2. The term BPH is a misnomer because the actual change is a hyperplasia & not hypertrophy.

4. PATHOPHYSIOLOGY serum levels of Luteinizing hormone, testosterone and luteinizing hormone – releasing hormone Pituitary gland stimulation to release of LH Testosterone production Combines with 5-alpha-reductase Dihydrotestosterone (DHT) formation Muscle contraction Restriction of urine flow Bladder outlet obstruction Detrusor muscle compensates Trabeculation and bladder diverticula occur bladder wall elasticity

6. May exhibit:Elevated BP (renal effects of advanced enlargement)

7. ELIMINATION

8. May report:Decreased force/caliber of urinary stream; dribbling

9. Hesitancy in initiating voiding

10. Inability to empty bladder completely; urgency and frequency of urination

11. Nocturia, dysuria, hematuria, Sitting to void

12. Recurrent UTIs, history of calculi (urinary stasis)

14. May exhibit:Firm mass in lower abdomen (distended bladder), bladder tenderness FOOD/FLUID May report:Anorexia; nausea, vomiting, Recent weight loss PAIN/DISCOMFORT May report:Suprapubic, flank, or back pain; sharp, intense (in acute prostatitis), Low back pain SAFETY May report:Fever

16. Fear of incontinence/dribbling during intimacy

17. Decrease in force of ejaculatory contractions

19. Use of antihypertensive or antidepressant medications, OTC cold/allergy medications containing sympathomimetics, urinary antibiotics or antibacterial agents

21. Weak stream

22. Prolonged micturition

23. Straining

24. Hesitancy

25. Intermittent stream

26. Feeling of incomplete bladder emptying

27. Irritative symptoms

28. Frequency

29. Nocturia

30. Urgency

31. Incontinence Systemic symptoms related to the UT: - Vesicoureteral reflux - Dilatation & hydronephrosis - Renal failure & symptoms of uremia Symptoms unrelated to the UT: - hernias, hemorrhoids and vesical calculus - change in the caliber of bowl movements Symptoms related to complications: - cystitis - pyelonephritis - bladder calculi - micro or gross hematuria.

33. Urinalysis & microscopic examination: to R/O infection or the presence of hematuria.

34. Serum U/E & creatinine: to provide baseline information on renal function & metabolic status.

35. Uroflowmetry: At a volume of 125-150ml, normal individuals have average flow rates of 12ml/sec & peak flow close to 20ml/sec.Mild 11-15 ml/sec Moderate  7 and  10 ml/sec Severe  7ml/sec

40. Vesicourethral reflux, hydroureter, hydronephrosis

41. Gross hematuria, urinary tract infection

42. Renal impairment

43. Bladder stones

44. Bladder damage (trabeculations, cellules, diverticula)

46. Assist with catheter introduction with guidewire or by way of suprapubic cystostomy as indicated.

47. Monitor intake and output

48. Maintain patency of catheter

49. Administer medications as ordered, and monitor for and teach patient about side effects.

50. Assess for and teach patient to report hematuria, signs of infectionPatient education and Health Maintenance NURSING DIAGNOSIS 1. Impaired Urinary Elimination related to obstruction of urethra. Rationale: BPH causes an enlargement that forms like a capsule in the urinary bladder that occludes urine flow causing changes in urinary elimination. The patient experiences manifestations such as frequency, urgency, hesitancy, change in stream, incontinence, retention and nocturia.

54. Monitor for bleeding

55. Prevent catheter dislodgment

56. Prevent Infection

57. Monitor for retention

59. Pharmacologic management

60. a-Adrenergic blockers such as doxazosin (Cardura), tamsulosin (FLomax), terazosin (Hytrin) – relax smooth muscle of bladder base and prostate to facilitate voiding.

61. 5 alpha reductase inhibitorFinasteride (Proscar) – antiandrogen effect on prostate cells, reverses or prevents hyperplasia

66. Assess ability to empty bladder

67. The bladder should be palpated for distention

68. If the client cannot void, a urethral catheter may have to be placed

69. Stop anticoagulants medications before the procedure

70. Assess clients knowledge about surgery and its outcomes

71. Provide health teaching to lessen clients fear and anxiety

73. Maintenance of urinary drainage

74. MIO

75. Document urine color

76. Proper positioning of the catheter and drainage system.

77. URINARY INCONTINECE Urinary incontinence is unintentional loss of urine that is sufficient enough in frequency and amount to cause physical and/or emotional distress in the person experiencing it. Women are affected by the disorder more frequently than are men; one in 10 women under age 65 suffer from urinary incontinence. Older Americans, too, are more prone to the condition. Twenty percent of Americans over age 65 are incontinent.

