NSG626 Systems Thinking For Quality Care

Introduction 

The fundamental objective of the paper is to present a case study based on an elderly patient who was suffering from a serious health issue. Acinar adenocarcinoma of prostate leading to radical retropubic prostatectomy has been chosen as a health issue as I work in urology surgical ward and radical prostatectomy is determined to be a main surgical process on my ward. This particular case study will describe the health condition of a 64-year old male Bobby Bob, who was suffering from acinar adenocarcinoma of the prostate base on his Gleason grade 4+5 on his latest transperineal prostate biopsy. Acinar adenocarcinoma of the prostate is regarded as a common malignancy, especially in the developing world (Hashmi et al., 2019). It is a histological sub-category of the gland that generates cancer which is identified when columnar and cuboidal shaped malignant cells within the neoplastic tissue develop tubules and acini. It is regarded as a usual form of cancer that occurs in the prostate gland and lung. Australia deals with an incidence of prostate cancer of 100 per 100,000 individuals every year, which is common among men (Divatia & Ro, 2016).

As a result, this disease is determined to be the most common form of cancer among Australian men. Moreover, this particular patient was chosen as he is 64-years of age, and the risk of this cancer is low below 50 years of age and increases after this age. However, Bobby Boob was admitted to the urology surgical ward for the surgical management of acinar adenocarcinoma of the prostate gland. He underwent radical open retropubic prostatectomy.

Health condition 

While assisting patients in urology surgical ward, I met with a 64-year old male patient who was admitted within the hospital as he was diagnosed with acinar adenocarcinoma of the prostate that resulted in radical retropubic prostatectomy. Bob was admitted in the surgical ward for the surgical management of acinar adenocarcinoma of the prostate gland. He underwent radical pubic prostatectomy where his postoperative recovery was successful with fewer complications as expected. In 2016 most of the time, he experienced painful urination and urinary frequency. To overcome this health issue, he referred to his general practitioner, who in turn referred Bob to a urologist. Since 2016, Bob was under active surveillance and went through regular transperineal prostate biopsies. In 2016 and 2017 he underwent last two biopsies that showed Gleason grade 3+3 and 3+4 which was previously 4+5. In 2018 he also went overseas and missed his regular biopsy. During the initial period of this year, he also experienced a painful micturition and went back to the urology clinic for a checkup. He also has a history of gastro-oesophageal reflux, hypertension and GOUT. He is not used to taking medications on a regular basis.

Moreover, based on the anatomy of the prostate gland prostate is considered to be a semioval bilobular exocrine gland which is a part of the male reproductive system that develops dorsal contact with ventral and rectum with the pubic symphysis which is lateral with the cranial and abdominal wall with the bladder (Tregnago & Epstein, 2018). However, in the case of Bob, I noticed that the thin layer of connective tissue had separated the seminal vesicles and prostate from the rectum due to which he is suffering from acinar adenocarcinoma of the prostate. As he undergoes the anatomic technique of radical prostatectomy, he is needed to use pads as he experiences urinary inconsistency.

On the other hand, based on the concept of the physiology of prostate gland, it is seen that prostate is responsible for the development of most of the seminal plasma that consists of the huge amount of proteins. One of the most common forms of proteins in human is created by both canine and human prostatic epithelia which is determined to be a prostate-specific antigen (Arista-Nasr, Martinez-Benitez, Mijangos-Trejo, Bornstein-Quevedo & Albores-Saavedra, 2017). In the case of Bob, I noticed that this protein is not secreted within the lumen of the prostate ducts. Under such psychological conditions, this protein is not able to come in contact with the bloodstream in a prostate. However, the protein cannot be found in his blood that resulted in the prostatic disease. It is also noticed that due to acinar adenocarcinoma of prostate Bob also experienced a new onset of erectile dysfunction, blood in the semen as well as in the urine. However, the cancer is identified because of abnormal PSA levels along with abnormal digital rectal examination (Yassaie et al., 2016).  

The molecular pathology related to the prostate gland is difficult where multiple genes are involved within the pathogenesis. There occur pathophysiological changes in environmental factors like inflammation and diet (Xiaojun et al., 2018). However, in the case of Bob, it has been noticed that he faced certain genetic changes that lead to the initiation, progression and development of acinar adenocarcinoma of the prostate. Meanwhile, due to the occurrence of acinar adenocarcinoma of prostate Bob had to face chromosomal abnormalities together with the putative genes involved within the chromosomal sites. In other words, it can be said that Bob experienced a chromosomal loss due to radical retropubic prostatectomy. Moreover, the preference of axial skeletal metastases is regarded as a significant reason for cord compression and changes in muscle strength (NCI Dictionary of Cancer Terms., 2019).

