Chapter 59: Prostatic Cancer/BPH (TURP)

Pelvic Lymph Node Dissection (PLND) p. 3922

1.

Transurethral Resection Syndrome S&S p. 3925

1.

Patient Teaching Perineal Exercises & post op p. 3935

1. 10 to 20 times each hour sitting/standing (Tense perineal muscles, press buttocks together) 2. Interrupt urinary stream for a few seconds -Urinate as soon as they feel the urge -dribbling is expected and diminished within a year -Urine may be cloudy for several weeks after surgery but clears as the prostate heals (6 to 8wks) *avoid valsalva activities which incr venous pressure -> hematuria. Avoid long sitting (car trips), spicy foods, alcohol and coffee cause bladder discomfort. Fluids help decr blood cot formation which obstructs urine flow. -Report to HCP complications: bleeding, passage of clots, dec urinary stream, urinary retention, UTI symptoms. [At Home Chart 59-5]

Prostate Cancer Risks p. 3911

1. AA men at highest risk. 2. Age>50 3. Fam HXY 4. Diet high in red Meat/Dairy/Fat 5. Hormones androgens & estrogens

BPH physiology

1. Hypertrophied lobes of the prostate may obstruct eat bladder neck or urethra 2. Incomplete bladder emptying 3. Urinary retention -> UTIs (retained urine medium for infective organisms) 4. Hydroureter and Hydronephrosis

Prostate Cancer Medical Mgmt p. 3913

1. Tx based on life expectancy, symptoms, risk of recurrence, size of tumor, Gleason score, PSA level, likelihood of complications, PXT preference. 2. Nonsurgical watchful waiting 3. Therapeutic vaccines

ABX for bladder

1. take last dose at bedtime (maintain drug levels overnight) 2. take with or without food 3. 2500 to 3000ml 4. void every 2-3 hours 5. Take time to empty bladder completely.

BPH Risk Factors p. 3907

1. Age, generally over 60 but anytime over 40. 2. Heredity 3. Ethnicity, Caucasian and black males 4. Elevated estrogen levels 5. Smoking 6. Alcohol 7. obesity/reduced activity 8. HTN, Heart Disease, DM 9. Western diet (high animal fat, protein, refined carbs, low fiber)

***Nursing Interventions Hemorrhage, Infection, Bladder Neck Obstruction

1. Alert PXT to changes that may occur after discharge and that need to be reported: -Continued bloody urine; passing blood clots -Freq of urination -Diminished urinary output -Incr loss of bladder control

BPH Pharmacological Therapy p. 3909

1. Alpha-Adrenergic blockers: relax smooth muscle of bladder neck. Improves urine flow and relives symptoms of BPH. alfuzosin (Uroxatral) terazosin (Hytrin): Monitor BP doxazosin (Cardura) tamsulosin SE: Dizziness, headache, asthenia/fatigue, postural hypotension, rhinitis, and sexual dysfunction. 2. 5-alpha-reductase inhibitors: Hormonal manipulation w/ antiandrogen agents. Prevents conversion of testosterone to DHT and decr prostate size finasteride (Proscar) dutasteride (Avodart) *Leuprolide (Lupron), bicalutamide (Casodex) =Suffix-ide SE: Decr libido, ejaculatory dysfunction, ED, gynecomastia, flushing *combined therapy of finasteride & doxazosin decr symptoms and reduce BPH progression. **Use of phytotherapeutic agents & other dietary supplements (Serenoa repens [saw palmetto berry] and Pygeum africanum [african plum]) are not recommended by medical community. Should not be used with finasteride, dutasteride or estrogen-containing medications.

***Nursing Interventions Imbalanced Nutrition p. 3916

1. Assess amount of food eaten 2. Routinely weigh PXT, same scale/conditions 3. Elicit PXT explanation on why they are unable to eat 4. Cater to food preferences, avoiding too spicy or too cold. 5. Recognize effect of radiation/medication on appetite. 6. Inform PXT that alterations in taste can occur 7. Oral hygiene 8. Control N/V: Antiemetic, oral hygiene after vomiting. Rest periods after meals. 9. Small freq meals in pleasant environment 10. Assess PXT ability to obtain and prepare foods

***Impaired physical mobility r/t tissue hypoxia, malnutrition and exhaustion and to spinal cord or nerve compression from metastases

