to ward with CBI. Goal: Patient will be free from bleeding 22-3 hours after nursing intervention given and during hospitalization.

Nursing intervention: 1) Assess patient site and severity of bleeding such as amount and color of blood. Act as baseline data and plan appropriate nursing care. I- I assess the site of surgery and check the amount blood in the urine bag and how the color dark red or no. 2) Monitor patient vital sign such as blood pressure, pulse, respiration and temperature. If patient is severe bleeding blood pressure will decrease can lead to hypovolemic shock. I- I do observation to patient 4 hourly and check the blood pressure, pulse, temperature. 3) Observe sign and symptom of bleeding such as blood pressure decrease, and rapid pulse. To prevent severe bleeding occurs. I- I do observation especially blood pressure and pulse to know any changes in patient vital sign.

4) Set up intravenous drip such as Hartmans solution Hartman can increasing the blood pressure and reduce the bleeding. I- I assist the staff nurse to set up the intravenous line. 5) Position patient in the recumbent position. To reducing the bleeding. I- I position him in recumbent position and encourage him to relax. 6) Avoid to do hot compress Hot compress can dilate the blood vessel and can cause severe bleeding. I- I did not give hot compress to patient.

7)Avoid to serve anticoagulant drug such as wafarin, heparin. If can cause more bleeding. I- I did not serve the anticoagulant drug to patient. Evaluation: Patient free from excessive bleeding after nursing intervention given and during hospitalization. Supporting data: 1. Patient blood pressure in normal range 140/70 mmHg 2. Patient facial expressions not pale. Date: 3 January 2007 Time: 2210

NCP 5 Date: 4 January 2007 Time: 0830 Potential infection due to poor care of CBD. Goal: Patient will free from infection after nursing intervention given and during hospitalization. Nursing intervention: 1) Assess patient general condition such as site of CBD. Act as baseline data and plan appropriate nursing care to patient. I- I check patient catheter and ensure it is clean and intact.

3) Maintain personal hygiene. To prevent getting infection. I-I do perineal care to him for first hours after operation because patient in RIB. 4) Ensure wash hand before and after handling patient with CBD. To prevent transmission of microorganism. I-I wash hand before and after attend to patient. 5) Empty the CBD 8 hourly or PRN. To prevent retention of urine in the bladder. I- I empting the urine bag when it is full and chart in intake and output chart. 6) Avoid patient to touch the catheter. To prevent cross infection happened. I- I advice to him do not necessary touch the catheter

2)Monitor patient vital sign such as blood pressure, temperature, pulse and respiration. High temperature may indicate patient in infection. I-I do observation to him and his not develop fever and the temperature is 36.3. 3) Maintain personal hygiene. To prevent getting infection. I-I do perineal care to him for first hours after operation because patient in RIB. 4) Ensure wash hand before and after handling patient with CBD. To prevent transmission of microorganism. I-I wash hand before and after attend to patient.

5) Empty the CBD 8 hourly or PRN. To prevent retention of urine in the bladder. I- I empting the urine bag when it is full and chart in intake and output chart. 6) Avoid patient to touch the catheter. To prevent cross infection happened. I- I advice to him do not necessary touch the catheter. 7) Observe the sign and symptom of infection such as itchiness and redness. To detect infection early. I-I check the site if have redness and I asking him that he feel itchy or no.

Evaluation: Patient free from infection after nursing intervention given and during hospitalization. Supporting data: No redness and patient no complaint feel itchiness. The area is clean and dry. Date: 5 January 2007 Time: 1330

Health education
     

Diet Exercise Lifestyle Hygiene Medication Follow up

DISCHARGE My patient discharge on 5 January 2007 at 1330. I told to him that the bill is ready and can settle down at counter 38 on ground floor. I also told him to take the medication at the nurses counter in the ward. Staff nurse give explanation to him regarding the medicine and lastly I off the vasocan. The doctors was order the tab maxolon I/I TDS/PRN x 3/7 , zinnat 250 mg BD x 3/7, proscar 5 mg OM TDS/PRN x 3/7 . I also remind him about the follow up on 18 January 2007.

Follow up My patient appointment on 18 January 2007 for follows up and Dr.L order to do ultrasound abdomen and do the ureflowmetry to check still got the obstruction or no.

And the result show the patient not having the obstruction.

SUMMARY

Mr. X was admitted on 3rd January 2007 at O710am. He was complaint of difficulty in passing urine for 1 week, Dr. L diagnose him a Benign prostate hyperplasia (BPH) and transurethral resection of prostate (TURP) was done to patient on 3rd January 2007 at 1330pm. He was hospitalized for 2 days and discharge on 5 January 2007. There was no complaint of difficulty in passing urine anymore. Health educations were given on regarding the CBD and follow up appointment on 19 January 2007. Dr. L was ordered maxolon and zinnat 250mg to him.

CONCLUSION Thank you, to all staff in Puteri Specialist Hospital (PSH) especially to Sister Marina who that guide me to do and finish my case study. Not forgotten to my collogue in guided me also thank you so much. Not forgetting to my parents support in do my case study. I choose this case because it is interesting case and of course common happen in male population in the world.But not so worry because now we have the treatment to treat it become enlarge the treatment called transurethral resection of prostate. Thank you so much once again to my collogue and staff PSH may Allah bless u.

REFERENCE Medical surgical nursing book 10th edition editor by Mark Johnson page 1192,1195,1196,1958. A Complete Hospital Manual of INSTRUMENT AND PROCEDURES editor by MM Kapur New Delhi page 288, 289. Operating room technique editor by Berry and Kohns page 709,710,711,712,713,714. Benign prostate hyperplasia editor by Axeanders and Jane C. Rothrock page 1020,1021,1022. Watsons clinical nursing and related sciences editor by Mike Walsh page 980,981,985. MIMS 99TH Edition 2004 page 13,73,128,177. http://www.benignprostatehyperplasia.com/GUT /urinary system http://www.TURPprocedures.com.my/treatment http://www.anatomy&physiologyofprostategland http://www.uroflowmetryprocedures.com.my

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