NRSG258 : Acute Care Nursing

Introduction:

Benign Prostatic Hyperplasia (BPH) is very common in men. This paper will explain the pathophysiology and aetiology of BPH and the underlying pathophysiology of the post-operative condition of the patient. Lastly, the paper will prioritize and discuss the nursing management for the patient and identify three (3) interdisciplinary healthcare team members who are important in patient care.

Aetiology and Pathophysiology of BPH

BPH is the enlargement (hypertrophy) of the prostate gland. The exact cause of BPH has not been well established but its suggested to be associated with hormonal changes/testicular androgens. Elevated levels of estrogen hormone in men result to increased sensitivity of prostate tissue. Smoking, alcoholism and sedentary life style are associated with increased risk of BPH development. Western nutrition especially a diet with high levels of protein and animal fat and refined carbohydrates with low fibre content predisposes men to BPH. Other risk factors for the development of BPH include; aging family history of BPH, overweight and obesity (Chughtai et al, 2016).

The prostate gland is a small and muscular gland surrounding the urethra and forms the main component of the fluid in male semen. BPH occurs due to rapid and uncontrollable multiplication of prostate gland cells. The extra cells lead to swelling of the prostate gland which consequently squeezes the urethra limiting urine flow.

Men produce sufficient amounts of testicular androgens such as testosterone and some female hormones like estrogen. The amount of testosterone hormone produced in men decreases with aging leading to sexual impairment. Consequently, this leads to development of BPH. Continuous accumulation of dihydrotestosterone (DHT) also contribute to the development of BPH. The connection between androgen receptors and DHT in the cell nuclei results to development of BPH (Chughtai et al, 2016).

Bladder dysfunctions induced by obstruction may also contribute to the development of the disease manifestations. Increased prostate resistivity usually referred to as detrusor overactivity in the urinary bladder is associated with urinary frequency and manifestations of BPH.  With time, as the disease progresses, the walls of the urinary bladder get weak leading to organ failure whereby the urinary bladder is no longer able to empty fully during micturition (Chughtai et al, 2016).

Other mechanisms involved in the development of BPH are; (1) resistance whereby BPH develops following complex interactions which involve resistance to spastic and mechanical effects in the prostatic urethra. (2) Obstruction due to the hypertrophied prostate lobes may block the urethra or bladder neck resulting to incomplete ability to empty the bladder. Eventually, incomplete bladder emptying leads to development of urinary retention, urinary tract infections, hydroureter and hydronephrosis. (3) Gradual dilation of the kidneys and ureters may lead to development of BPH. Some of the manifestations of BPH are urinary frequency, urinary urgency, nocturia, intermittent and decreased force of urinary stream, dribbling urine and straining when urinating (Chughtai et al, 2016).

Pathophysiology for the Post-operative Patient Deterioration

On presentation to the ward the patient had respiration rate of 30 breaths/ minute (Tachypnea) when compared to a normal respiration rate of 12-20 respirations/minute. His blood pressure was 100/60mmH (Hypotension) against a normal range of 120/80 to 140/90 mmHg. The patient had a pulse rate of 128beats/minute (Tachycardia) against a normal range of 60-100 beats per minute. He also had a temperature of 35.0⁰C (Hypothermia) against a reference range of 36.1⁰C to37.2⁰C. The normal urine output is usually 0.5mL/Kg/Hr in an adult. Oliguria is commonly caused by bladder obstruction, dehydration, urinary retention and poor kidney perfusion.

Spinal anesthesia causes hypotension. Local anesthesia is often injected in order to block afferent sensory fibre conduction which is responsible for transmission of pain impulses to the brain. Blockage of the conduction in local anesthesia is usually non-specific and it affects the preganglionic fibres of the sympathetic chain. This results to hypotension and sympathetic shock hence leading to hypoperfusion of the urinary system.  When a patient is put under spinal anesthesia, hypotension results from the decrease in cardiac output (CO) and systemic vascular resistance (SVR) (Chughtai et al, 2016).

There are various reasons that are associated with hypothermia in a patient. Post-operative hypothermia is attributed to older age of the patient, male gender, amount of intravenous fluid administered for replaced, prolonged duration of surgery or anesthesia, body mass index, temperature of the operating room and physical status of the patient.  Other factors associated with post-operative hypothermia in a patient are; patient’s body temperature pre-operatively and temperature monitoring and maintenance techniques pre-operatively and intraoperatively. Administration of cold fluids to the patient for irrigation of the urinary bladder is also a possible cause of hypothermia. Hypothermia also presents as an intended side effect of anesthesia (Lee & Sharifi, 2014).

Post-operatively, tachycardia is associated with production and release of catecholamines in response to surgery-induced stress/anxiety. Post-operative hypoxia and urinary retention may cause tachypnea, tachycardia and anxiety. Tachypnea and tachycardia could also be attributed to hemorrhage. Hypothermia causes of tachycardia, hypotension and tachypnea (Lee & Sharifi, 2014).

Nursing Care priorities: Hypothermia, Hypotension, Tachycardia, tachypnea and risk for infections

Abnormal Vital Signs

Respiration Rate-30 breaths/ minute (Tachypnea)

Blood Pressure-100/60mmH (Hypotension)

Pulse Rate- 128beats/minute (Tachycardia)

Temperature- 35.0⁰C (Hypothermia)

Nursing Interventions for the Abnormal Vital signs.