1. Assess for factors causing limited mobility (pain, hypercalcemia, limited exercise tolerance. 2. Provide pain relief by administering prescribed meds 3. Encourage use of assistive devices (cane, walker) 4. Provide positive reinforcement for achievement of small gains. 5. Involve significant others in helping PXT w/ROM exercises, positioning and walking. 6. Assess nutritional status

***Acute pain r/t progression of disease & Tx modalities

1. Assess location, intensity, and nature of pain using rating scale. 2. Avoid activities that aggravate pain 3. Due to pain r/t bone metastasis, ensure PXT bed has a bed board on a firm mattress. In addition, protect from falls/injuries. 4.Provide support for affected extremities 5. Prepare PXT for radiation therapy if Rx'd 6. Analgesic/opioids 7. Initiate bowel program to prevent constipation

Prostatectomy (Prostatic Cancer & BPH -TURP) Nursing Process - Assessment p. 3926

1. Assess, act lvl/tolerance change, urinary problem (in PXTs own words), flow, decr ability to initiate, urgency, freq, nocturia, dysuria, urinary ret, or hematuria. -back pain, flank pain, lower abdominal, suprapubic discomfort -ED or changes in freq *Causes: Infection, retention and renal colic -Family HXY of cancer, heart or kidney disease, HTN -Lost weight, pale? Mobility ADL's

Prostate Cancer Clinical Manifestations p. 3911

1. Asymptomatic in early stages 2. Urinary obstruction symptoms happen in advanced disease. 3. Hematuria, Blood in semen 4. Painful ejaculation 5. Sexual dysfunction *Can spread to lymph notes & bone.

BPH laser surgery is possibility of

1. Because of edema, urinary retention and delayed sloughing of tissue that occurs w/ laser prostatectomy, patient will have a post procedure catheter for up to 7 days. No issues with incontinence/urinary retention.

***Nursing Interventions Sexual Dysfunction p. 3917

1. Determine effect medical condition is having on sexual functioning 2. Inform PXT the effects of prostate surgery, orchiectomy, chemotherapy, irradiation, and hormonal therapy on sexual function. 3. Include partner

Urinary Obstruction S&S

1. Difficulty urinating 2. Frequency of urination 3. Urinary retention 4. Decr size and force of bladder stream

Prostatectomy (Prostatic Cancer & BPH -TURP) Nursing Process - POSTOP Interventions Complications [Sexual Dysfunction] p. 3934

1. ED, Decr libido & fatigue. Nerve-sparing radical prostatectomy, recovering ability to have erections is better for men who are younger/both neuromuscular bundles spared. -decr libido due to impact of surgery on the body - > will return once healed. 2. Treat ED Penile implants, negative-pressure devices, PDE-5 inhibitors

BPH Generalized Symptoms p. 3908

1. Fatigue 2. Anorexia 3. Nausea/Vomiting 4. Pelvic discomfort

Laparoscopic Radical Prostatectomy (LRP)

1. Fewer risks that compared with open radical prostatectomy 2. Robotic Assisted LRP

Prostate Cancer Radical Prostatectomy p. 3913

1. First-line Tx, if tumor is confined to prostate *Laparoscopic radical prostatectomy 2. SE: Sexual impotency (less sexual dysfunction if nerves are spared)

BPH Clinical Manifestations p. 3908

1. Frequency, urgency, nocturia, hesitancy 2. Difficulty starting urine stream 3. Decr & intermittent force/vol of stream, 3. Sensation of incomplete emptying 4. Dysuria 6. Frequent UTIs. (Severity of symptoms incr w/age) 7. Oliguria aka dribbling. *Urinary retention leads to azotemia, accumulation of nitrogenous waste products & kidney failure.

BPH Assessment & Diagnostics p. 3908

1. HXY on urinary tracts, previous surgical procedures, general health issues, family HXY of prostate disease, and fitness for possible surgery. 2. Voiding Diary: freq, urine volume Diagnostic 1. Digital Rectal Exam (DRE): large, rubbery and nontender prostate gland, nodules. Assess posterior lobe. *Yearly >50 (>45 for high risk AA) 2. UA: screen for hematuria and UTI 3. PSA: Cancer screen 4. American Urological Association (AUA) Symptom Index or International Prostate Symptom Score (IPSS): Assess the severity of symptoms. 5. Urinary flow rate & postpaid residual urine 6. Testicular exam If Invasive Therapy Considered 1. Urodynamic Studies 2. Urethrocystoscopy 3. Ultrasound 4. CBC's 5. Cardiac status & Respiratory function: Large number of PBH PXTs have these types of disorders due to their age.

