Prostate cancer is the most common type of cancer in men and the second leading cause of death among men in the United States. The American Cancer Society estimated that, in 2005, there would be 232,090 new cases and 30,350 men would die from prostate cancer. Overall, 1 in 6 men are diagnosed with prostate cancer and 1 in 33 die from this disease. The 5-year survival rate is 99%. Prostate cancer may begin with a condition called prostatic intraepithelial neoplasia (PIN), which can develop in men in their 20s. In this condition, there are microscopic changes in the size and shape of the prostate gland cells. The more abnormal the cells look, the more likely that cancer is present. It has been noted that 50% of men have PIN by the time they are 50 years old.
Adenocarcinomas compose 99% of the prostate cancers. They most frequently begin in the outer portion of the posterior lobe in the glandular cells of the prostate gland. Local spread occurs to the seminal vesicles, bladder, and peritoneum. Prostate cancer metastasizes to other sites via the hematologic and lymphatic systems, following a fairly predictable pattern. The pelvic and perivesicular lymph nodes and bones of the pelvis, sacrum, and lumbar spine are usually the first areas to be affected. Metastasis to other organs usually occurs late in the course of the disease, with the lungs, liver, and kidneys being most frequently involved.
Although the recommendation is controversial, the American Cancer Society now advises screening for prostate cancer in asymptomatic men beginning at age 40. American Cancer Society guidelines include an annual digital rectal examination beginning at age 40 and annual serum prostate-specific antigen (PSA) testing beginning at age 50.
The cause of prostate cancer remains unclear, but age, viruses, family history, diet, and androgens are thought to have contributing roles. Men who have an affected first- and second-degree relative have an eightfold increased risk of developing prostate cancer. A high-fat diet may alter the production of sex hormones and growth factors, increasing the risk of prostate cancer. Environmental exposure to cadmium (an element found in cigarettes and alkaline batteries) is also considered a risk factor.
Nursing care plan assessment and physical examination
Ask about family history of prostate cancer, an occupational exposure to cadmium, and the usual urinary pattern. A patient may report symptoms such as urinary urgency, frequency, nocturia, dysuria, slow urinary stream, impotence, or hematuria if the disease has spread beyond the periphery of the prostate gland or if benign prostatic hypertrophy is also present. Presenting symptoms that include weight loss, back pain, anemia, and shortness of breath are often indicative of advanced or metastatic disease.
Most men with early-stage prostate cancer are asymptomatic. The physician palpates the prostate gland via a digital rectal examination. A normal prostate gland feels soft, smooth, and rubbery. Early-stage prostate cancer may present as a nonraised, firm lesion with a sharp edge. An advanced lesion is often hard and stonelike with irregular borders. A suspicious prostatic mass is further evaluated by extending the examination to the groin to look for the presence of enlarged or tender lymph nodes.
Men have reported not having a rectal exam because of embarrassment. In addition, treatment for prostate cancer can be accompanied by distressful side effects, such as sexual dysfunction and urinary incontinence. Assess the patient’s knowledge and feelings related to these issues and the presence of support systems. Note the coping strategies the patient has used in the past to manage stressors. Include the patient’s spouse or significant other in conversations.
Nursing care plan primary nursing diagnosis: Pain (chronic bone) related to metastatic spread of disease.
Nursing care plan intervention and treatment plan
Periodic observation, or “watchful waiting,” may be proposed to a patient with early-stage, less-aggressive prostate cancer. With this option, no specific treatment is given, but the progression of the disease is monitored via periodic diagnostic tests.
Radical prostatectomy has been the recommended treatment option for men with middle-stage disease because of high cure rates. This procedure removes the entire prostate gland, including the prostatic capsule, the seminal vesicles, and a portion of the bladder neck. Two common side effects of prostatectomy are urinary incontinence and impotence. The urinary incontinence usually resolves with time and after performing Kegel exercises, although 10% to 15% of men continue to experience incontinence 6 months after surgery. Impotence occurs in 85% to 90% of patients. All men who undergo radical prostatectomy lack emission and ejaculation because of the removal of the seminal vesicles and transection of the vas deferens. Newer surgical techniques (nerve-sparing prostatectomy) preserves continence in most men, and erectile function in selected cases.
Transurethral resection of the prostate (TURP) may be recommended for men with more advanced disease, especially if it is accompanied by symptoms of bladder outlet obstruction. This procedure is not a curative surgical technique for prostate cancer but does remove excess prostatic tissue that is obstructing the flow of urine through the urethra. The incidence of impotence following TURP is rare, although retrograde ejaculation (passage of seminal fluid back into the bladder) almost always occurs because of the destruction of the internal bladder sphincter during the procedure. Many men equate ejaculation with normal sexual functioning, and to some the loss of the ejaculatory sensation may be confused with the loss of sexual interest or potency. Also, a bilateral orchiectomy may be done to eliminate the source of the androgens since 85% of prostatic cancer is related to androgens.
All patients return from surgery with a large-lumen three-way Foley catheter. The large lumen of the catheter and the large volume in the balloon (30 mL) help splint the urethral anastomosis and maintain hemostasis. Blood-tinged urine is common for several days after surgery, but dark red urine may indicate hemorrhage. If continuous urinary drainage is used, maintain the flow rate to keep the urine light pink to yellow in color and free from clots, but avoid overdistension of the bladder.