84. Stress test - the patient relaxes, then coughs vigorously as the doctor watches for loss of urine.

85. Urinalysis - urine is tested for evidence of infection, urinary stones, or other contributing causes.

86. Blood tests - blood is taken, sent to a laboratory, and examined for substances related to causes of incontinence.

87. Ultrasound - sound waves are used to visualize the kidneys, ureters, bladder, and urethra.

88. Cystoscopy - a thin tube with a tiny camera is inserted in the urethra and used to see the inside of the urethra and bladder.

90. Urinary tract infections.

91. Changes in your activities.

92. Changes in your work life.

94. 3. Situational low self-esteem related to functional impairment. Rationale: One’s self esteem is affected by the ability to function well and relate to others. Functional impairment such as Urinary incontinence could make a person becomes consciouson how pther people react

96. Tricyclic antidepressants (imipramine, doxepin)

97. Pseudoephedrine (Sudafed)

101. Bladder outlet reconstruction

102. Artificial urinary sphincter

103. Closure of the bladder outlet

105. Avoid caffeine and alcohol

106. Avoid drinking a lot of fluids in the evening

107. Regular voiding by the clock

108. Gradual increase in time between voids

110. Administer antibiotics, as ordered.

111. Monitor TPR every 4 hours and administer antipyretic drugs and antibiotics as prescribed

112. Analgesics PRN

113. Instruct patient to complete full prescription of antibiotic and have a follow up urine culture 2weeks after completion of antibiotic therapy.

114. Careful monitoring of renal function with proper adjustment of dosages depending on renal clearance

115. Unless contraindicated, liberal fluid intake up to 3 to 4 li/day.

117. diabetes mellitus

118. Lupus erythematosus

119. Amylodidosis

121. decreased levels of serum albumin (albumin < 3 g/dl -hypoalbuminemia),

122. severe edema,

123. elevated serum lipids (hyperlipidemia),

124. lipiduria,

126. When a clinician encounters a patient with the NS it is important for him to determine the underlying condition, because the course and prognosis will depend on the underlying diseaseNS

127. SECONDARY DISEASE ASSOCIATED WITH THE NEPHROTIC SYNDROME

128. NEPHROTIC SYNDROME GLOMERULAR DAMAGE Protein loss Reduced GFR Activation of the renein-angiotensin system Hypoalbuminemia Proteinuria Increased aldosterone Reduced blood oncotic pressure Hepatic lipoprotein synthesis Sodium/water retention Systemic edema Hyper-lipidemia Hyper-coaguability

129. SYMPTOMS AND SIGNS

131. At presentation, proteinuria is usually > 2 gm/m2/day, or a urine protein/creatinine ratio is > 2

132. Symptoms and signs include anorexia, malaise, puffy eyelids, retinal sheen, abdominal pain, wasting of muscles, and edema.

133. Focal edema may be the reason for seeking help for such complaints as:

134. difficulty breathing (pleural effusion or laryngeal edema),

135. substernal chest pain (pericardial effusion),

136. scrotal swelling,

137. swollen knees (hydroarthrosis),

138. swollen abdomen (ascites),

140. Orthostatic hypotension and even shock may develop in children.

141. Adults may be hypo-, normo-, or hypertensive.

143. The initial episode and the subsequent relapses may follow an apparent viral upper respiratory tract infection.

144. Edema is the predominant feature and initially develops around the eyes and lower extremities.

145. With time, the edema becomes generalized and may be associated with an increase in weight, the development of an ascitic or pleural effusion, and a decline in urine output.

147. Urinalysis

148. Blood analysis

150. urinary tract infection

151. Blood clots

152. High blood cholesterol and elevated blood triglycerides

153. Poor nutrition

154. High blood pressure

155. Acute kidney failure

157. Risk for Fluid Volume Deficit related to disease process

158. Risk for Infection Related to Altered Immune Response Secondary to Treatment

159. Potential Impairment of Skin Integrity related to Edema

161. Diuretics(edema)

162. ACE inhibitors( in combination with loop diuretics – Proteinuria), anti hypertensives

163. Glucocorticoids

164. Antineoplastic agents(cyclophosphamide-Cytoxan)

165. Immunosuppresants(cyclosporine- Neoral)

166. Low-sodium diet, liberal amounts of Potassium(no hyperkalemia)

168. Patient Education

169. Monitor Serum BUN and creatinine to assess renal function

170. Infuse IV albumin as ordered

171. Encourage Bed Rest for a few days to help mobilize edema; however some ambulation is necessary to reduce risk of thromboembolic complications

172. Fluid Restriction if edema is severe