Prostate Surgery Complications p. 3923

1. Hemorrhage 2. Clot formation 3. Catheter obstruction 4. Sexual dysfunction 5. Risk of impotence (potential damage to the pudendal nerves) -sexual activity resumed 6 to 8 wks (time to heal) 6. Retrograde ejaculation. (vasectomy may be performed to prevent infection) *After total prostatectomy (cancer), the risk for impotence is high. if this is unacceptable to the PXT, options to produce erections are: -prosthetic penile implants, negative-pressure (vacuum) devices, and pharmacologic interventions.

***Nursing Interventions Prostate Cancer p. 3916

1. Identify ways to reduce pressure on operative area after prostatectomy -Avoid prolonged sitting (chair, long car rides), standing, walking -Avoid straining, such as during exercises, bowel moment, lifting, sex 2. PXT Teaching: Bladder Control -Urination q 2-3 hrs, discourage voiding when supine -Avoid: cola, caffein, cutoff time for drinking before bedtime. -Perineal exercises to perform q hour. -Develop a schedule that fits into PXTs routine 3. PXT demonstration of catheter care

Prostate Surgery p. 3921

1. Indicated for BPH or prostate cancer. -Assess general health, optimal kidney function 2. Performed before acute urinary retention develops and damages upper urinary tract and collecting system, or cancer progression 3. Surgical approaches all cancerous or hyper plastic tissue is removed, leaving behind only the capsule of the prostate.

Prostatectomy (Prostatic Cancer & BPH -TURP) Nursing Process - POSTOP Interventions Complications [Infection/VTE] p. 3931

1. Infection: First dressing changed by HCP -aseptic technique, dressings: double tailed, T-binder or padded athletic supporter. -AVOID rectal thermometers, rectal tubes, enemas are avoided b/c of risk of injury to prostate. -Sitz bath and heat lamp over perineal area may be used to promote healing. -Complications: UTIs & epididymitis. ABX prescribed. Monitor for S&S of infection (fever, chills, sweating, myalgia, dysuria, urinary freq, & urgency) contact HCP 2. Venous Thromboembolism (VTE): Risk for VTE, DVT & PE -Early postop ambulation, antithrombotic medications

Transurethral Resection of the Prostate (TURP) p. 3921/23 [Chart]

1. Most common, prostate gland removed in small chips with electric cutting loop. Ideal for poor surgical risk PXTs. 2. Eliminates risk of transurethral resection syndrome -(Hyponatremia, Hypovolemia) 3. Overnight stay 4. Urethral strictures are more frequent than with nontransurethral procedures 5. Repeated procedures may be needed due to regrowth. 6. Rarely causes ED but may trigger retrograde ejaculation. Seminal fluid backs up into bladder. *Monitor for Hemorrhage *Observe for S&S of urethral stricture -Dysuria, straining, weak urinary stream

Suprapubic Prostatectomy p. 3922 [Chart p. 3923]

1. Open surgical procedure 2. Disadvantages: blood loss, need for abdominal incision, risks associated w/ abdominal surgery

Perineal Prostatectomy p. 3922

1. Practical when other approaches are not possible and is useful for open biopsy. 2. Complications: Incontinence, sexual dysfunction, rectal injury

Prostatectomy (Prostatic Cancer & BPH -TURP) Nursing Process - Diagnosis p. 3927

1. Preop: -Anxiety about surgery and its outcome -Aute pain r/t bladder distention -Deficient knowledge about factors r/t disorder and the tx protocol 2. Postop: -Risk for imbalanced fluid volume -Acute pain r/t surgical incision, catheter placement and bladder spasms -Deficient knowledge about postop care 3. Complications: -Hemorrhage and shock -Infection -Venous thromboembolism (VTE) -Catheter obstruction, removal complications -Urinary incontinence -Sexual dysfunction

Clients with HXY of BPH

1. Privacy and time to void 2. monitor I&O 3. Assess for Urinary retention 4. Test ofr hematuria

Prostatectomy (Prostatic Cancer & BPH -TURP) Nursing Process - POSTOP Interventions Complications [Urinary Incontinence] p. 3933

1. Puboprostatic: Surgery (ligament sparing) to reduce post urinary incontinence. 2. Male sling 3. Preventing incontinence: Incr voiding freq, avoiding positions that encourage urge to void and decr fluid intake prior to activities. Pelvic floor exercises, biofeedback and electrical stimulation. -anticipate leakage, pads, extra clothes, know bathroom locations -Long term incontinence: collagen injections, artificial sphincter implants, medications and leg bag.