Treatment 

The management of patients who develops acinar adenocarcinoma of the prostate at an initial stage demonstrates a major challenge for healthcare professionals. Based on the fundamental needs that allow for early intervention in high-risk patients involves the availability of active systemic therapeutic modalities and significant prognostic factors for patients with advanced disease (Cordeiro-Rudnisky, Sun & Saade, 2019). Depending upon the health condition of Bob, the goal of treatment is to cure acinar adenocarcinoma of the prostate, which is followed by radical retropubic prostatectomy. The major goal is to remove the entire prostate and the prostate cancer cells that are present inside. For men with clinically localized prostate cancer, the most common treatment option includes radical prostatectomy. However, an individual above the age of 60-years old who indicates a nonpalpable tumor, an adenocarcinoma with a Gleason score of 8 and serum PSA level prefers radical prostatectomy as compared to other therapies. This particular treatment option is chosen for Bob as he falls under the category mentioned above. As per the reports, the patients who undergo this surgery gains a life expectancy of 12.3 years if the prostate cancer gets cured (Hahn, Liu, Vesprini, Xu & Downes, 2018). It is also observed that this particular surgery help patients to gain a survival advantage without a reduction in quality of life and greater complications. This treatment option is discussed below in more detail:

Radical retropubic prostatectomy surgery

For acinar adenocarcinoma of the prostate, the main type of surgery is Radical prostatectomy surgery (Surgery: radical prostatectomy., 2019). In this operation, the surgeon takes out the whole prostate gland along with the tissues that involve seminal vesicles (Wobker & Epstein, 2016). It is regarded as an open surgery where the surgeon makes an incision in the lower abdomen of the patient from the belly button to the pubic bone. During the surgery, the removed prostate is examined under a microscope to observe whether cancer has reached the edge of the prostate. There possess two bundles of the prostate gland that are linked with the prostate that helps a patient to get erections. However, during the surgery, the surgeon tries to protect these nerves, which is known as nerve-sparing surgery. Moreover, if the surgeon believes that cancer might spread to the nerves, there is a need to take out one or both of these bundles. This will result in problems receiving an erection without any medical support (Paner et al., 2016). It is also noticed that radical prostatectomy creates a huge impact on reducing cancer-specific mortality among men who experiences high-grade prostate cancers. Generally, this surgery includes a minimum of 4-8 days of hospital stay. After the operation, a urinary catheter along with a urine bag, is attached in place for two weeks.

This is determined to be a primary treatment option for Bob due to significant advantages such as morbidity of treatment, ability to cure the disease, natural history of the prostate cancer along with life and age expectancy. All these advantages are regarded as an evidence-based approach that proves to be beneficial for the patients (Morais, Lobo, Barreto, Lobo & Gonçalves, 2019). The aspect of metastases disease like extension and huge local involvement into the bladder and virtual replacement of the vertebral body is closely related to anatomic proximity to the nerve root. This will help Bob to overcome with urinary frequency and painful urination. Apart from this surgery, there is a need to implement local palliative measures (Luciani et al., 2017). Significantly, the constellation of symptoms and signs of Bob underscored the significant requirements to choose this surgery that will result in a rapid decrease in the serum testosterone. It will also help in enabling the prompt control of acinar adenocarcinoma of prostate experienced by Bob. Therefore, Bob was treated with a gonadotropin-releasing hormone antagonist, namely abarelix. In other words, it can be said that Bob has been treated with a short course of hormone treatment.

The significant role of Radical retropubic prostatectomy surgery in treating patient’s disease is focused on controlling local obstructive problems and is primarily regarded as palliative (Baum & Nanni, 2017). However, after a 2-month of treatment with abarelix, Bob experienced a huge amount of improvement of his urological symptoms related to acinar adenocarcinoma of the prostate. In order to provide relief of obstruction and improve local control which is a course of a palliative external beam of radiation that was administered to Bob. Over eight weeks that possesses 3-dimensional conformal surgery where a total of 40 treatments were conducted.

