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The term BPH is a misnomer because the actual change is a hyperplasia & not hypertrophy.
BPH becomes a disorder when enlargement obstructs the urinary channel and causes changes in the urinary tract with associated manifestations. </li></li></ul><li>The etiology of BPH is unclear.<br /><ul><li>Two factors necessary for BPH to occur are:</li></ul> (1) endocrine control (DHT)<br /> (2) aging<br /><ul><li>Hormonal Alteration: The relative roles of androgen & estrogen in inducing BPH, however , are complex & not completely understood.</li></ul>- Prostatic enlargement eventually occurs in 80% of men. By age 50, about 50% of men have some degree of BPH. <br />- Increased in African American men and is lower in Asians. <br />
Recurrent UTIs, history of calculi (urinary stasis)
Chronic constipation (protrusion of prostate into rectum) </li></li></ul><li>Cont. ASSESSMENT<br /><ul><li> Inguinal hernia; hemorrhoids (result of increased abdominal pressure required to empty bladder against resistance)
May exhibit:Firm mass in lower abdomen (distended bladder), bladder tenderness </li></ul>FOOD/FLUID <br /> May report:Anorexia; nausea, vomiting, Recent weight loss<br />PAIN/DISCOMFORT <br /> May report:Suprapubic, flank, or back pain; sharp, intense (in acute prostatitis), Low back pain <br />SAFETY <br /> May report:Fever <br />
Cont. ASSESSMENT<br />SEXUALITY <br /><ul><li>May report:Concerns about effects of condition/therapy on sexual abilities
Fear of incontinence/dribbling during intimacy
Incontinence </li></ul>Systemic symptoms related to the UT:<br /> - Vesicoureteral reflux<br /> - Dilatation & hydronephrosis<br /> - Renal failure & symptoms of uremia<br />Symptoms unrelated to the UT:<br /> - hernias, hemorrhoids and vesical calculus<br /> - change in the caliber of bowl movements<br />Symptoms related to complications:<br /> - cystitis<br /> - pyelonephritis<br /> - bladder calculi <br /> - micro or gross hematuria.<br />
DIAGNOSTICS<br /><ul><li>Digital Rectal Examination (DRE) – smooth, firm, symmetric enlargement of the prostate
Urinalysis & microscopic examination: to R/O infection or the presence of hematuria.
Serum U/E & creatinine: to provide baseline information on renal function & metabolic status.
Uroflowmetry: At a volume of 125-150ml, normal individuals have average flow rates of 12ml/sec & peak flow close to 20ml/sec.</li></ul>Mild 11-15 ml/sec<br /> Moderate 7 and 10 ml/sec<br /> Severe 7ml/sec<br />
<ul><li>Residual Urine: estimated by U/S or catheterizations. Volumes >150 ml are considered significant since they constitute approximately one-third of normal bladder volume
Serum Prostate-Specific Antigen (PSA) – to rule out cancer, but may also be elevated in BPH </li></ul>Optional diagnostics for further evaluation:<br /><ul><li>Urodynamics –measures peak urine flow rate, voiding time and volume, and status of the bladder’s ability to effectively contract.</li></li></ul><li><ul><li>Measurement of postvoid residual urine; by ultrasound or catheterization
Cystourethroscopy – to inspect urethra and bladder and evaluate prostatic size </li></li></ul><li>Ultrasonography:<br />In BPH, it is most useful for measuring bladder & prostate volume as well as residual urine.<br />Estimation of prostatic size is important because most urologists prefer to perform TURP for glands under 100g.<br />TRUS must be used as it is more accurate. <br />IVP:<br />For UTI & complications of BPH<br />
Administer medications as ordered, and monitor for and teach patient about side effects.
Assess for and teach patient to report hematuria, signs of infection</li></ul>Patient education and Health Maintenance<br />NURSING DIAGNOSIS<br />1. Impaired Urinary Elimination related to obstruction of urethra.<br />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.<br />
2. Acute Pain related to surgery and bladder spasms<br />Rationale: Bladder spasms frequently occur after prostate procedures, and incisional pain will occur if an open surgery is completed due to stimulating actions on nociceptors which are responsible for pain sensation. <br />Interventions: <br /><ul><li>Ensure that the drainage system is not blocked
Administer medications for relief of bladder spasms (Antispasmodic medications)</li></ul>-Belladonna and opium suppositories <br />-Propantheline bromide (Pro-Banthine) or immediate relase oxybutynin (Ditropan IR)<br /><ul><li>Have proper interventions for side effects of drugs </li></ul>Dry mouth, drowsiness, acute confusion in the older clients<br />Stool softeners such as docusate sodium (Colace) should be given for constipation since straining at stool can precipitate bleeding from the operative site.<br />
3.Risk for Injury related to presence of urinary catheters, hematuria, irrigation, or suprapubic drains <br />Rationale: Medical and surgical management for BPH require irrigation drainage such as urinary catheter. Blockage of an irrigated bladder is always possible in such situations that lead to overdistention, secondary hemorrhage, and formation of blood clots or infection. <br />Interventions:<br /><ul><li>Maintain irrigation
Manage temporary incontence</li></li></ul><li>INTERVENTIONS<br /><ul><li>Patients with mild symptoms (in the absence of significant bladder or renal impairment) are followed annually; BPH does not necessarily worsen in all men.
a-Adrenergic blockers such as doxazosin (Cardura), tamsulosin (FLomax), terazosin (Hytrin) – relax smooth muscle of bladder base and prostate to facilitate voiding.