Prostate Cancer Tumor Grading [Gleason Score] p. 3912

1. Ranges from 2-10 2. Higher score = higher aggressiveness (undifferentiated cells) Score 8-10 = high grade cancer.

Prostatectomy (Prostatic Cancer & BPH -TURP) Nursing Process - Planning & Goals PREOP Interventions p. 3927

1. Reduce anxiety/teach about the disorder, preoperative experience. Verbalize feelings & concerns 2. Postop goals, fluid volume balance, pain relief & discomfort, ability to perform self-care and absence of complications 3. Relieving discomfort: Intervention Preop: Bedrest, analgesics, relive anxiety. -monitor voiding patterns, watch for bladder distention, assist w/catheterization. -Indwelling catheter is inserted if PXT has continuing urinary retention or if close monitoring is needed b/c lab test indicate azotemia (nitrogenous waste in blood), *catheterization helps decompress bladder gradually (too quick can cause Hypotension), esp useful in over PXTs that are HTN, diminished kidney function, urinary retention that has existed formally weeks. -Few days after bladder begins draining Blood pressure may fluctuate and kidney function may decline. -If PXT cannot tolerate catheter, he is prepared for a cystotomy (insertion of a suprapubic catheter) 3. Providing Education: Preop: Reviews PXT anatomy of affected structures/function. Web based education before/after surgery -Antiembolism stockings are applied before surgery to prevent VTE, especially important to prevent VTE if PXT is place in a lithotomy position during surgery. (intervention)

BPH Medical Mgmt p. 3908

1. Retention catheter (Emergency PXT unable to void) *Cystotomy: incision into the bladder may be needed to provide drainage. 2. PXTs with mild to severe symptoms who are not bothered by them and have not developed complications may be manages with "watchful waiting". Monitored and reexamined annually but no active intervention. Other PXTs explore pharmacological Tx, minimally invasive procedures and surgery.

Prostate-Specific Antigen (PSA)

1. Sensitive to prostate 2. Incr levels may indicate -BPH -Acute Urinary Retention -Cancer 3. <4 monograms/ml = Normal

Retropubic Prostatectomy p. 3922

1. Suitable for large glands located high in the pelvis. 2. Infections readily start in retropubic area

Transurethral Incision of the Prostate (TUIP)

1. Surgical procedure that widens the urethra by making small incisions in the bladder and the prostate gland to facilitate urination

Prostate Cancer Radiation Therapy p. 3914

1. Teletherapy - Beam: 5 days a week for 5 1/2 wks (external beam radiation therapy); experimenting w/ cpu controlled radiation therapy. 2.Brachytherapy: Interstitial radioactive seeds placed in prostate organ. -Avoid contact w/pregnant persons, infants. -Strain urine -Avoid sex or use condom for 3 wks after insertion (to catch seeds) 3. SE: Inflammation of rectum & bowel, painful urination

Prostatectomy (Prostatic Cancer & BPH -TURP) Nursing Process - POSTOP Interventions Complications [Catheter Problems] p. 3931

Catheter Problems 1. TURP: must drain well, obstructed catheter produces prostatic distention -> Hemorrhage. Will create urge to void from placement and bladder spasms. -Furosemide (Lasix) prescribed to promote urination and initiate postop dieresis, helps keep catheter patent. -Observe lower abdomen, distinct rounded swelling above pubis = overextended bladder -> bladder scanner to determine if urine retention is the problem. -BP, pulse, RR are compared to baseline to detect hypotension. -Observe for restlessness, diaphoresis, pallor, drop in BP and incr pulse rate -Drainage: Closed sterile drainage system, 3 way lumen to drain and prevent clot formation. CBI used with TURP. -Amount of drainage = fluid instilled. Over distention of the bladder should be avoided ->secondary hemorrhage. -Secured to inner thigh to prevent traction on the bladder. -Cystostomy catheter secured to abdomen. -Bladder spasms: anticholinergics given. Perineal, Suprapubic or retropubic surgery -Urine may leak around the wound for several days. -Some urinary incontinence may occur after catheter removal and will subside over time. -Urinary freq, burning after removed.

