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Nursing Care Plan | NCP Benign Prostatic Hyperplasia

Benign prostatic hyperplasia (BPH; excessive proliferation of normal cells in normal organs) or hypertrophy (an increase in size of an organ), one of the most common disorders of older men, is a nonmalignant enlargement of the prostate gland. It is the most common cause of obstruction of urine flow in men and results in more than 4.5 million visits to healthcare providers annually in the United States. The degree of enlargement determines whether or not bladder outflow obstruction occurs. As the urethra becomes obstructed, the muscle inside the bladder hypertrophies in an attempt to assist the bladder to force out the urine. Benign prostatic hyperplasia may also cause the formation of a bladder diverticulum that remains full of urine when the patient empties the bladder.

As the obstruction progresses, the bladder wall becomes thickened and irritable, and as it hypertrophies, it increases its own contractile force, leading to sensitivity even with small volumes of urine. Ultimately, the bladder gradually weakens and loses the ability to empty completely, leading to increased residual urine volume and urinary retention. With marked bladder distension, overflow incontinence may occur with any increase in intra-abdominal pressure such as that which occurs with coughing and sneezing. Complications of Benign prostatic hyperplasia include urinary stasis, urinary tract infection, renal calculi, overflow incontinence, hypertrophy of the bladder muscle, acute renal failure, hydronephrosis, and even chronic renal failure.

Because the condition occurs in older men, changes in hormone balances have been associated with the cause. Androgens (testosterone) and estrogen appear to contribute to the hyperplastic changes that occur. Other theories, such as those involving diet, heredity, race, and history of chronic inflammation, have been associated with Benign prostatic hyperplasia, but no definitive links have been made with these potential contributing factors.

Nursing care plan assessment and examination
Generally, men with suspected Benign prostatic hyperplasia have a history of frequent urination, nocturia, straining to urinate, weak stream, and an incomplete emptying of the bladder. Distinguish between these obstructive symptoms and irritative symptoms such as dysuria, frequency, and urgency, which may indicate an infection or inflammatory process. A “voiding diary” can also be obtained to determine the frequency and nature of the complaints. The International Prostate Symptom Score (IPSS) has been adopted worldwide and provides information regarding symptoms and response to treatment
Nursing care plan
Inspect and palpate the bladder for distension. A digital rectal exam (DRE) reveals a rubbery enlargement of the prostate, but the degree of enlargement does not consistently correlate with the degree of urinary obstruction. Some men have enlarged prostates that extend out into soft tissue without compressing the urethra. Determine the amount of pain and discomfort that is associated with the DRE.

The patient who is experiencingBenign prostatic hyperplasia may voice concerns related to sexual functioning after treatment. The patient’s degree of anxiety, as well as his ability to cope with the potential alterations in sexual function (a possible cessation of intercourse for several weeks, possibility of sterility or retrograde ejaculation) should also be determined to provide appropriate follow-up care.

Nursing care plan primary nursing diagnosis: Urinary retention (acute or chronic) related to bladder obstruction.

Nursing care plan treatment and intervention
Those patients with the most severe cases, in which there is total urinary obstruction, chronic urinary retention, and recurrent urinary tract infection, usually require surgery. Transurethral resection of the prostate (TURP) is the most common surgical intervention. The procedure is performed by inserting a resectoscope through the urethra. Hypertrophic tissue is cut away, thereby relieving pressure on the urethra. Prostatectomy can be performed, in which the portion of the prostate gland causing the obstruction is removed. The relatively newer surgical procedure called TUIP involves making an incision in the portion of the prostate attached to the bladder. The gland is split, reducing pressure on the urethra. TUIP is more helpful in men with smaller prostate glands that cause obstruction.

Other minimally invasive treatments for Benign prostatic hyperplasia rely on heat to cause destruction of the prostate gland. The heat is delivered in a controlled fashion through a urinary catheter or a transrectal route, has the potential to reduce the complications associated with TURP, and has a lower anesthetic risk for the patient. Minimally invasive procedures include heat from laser energy, microwaves, radiofrequency energy, high-intensity ultrasound waves, and high-voltage electrical energy.

Postsurgical care involves supportive care and maintenance of the indwelling catheter to ensure patency and adequacy of irrigation. Belladonna and opium suppositories may relieve bladder spasms. Stool softeners are used to prevent straining during defecation after surgery. Ongoing monitoring of the drainage from the catheter determines the color, consistency, and amount of urine flow. The urine should be clear yellow or slightly pink in color. If the patient develops frank hematuria or an abrupt change in urinary output, the surgeon should be notified immediately. The most critical complications that can occur are septic or hemorrhagic
shock.

In patients who are not candidates for surgery, a permanent indwelling catheter is inserted. If the catheter cannot be placed in the urethra because of obstruction, the patient may need a suprapubic cystostomy. Conservative therapy also includes prostatic massage, warm sitz baths, and a short-term fluid restriction to prevent bladder distension. Regular ejaculation may help decrease congestion of the prostate gland.

Patients with severe alterations in urinary elimination may require a catheter to assist with emptying the bladder. Never force a urinary catheter into the urethra. If there is resistance during insertion, stop the catheterization procedure and notify the physician. Monitor the patient for bleeding and discomfort during insertion. In addition, assess the patient for signs of shock from postobstruction diuresis after catheter insertion. Ensure adequate fluid balance. Encourage the patient to drink at least 2 L of fluid per day to prevent stasis and infection from a decreased intake. Encourage the patient to avoid the following medications, which may worsen the symptoms: anticholinergics, decongestants (over-the-counter and prescribed), tranquilizers, alcohol, and antidepressants.

Evaluate the patient’s and partner’s feelings about the risk for sexual dysfunction. Retrograde ejaculation or sterility may occur after surgery. Explain alternative sexual practices, and answer the patient’s questions. Some patients would prefer to talk to a person of the same gender when discussing sexual matters. Provide supportive care of the patient and significant others, and
make referrals for sexual counseling if appropriate.

Nursing care plan discharge and home health care guidelines
Instruct patients about the need to maintain a high fluid intake (at least 2 L/day) to ensure adequate urine output. Teach the patient to monitor urinary output for 4 to 6 weeks after surgery to ensure adequacy in volume of elimination combined with a decrease in volume of retention.

Provide instructions about all medications used to relax the smooth muscles of the bladder or to shrink the prostate gland. Provide instructions on the correct dosage, route, action, side effects, and potential drug interactions and when to notify these to the physician.

Instruct the patient to report any difficulties with urination to the physician immediately. Explain that BPH can recur and that he should notify the physician if symptoms of urgency, frequency, difficulty initiating stream, retention, nocturia, or bladder distension recur.

Encourage the patient to discuss any sexual concerns he or his partner may have after surgery with the appropriate counselors. Reassure the patient that a session can be set up by the nurse or physician whenever one is indicated. Usually, the physician recommends that the patient have no sexual intercourse or masturbation for several weeks after invasive procedures.
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