When the nurse comes in contact with patient in the ward, he or she should conduct an assessment based on ABCD criteria to check for airway obstructions/secretions, breathing patterns/rhythm, circulation for blood pressure and heart rate and disorder or disease. Hypothermia among patients results to pathological and physiological dysfunctions and responses such as increased consumption of energy and oxygen, drug metabolism inhibition, disturbance in mechanisms of blood clotting, and variations in mental status leading to prolonged hospital stay (Gordon, 2014). 

Regarding patient assessment, the nurse should monitor patient’ vital signs such as blood pressure, pulse and heart rhythm because progressive hypothermia leads to a drop in BP and pulse rate. Severe hypothermia is associated with increased risk of dysrhythmias and ventricular fibrillation. Frequent and regular assessment of peripheral perfusion would be important because hypothermia aggravates peripheral vascular constriction, a compensatory mechanism for preventing loss of heat from the patient’s extremities (Lee & Sharifi, 2014). 

The nurse should monitor patient’s urine output and fluid intake because reduced urine output may be an indication of poor renal perfusion, dehydration or urinary obstruction either by blood clots or disease process. If the patient had been exposed to cold for a long time, the nurse should check for frostbite sign since severe hypothermia is associated with generation of ice crystals inside cells leading to their bursting and death. The patient should be relocated to a warm room and covered with warm and dry linens to encourage passive and gradual generation of body heat since rapid warming can lead to ventricular fibrillation (Gordon, 2014). The nurse should provide additional sources of heat such as heat lamp, moisturized and heated oxygen. The patient should be put on oxygenation to enable him respond to high oxygen demands and achieve an oxygen saturation of more than 90%.

The nurse should implement interventions aimed at preventing risk of infection. The nurses should always ensure asepsis when handing the patient for example wound care, care of the surgical site, catheter care and intravenous management. Aseptic techniques reduce the chances of pathogen spread and transmission. Interrupting the chain of infection through asepsis helps in prevention of infections (Gordon, 2014). 

The nurse should enlighten the patient and significant other to wash their hands with antiseptic soap before touching the patient and between procedures. Friction and adequately running tap water remove microorganisms effectively from one’s hands. Washing hands between procedures prevents transmission of microorganisms. The nurse should also put on protective garments such as gloves, gowns and face mask when handling the patient and change them before coming into contact with another patient. This would important in infection prevention (Gordon, 2014). 

The patient should be provided with a restful environment free of unnecessary disturbances. Resting decreases patient’s energy and oxygen consumption. The nurse should weigh the patient regularly on daily basis. Accurate body weight indicates fluid balance while increased weight is an indicator of fluid retention. Assessing the patient for apprehension and anxiety would help in techniques of managing anxiety and stress such as breathing exercise and music. These techniques reduce anxiety, heart rate and other cardiac complications (Gordon, 2014). 

Post-operatively, the nurse should not keep on turning the patient from lithotomy to horizontal and from lateral to supine positions and vice versa. Patient movement from one position to another worsens hypotension. The nurse is an advocate of patient’s safety, therefore he or she should properly secure restraints for IV therapy, appropriately position the patient, raise the side rails to prevent patient’s falls and eliminate any possible sources of accidents and injuries in patient’s room and other places used for patient care (Gordon, 2014). 

Members of  the Multidisciplinary Team (MDT)

Registered Nutritionist/Dietitian: He or she would help in provision of nutritional guidance and prescription to the patient based on his diagnosis. He can help in choosing diet with appropriate amount of fats, calories, proteins, vitamins, minerals necessary for treatment of the patient.

Social Worker: His or her role in patient care would be assisting and counselling the patient and his relatives regarding the health of the patient. He or she would also help in provision of resources concerning patient treatment, finance, support groups, home care and transportation assistance.

Psychologist: He or she would help in provision of psychological support and counselling to the patient. The patient is an alcoholic, the psychologist would help in enlightening the patient on impacts of alcohol on one’s health.

Conclusion:

Benign Prostatic Hyperplasia in men is associated with aging, hormonal changes, obesity, family history, diet and microscopic factors. Transurethral resection of the prostate (TURP) is most effective method of managing BPH. Post-operatively, a patient may develop hypotension, tachypnea, tachycardia, hypothermia and urinary incontinence based on surgical pre-operative and intra-operative techniques applied. Interdisciplinary healthcare team is important is patient care.

References:

Chughtai, B., Forde, J. C., Thomas, D. D., Laor, L., Hossack, T., Woo, H. H., & Kaplan, S. A. (2016). Benign prostatic hyperplasia. Nature Reviews Disease Primers, 46(2), 16031. doi:10.1038/nrdp.2016.31

Gordon, M. (2014). Manual of nursing diagnosis (13th ed.). Brownstown U.S.A.), MI: Jones & Bartlett Publishers.

Lee, M., & Sharifi, R. (2014). Benign prostatic hyperplasia. Pharmacotherapy: A pathophysiologic approach: (9th ed.). New York, NY: McGraw-Hill Medical.