Prostate Cancer Metastasis Screening p. 3913

Determine if the cancer has spread to the lymph nodes. 1. Bone scans 2. Skeletal X-rays 3. MRI 4. Pelvic CT scans 5. ProstaScint: Radiolabeled monoclonal antibody (detect recurrent prostate cancer at low PSA levels or metastatic disease. 6. Vaccine: (Provenge) Developed to kill cancer cell and help provide immunity for men with metastatic disease.

Prostate Cancer Assessment & Diagnostic p. 3912

If caught early, the likelihood of cure is high. 1. DRE: Routine repeated (preferably by same Dr.) *nodule w/in the gland or as an extensive hardening in posterior lobe. 2. PSA levels: >4/ng/ml = elevated, 4-10ng/ml suspicious -> Confirm with repeat test->biopsy 3. Ultrasound-guided TRUS w/biopsy: 4. Diagnosis of cancer is confirmed by histologic examination of tissue removed surgically by TURP, open prostatectomy, or ultrasound-guided transrectal needs biopsy (Gleason Score 1-10). Fine needle aspiration (quick, painless) 5. Prosta Scint: Detects recurrence early 6. Vaccine: (Provenge) Developed to kill cancer cell and help provide immunity for men with metastatic disease. Most prostate cancers are detected when a man seeks medical attention for symptoms of urinary obstruction or are found by routine DRE & PSA testing. Also found from TURP. -DRE/PSA: elevated levels raise suspicion of cancer but confirmed w/ prostate biopsy.

Signs and Symptoms of Infection/Post op S&S

Infection: Fever, chills, sweating, myalgia, dysuria, ruinary frequency, urgency. Contact HCP. Post op: Hematuria, decr urine output, fever, change in wound drainage, calf tenderness)

Prostatectomy (Prostatic Cancer & BPH -TURP) Nursing Process - POSTOP Interventions Complications [Hemorrhage] p. 3930

Major Complications: Hemorrhage, Infection, VTE, Catheter Problems, Sexual Dysfunction. 1. Hemorrhage/Shock: Discontinue Aspirin, NSAIDs, Antiplatelet 10 to 14 days before surgery to prevent excessive bleeding. -Prostate very vascular, bleeding may cause clots and obstruct urinary flow. -Drainage: begins reddish-pink and then clears to light pink w/in 24hrs. -Bright red bleeding w/increased viscosity and numerous clots indicate arterial bleeding. Requires surgical intervention. -Darker/less viscous = venous blood. Controlled w/prescribed traction to the catheter so that the balloon holding catheter in place applies pressure to the prostatic fossa. (tapes to thigh). 1A. Nursing interventions include closely monitoring V/S, meds, IV fluids and blood component therapy, I&O's, monitoring drainage to ensure urine flow & potency of drainage system.

Prostate Cancer Metastases p. 3911

May be the first indications of prostate cancer. 1. Backache 2. Hip pain 3. Perineal/rectal discomfort 4. Anemia 5. Weight loss 6. Weakness 7. Nausea 8. Oliguria 9. Spontaneous pathologic fractures (broken bones caused disease rather injury.)

BPH Surgical Mgmt p. 3909

Minimally Invasive Therapy 1. Transurethral microwave thermotherapy (TUMT): involves the application of heat to the prostate. Target tissue becomes necrotic and sloughs. 2. Transurethral Needle Ablation (TUNA): low wave radiofreq delivered by thin needles, localized heat destroys tissue. *Prostatic steps are associated with significant complications, encrustation, infection, chronic pain, therefore, they are used only for PXTs w/urinary retention or PXTs who are poor surgical risks

Benign Prostatic Hyperplasia (BPH)

Non cancerous enlargement or hypertrophy of the prostate. One of the most common diseases in aging men.