Antispasmodics may be ordered for bladder spasms. Anticholinergic and antispasmodic drugs may also be prescribed to help relieve urinary incontinence after the Foley catheter is removed. Because of the close proximity of the rectum and the operative site, trauma to the rectum should be avoided as a means of preventing hemorrhage. Stool softeners and a low-residue diet are usually ordered to limit straining with a bowel movement. Rectal tubes, enemas, and rectal thermometers should not be used.
Both external beam radiotherapy and internal implant (brachytherapy) are used in the treatment of prostate cancer. Radiation therapy is also used in areas of bone metastasis. The goal in extensive disease is palliation: Reduce the size of the prostate gland and relieve bone pain. Brachytherapy involving the permanent (iodine-125 or gold-198) or temporary (iridium- 192) placement of radioactive isotopes can be used alone or in combination with external radiation therapy. Patients who receive permanently placed radioisotopes are hospitalized for as long as the radiation source is considered a danger to persons around them. The principles of time, distance, and shielding need to be implemented. Care needs to be exerted so that the radioisotope does not become dislodged. Dressings and bed linens need to be checked by the radiation therapy department before these items are removed from the patient’s room.
Dispel misconceptions, and explain all diagnostic procedures. Patients with early-stage disease need support while they make decisions about treatment options. Encourage the patient and his partner to verbalize their feelings and fears. Clarify the differences between the various treatment options and reinforce the treatment goals. Provide written materials, such as Facts on Prostate Cancer published by the American Cancer Society or What You Need to Know about Prostate Cancer published by the National Cancer Institute. Suggest that the patient write down questions that arise so they are not forgotten during visits with the physician.
Ask about pain regularly, and assess pain systematically. Believe the patient and family in their reports of pain. Inform the patient and family of options for pain relief as proposed by the National Cancer Institute (pharmacologic, physical, psychosocial, and cognitive-behavioral interventions), and involve the patient and family in determining pain relief measures.
Implement postoperative strategies to decrease complications. Patients are usually able to ambulate on the first day after surgery. Help the patient to get out of bed and walk in the halls to his tolerance level, usually three or four times a day. Once nausea has passed, bowel sounds are present, and fluids are allowed, encourage a fluid intake of 2500 to 3000 mL/day to maintain good urine output. Adequate fluid intake, and thus output, minimizes the formation of blood clots in the urinary bladder that can obstruct the Foley catheter.
Be alert for behavior indicating denial, grief, hostility, or depression. Inform the physician of any ineffective coping behaviors and the patient’s need for more information or a referral for counseling. Postoperative incontinence and impotence may be difficult for patients to discuss. Inform patients of exercises, medications and products that can assist with incontinence. Suggest alternative sexual behaviors, such as touching and caressing. Patients who are undergoing orchiectomy need extensive emotional support. Establish a therapeutic relationship to promote the expression of feelings. Be sensitive to the patient’s fear of his loss of masculinity. Reinforce that having the testes removed in adulthood does not affect the ability to have an erection and orgasm.
Stress to patients who are hospitalized for insertion of a radioactive implant that, while the temporary implant is in place, interactions with nurses and other individuals occur only during brief time periods. Attempt to relieve feelings of abandonment and isolation by communicating with the patient via the hospital intercom system. Once the temporary implant has been removed or the permanent radioactive substance has decayed, remind the patient that he is no longer a danger to others.
Nursing care plan discharge and home health care guidelines
Provide the following instructions to patients who have undergone a radical
prostatectomy: Perform Kegel exercises to enhance sphincter control after the Foley catheter is removed. Establish a voiding pattern of every 2 hours during the day and every 4 hours during the night. With each voiding, contract the pelvic muscles to start and stop urinary flow several times. Contract the pelvic floor muscles and the muscle around the anus as though to stop a bowel movement 10 to 20 times, four times each day. Maintain an oral fluid intake of 2000 to 3000 mL/day. Avoid alcoholic and caffeinated beverages. Eat high-fiber foods and take stool softeners to prevent constipation. Avoid straining with bowel movements and do not use suppositories and enemas. Avoid strenuous exercise, heavy lifting, and driving an automobile until the physician allows. Avoid sitting with the legs in a dependent position for 3 to 4 weeks, and avoid sexual intercourse for 6 weeks.
Instruct the patient to do the following: Wash the skin gently with mild soap, rinse with warm water, and pat dry daily. Leave (not wash off) the dark ink markings that outline the radiation field. Avoid applying any lotions, perfumes, deodorants, or powder to the treatment area. Wear soft, nonrestrictive cotton clothing directly over the treatment area. Protect the skin from sunlight and extreme cold.
Instruct the patient to observe for lost seeds in bed linens. Teach the patient to use tweezers to place lost seeds in aluminum foil, wrap them tightly, and take them to the radiation oncology department at the hospital. Teach the patient to call the physician if he experiences a temperature over 100°F, burning or difficulty with urination, excessive bleeding or clots in urine, or rectal bleeding. Teach the patient when to see the physician for follow-up care and to watch for any sign of recurrent disease.