In the case of Bob, he underwent tests within the hospital a week before the surgery took place to ensure that he is fit enough for the operation. He has been instructed to do pelvic floor muscle exercises for a few of the weeks before the surgery. This was done to help him to recover rapidly from urinary issues caused due to the operation (McDougal, Wein, Kavoussi, Partin & Peters, 2015). He was also instructed to stop taking some of the drugs that he was taking earlier before the operation. It helps the patients to get organized to make life easier after leaving the hospital. Before this surgery, the patients are also not allowed to lift heavyweight and needs complete rest. In the case of Bob, he has been given anaesthesia at the time of the operation. The prostate gland of Bob has been removed along with few of the lymph nodes. However, after the surgery, Bob experienced certain changes in his bowel habits that took a few weeks to get back to a normal state. After the surgery, the patients do not have bowel movements for several days that are caused due to the intake of painkillers. After the treatment, Bob was given instructions to eat high fibre foods like fruit and whole grains, drink a lot of fluids and exercise physical activity. The prostate gland of Bob has been removed along with few of the lymph nodes. It is analyzed that radical prostatectomy possesses less risk in comparison with other treatment options.

Follow-up treatment after radical retropubic prostatectomy

After the surgery, a follow-up at six months presented a healthy-looking patient with PSA level ? 0.1 ng/mL. Bob was continued with routine blood evaluations and serial physical exams that involve serums PSA considerations at regular intervals in every 2-3 months. To reduce the impact of radical retropubic prostatectomy, a radiological assessment was conducted in every 6 to 12 months (Prostate Cancer – 2nd Edition., 2019). However, less than 10% of male patients face complications after prostatectomy, and usually, these are short-term and treatable. It is seen that if the cancer is cancer is completely present within the prostate, then the operation will take out all of the cancer. This will give a clear idea to the healthcare professionals of whether the cancer was completely taken out at the time of surgery. However, there comprise of certain risk associated with this particular surgery such as inconsistency in urination or urinary leak, erectile dysfunction, infection, blood clots, groin hernia, blocking urine flow and bleeding after the operation (Gomella & Kundavaram, 2016).

Meanwhile, the process of prostatectomy is complex; it helps in detecting the recurrence of the disease. At the time of follow-up, an identifiable PSA presents a biochemical recurrence of prostate cancer (Spector, Brooks, Strigenz & Brown, 2016). Thus it is significant to implement strategies for disease management and assessment. In the case of Bob, the follow-up strategy has been implemented after the operation that enabled the recognition of biochemical recurrence. On the other hand, a robust and efficient follow-up strategy has been adopted to help Bob to overcome this disease. It is seen that the contemporary guidelines help in outlining whether the disease is highly conflicting or heterogeneous (van Poppel, Everaerts, Tosco & Joniau, 2019). Hence, while assisting Bob, I implemented a protocol-based follow-up scheme to enhance the expeditious recognition of the disease. As a result, the follow-up that has been undertaken after the surgery helped Bob to acknowledge whether his health condition is improved or not. He also learned various ways to take care of him without facing any complications.

Conclusion 

The paper demonstrated an understanding of one of the significant health issue that is acinar adenocarcinoma of the prostate. Based on this health issue, it provided a case study where Bobby Bob, a 64-year old male, was suffering from this disease. However, the occurrence of this disease led to radical retropubic prostatectomy. Due to the appearance of this disease, Bob has to deal with painful urination and urinary frequency. Furthermore, the paper provided a brief description of his health condition related to this particular disease. It demonstrated Bob’s health condition with the help of anatomical, physiological and pathophysiological concepts that are impacted by the disease process.

However, it is analyzed that to address this disease; radical retropubic prostatectomy is determined to be the better treatment option as compared to other therapies or surgeries. It is determined to be the most commonly utilized curative measures for treating the localized acinar adenocarcinoma of the prostate. The goal of this treatment option is to remove prostate along with cancer cells present inside it. The treatment aims to enhance the quality of life of the patients who are suffering from prostate cancer. However, this particular treatment option is relevant for Bob as it can be applied to the individuals who are above 60 years of age and suffers from adenocarcinoma. As a result, it helped Bob to recover from this disease, although he has to face urinary inconsistency for a few days after the surgery. It is seen that radical retropubic prostatectomy surgery possess low risk as well as more effective as compared to other surgeries or therapies. Thus, this particular treatment option also helped Bob to recover from acinar adenocarcinoma of prostate without facing many complications.

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