5 alpha reductase inhibitor</li></ul>Finasteride (Proscar) – antiandrogen effect on prostate cells, reverses or prevents hyperplasia<br />
<ul><li>Surgery </li></ul>TURP, transurethral incision of the prostate (TUIP), or open prostatectomy for very large prostate, usually by suprapubic approach<br />Newer approaches – laser surgery, transurethral electrovaporization, transurethral needle ablation, insertion of intraurethral stents, hyperthermia, and thermotherapy.<br />
Proper positioning of the catheter and drainage system. </li></ul> <br /> <br />
URINARY INCONTINECE<br />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.<br />Women are affected by the disorder more frequently than are men; one in 10 women under age 65 suffer from urinary incontinence. <br />Older Americans, too, are more prone to the condition. Twenty percent of Americans over age 65 are incontinent.<br />
Changes in your personal life.</li></li></ul><li>NURSING DIAGNOSIS<br />1. Acute Pain<br />May be related to: Increased frequency/force of ureteral contractions,Tissue trauma, edema formation; cellular ischemia <br />2. Impaired Urinary Elimination related to uninhibited bladder contraction<br />Rationale: Uninhibited bladder contraction as a result of insufficient bladder control causes unannounced need to void. This inability of a person to delay voiding cause a disturbance in thr normal pattern of his/her urinary elimination.<br />
3. Situational low self-esteem related to functional impairment.<br />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<br />
INTERVENTIONS<br />A. Medical management: <br /><ul><li>Anticholinergics (oxybutynin, dicyclomine)
Instruct patient to complete full prescription of antibiotic and have a follow up urine culture 2weeks after completion of antibiotic therapy.
Careful monitoring of renal function with proper adjustment of dosages depending on renal clearance
Unless contraindicated, liberal fluid intake up to 3 to 4 li/day.
Establish Realistic Endpoints based on Improvement of Symptoms versus Cure </li></li></ul><li>NEPHROTIC SYNDROME<br /><ul><li>Is a set of clinical manifestations caused by protein wasting secondary to diffuse glomerular damage.</li></li></ul><li>ETIOLOGY<br /><ul><li>Nephrotic syndrome is a protein wasting disease</li></ul>Caused by:<br /><ul><li>glomerulonephritis
Carcinoma</li></li></ul><li>The nephrotic syndrome is a clinical complex characterized by a number of renal and extra renal features the most prominent of which are:<br /><ul><li>heavy proteinuria(in practice >3.0 to 3.5 g/1.73 m2 per 24 hours), which leads to hypoproteinemia
decreased levels of serum albumin (albumin < 3 g/dl -hypoalbuminemia),
and hypercoagulability</li></li></ul><li>NEPHROTIC SYNDROME<br /><ul><li>It is important to realize that the NS is not a disease; it is a syndrome caused by many different renal diseases
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 disease</li></ul>NS<br />
SECONDARY DISEASE ASSOCIATED WITH THE NEPHROTIC SYNDROME <br />
and (in children) abdominal pain from edema of the mesentery. </li></li></ul><li>SIGNS AND SYMPTOMS<br /><ul><li>Most often, the edema is mobile - detected in the eyelids in the morning and in the ankles after ambulation.
Orthostatic hypotension and even shock may develop in children.
Adults may be hypo-, normo-, or hypertensive.
Oliguria and even acute renal failure may develop because of hypovolemia and diminished perfusion.</li></li></ul><li>PHYSICAL: <br /><ul><li>Patients present with increasing edema over a few days or weeks, lethargy, poor appetite, weakness, and occasional abdominal pain.
The initial episode and the subsequent relapses may follow an apparent viral upper respiratory tract infection.
Edema is the predominant feature and initially develops around the eyes and lower extremities.
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.
Hematuria and hypertension are unusual but manifest in a minority of patients.</li></li></ul><li>Diagnostics:<br /><ul><li>Complete medical history and physical examination
High Protein Diet</li></li></ul><li>References:<br />SMELTZER, BARE, ET.AL<br />BRUNNER AND SUDDARTH’S MEDICAL-SURGICAL NURSING, VOLUME 2 , 2008, 11th edition , PP. 1520-1525, 1578-1581, 1751-1573<br />PORTH,PATHOPHYSIOLOGY-Concepts of Ltered Health States, 2002, 6th Ed, pp.768, 805-809,977-979<br />Joyce M Black,Medical Surgical Nursing, 2002 ,6th Edition,pp.805-806, 856-867<br />Langford & Thompson,Handbook of Diseases,3rd Edition,pp.674-676<br />Gulanick, Myers, Nursing Care Plans,2007, 6th Ed. pp.75-77, 974<br />Doenges, et al., Nursing Care Plans, 2006, 7th Ed. pp.541-620<br />http://www. en.wikipedia.org/wiki/Urinary_system <br />http://www . kidney.niddk.nih.gov/kudiseases/pubs/utiadult <br />http://www. emedicinehealth.com/urinary_tract_infections/article_em.htm <br />http://www. lab.anhb.uwa.edu.au/mb140/CorePages/Urinary/urinary.htm <br />http://www. answers.com/topic/urinary-system <br />http://www. faqs.org/health/Body-by-Design-V2/The-Urinary-System.html <br />"View a negative experience in your life like you'd look at a photo negative. A single negative can create an unlimited number of positive prints."<br />