***Urinary Retention Nursing Process p. 3915

Nursing Interventions 1. Determine usual pattern 2. S/S of urinary retention -amount, freq, suprapubic distention, complaints of urgency & discomfort 3. Catheterize to determine residual volume 4. Initiate measures to treat retention -Normal position for voiding -Recommend valsalva maneuver ONLY PREOP unless contraindicated. -Cholinergic agent, Monitor effects of meds 5. Consult w/HCP regarding intermittent or indwelling catheterization. -Monitor, maintain sterility of closed system, irrigate as required. Prepare PXT for surgery if indicated.

Uncomplicated BPH S&S

Obstructive symptoms vs Classic uncomplicated BPH

Model of Sexual Assessment & Intervention

PLISSIT 1. Permission: recognize personal factor 2. Limited Information -> PXT's comfort zone 3. Specific Suggestions -> good listening 4. Intensive Therapy -> more complicated issues referred to a specialist

Prostatectomy (Prostatic Cancer & BPH -TURP) Nursing Process - Planning & Goals POSTOP Interventions p. 3929

Post Op: 1. Maintain Fluid Balance -Due to irrigation of surgical site during/after surgery -Due to continuous bladder irrigation (CBI) to prevent obstruction by blood clots, fluid may be absorbed thru open surgical site and retained, incr risk of excessive fluid retention, fluid imbalance, water intoxication. -Urine output (I&O's) and amount of fluid used for irrigation must be closely monitored to determine if fluid is being retained and to ensure adequate urine output. -I&O including irrigation fluids. -Monitor for fluid and electrolyte (F&E) imbalances (hyponatremia), incr blood pressure (BP), confusion and respiratory distress. -Bladder spasms: urgency to void, feeling pressure or fullness in bladder, bleeding from urethra around catheter. Meds to relax smooth muscles can help spasms (flavoxate [Urispas] & oxybutynin [Ditropan]) *Warm compress on pubis or sits baths help relive spasms. 2. Monitor drainage of tubing for obstructions -Catheter irrigated with 50mL of irrigating fluid at a time. (3 lumen). *Same amount of fluid should be recovered in drainage receptacle. -Secure the drainage tube to leg or abdomen to decr tension on the catheter or prevent bladder irritation. Dressings should not be too snug. -Analgesics: Notify HCP if pain meds not working -Post op: when PXT is ambulatory, encouraged to walk but not sit for prolonged periods, b/c this increases intra-abdominal pressure and possibility of discomfort & bleeding. Intervention: Prune juice, stool softness are provided to ease bowel movements and prevent straining. Enema given with caution to avoid rectal perforation.

TURP Pros/Cons

Pros 1. Avoids abdominal incision 2. Safer surgical-risk 3. Shorter hospital stay 4. Lower morbidity rate 5. Less pain 6. Palliative approach w/ HXY of radiation therapy Cons 1. Highly skilled surgeon 2. Recurrent obstruction 3. Urethral trauma 4. Stricture may develop 5. Delayed bleeding may occur

BPH Surgical Mgmt (TURP) p. 3910

Surgical Resection 1. Transurethral Resection of the Prostate (TURP): Removal of inner portion of prostate through an endoscope inserted through the urethra (ultrasound guided). Performed outpatient. Usually less post op bleeding than traditional surgical prostatectomy. *Most common procedure, Resectoscopic excision and cauterization of prostate tissue -Can cause retrograde ejaculation -3 lumen catheter: continuous bladder irrigation (CBI), to achieve/maintain clear outflow and prevent close formation within the bladder. Initial rate is fast to achieve clear outflow. Stopping and clamping is done only under HCP direction and not expected until at least 1 day post op. If CBI becomes brighter red, increase the flow (CI if irrigation stopped) 1. ballon 2. irrigation inflow 3. outflow -urinary catheter can cause bladder spasms and create the urge to void even while catheter is working *Assess for respiratory paralysis if spinal anesthesia used. No need for deep breath and cough. *Dribbling of urine can persist for several months, may need to use pads for incontinence, won't be a chronic problem. PostOp 3 (Days) 1. Large amount of fluid (should be almost clear) 2. Call HCP is urine turns bright red

Prostate Cancer TRUS p. 3912

Transrectal ultrasound 1. Detects non palpable prostate cancers & assists with staging of localized prostate cancer. 2. Needle biopsies of prostate are guided by TRUS

Uroflowmetry

measures rate and degree of bladder emptying/urinary obstruction