HESI case study - Benign Prostatic Hyperplasia - Bob Hamilton

Mr. Hamilton's PSA level is 8 ng/mL, a slightly elevated level (normal is > 2.5 ng/mL). Mr. Hamilton appears distressed and he asks, "Do I have prostate cancer? Is that why I'm having these symptoms?" Which action by the nurse is most helpful?

Explain that PSA levels can be elevated with gland enlargement, as well as cancer, so more tests are needed. Elevated PSA levels are associated with prostate cancer. However, slight elevations may also occur in BPH. PSA levels may also be elevated as the result of infection, or if the prostate gland is manipulated during a digital rectal exam.

The HCP prescribes an infusion of aminocaproic acid (Amicar). The prescription is for a loading dose of aminocaproic acid (Amicar) IV 5 g to be infused in 250 mL of D5W over 1 hour. The tubing drop factor is 15 drops/mL. How many drops per minute would the nurse set for the IV rate? 63 (Enter numerical value only. If rounding is necessary, round to the whole number.)

63 Amount X Drop Factor \ Time to Infuse 250 X 15\60 minutes = 62.5= 63 drops/minute

When the transfusion is half infused, the unlicensed assistive personnel (UAP) tells the nurse that Mr. Hamilton is very nervous and has a headache. Which action should the nurse implement first?

Assess Mr. Hamilton for additional symptoms. Mr. Hamilton is exhibiting signs of a possible transfusion reaction. The nurse should immediately assess Mr. Hamilton for additional symptoms, such as the presence of fever or chills, and then obtain vital signs.

During administration of the aminocaproic acid (Amicar) infusion, the nurse monitors Mr. Hamilton for adverse effects of the medication. What assessment data would indicate the onset of a thrombotic complication?

Chest pain and dyspnea. Common manifestations of pulmonary embolism are chest pain and dyspnea.

A Complication Occurs The nurse reviews the client's vital signs taken by the UAP and identifies changes from the vital signs that were taken 4 hours earlier. Four hours earlier: blood pressure 112/64 mmHg, heart rate 82 beats/minute, respirations 16 breaths/minute, temperature 98.0° F (36.6o C), O2 saturation 94%. Current vital signs: blood pressure 88/50 mmHg, heart reate 106 beat/minute, temperature 97.2° F (36.2o C), O2 saturation 85%. The nurse assesses the client and determines that he is dyspneic, lethargic, pale, and cool and has a large amount of bright red bleeding in his urinary catheter. Which assessment finding warrants intervention by the nurse?

Confused to surroundings. Confusion is an acute symptom of cerebral hypoxia and require immediate intervention.Crawford, Lynne. (2020). Fundamentals of Nursing (2nd Ed.), St. Louis, Missouri. Elsevier. P. 290.

The nurse initiates a physical examination to further investigate the client's symptoms. Which assessment finding would indicate that the client is experiencing urinary retention related to BPH? (Select all that apply.)

Observance of bladder distention. Bladder distention is an assessment finding in urinary retention. Dullness heard on percussion below the umbilicus. A distended bladder will sound dull upon percussion. Observance of dribbling after voiding. This is a symptom of urinary retention.

Mr. Hamilton tells the nurse that he has cut back on drinking fluids to reduce his symptoms. Which instruction is most important for the nurse to provide to Mr. Hamilton?

Decrease fluid intake to increase the risk of developing a urinary tract infection. Men with BPH often restrict fluid intake to reduce symptoms, but this should be discouraged because it increases the risk for urinary tract infection.

Mr. Hamilton has continuous bladder irrigation (CBI) infusing with normal saline. Eight hours after surgery, the urinary drainage is reddish pink.

Document that the CBI is infusing correctly. Normal drainage is reddish pink, clearing to light pink within 24 hours postoperatively. The drainage should be clear yellow by the 4th postoperative day. Normal saline is the desired solution for irrigation because it is isotonic. Hypotonic or hypertonic solutions may result in fluid shifts.

The nurse administers oxygen per face mask, ensures that the IV catheter is patent, and notifies the HCP that the client is experiencing overt bleeding and manifestations of hypovolemic shock. Specimens for stat laboratory specimens and arterial blood gases are obtained. Which of the client's serum laboratory values requires intervention by the nurse?

Hematocrit 28 % (0.28) Normal hematocrit is 37 - 46 % (0.37 - 0.46). A low hematocrit would be expected in hypovolemic shock secondary to hemorrhage and requires immediate intervention. Crawford, Lynne. (2020). Fundamentals of Nursing (2nd Ed.), St. Louis, Missouri. Elsevier. P. 662, 917.

Early the next morning, the nurse notes that the catheter is draining a large volume of urine with bright red blood that seems thick. What actions should the nurse take?

Increase the flow rate of the CBI. The flow rate of the CBI should be increased, to decrease the risk for blood clot obstruction to the catheter. Notify the HCP of the findings. Bright red bleeding with increased viscosity ("ketchup" consistency) is an indication of arterial bleeding. The HCP should be notified immediately to determine the course of action necessary. In addition, the flow rate of the CBI should be increased or manual irrigation performed to decrease the risk for blood clot obstruction of the catheter. Perform manual irrigation. Manual irrigation can be performed to help prevent blood clot obstruction and to resolve obstruction to the catheter.

The nurse assesses that Mr. Hamilton's skin is warm and flushed. Mr. Hamilton reports having generalized body aches, and he starts experiencing chills. His BP is 114/68, his pulse is 92, his respirations are 18, and his temperature is 102.2° F. The nurse suspects that Mr. Hamilton is experiencing a febrile transfusion reaction What action should the nurse take next after stopping the transfusion?

Infuse 0.9% sodium chloride solution through separate IV tubing. After stopping the blood transfusion, the nurse should next infuse 0.9% sodium through a separate IV tubing to maintain IV patency. The client may experience shock and may need additional fluids and medications. Crawford, Lynne. (2020). Fundamentals of Nursing (2nd Ed.), St. Louis, Missouri. Elsevier. P. 987.

After surgery, Mr. Hamilton is admitted to the surgical nursing unit for overnight observation and postoperative care. Which postoperative intervention should the nurse perform first?

Observe the urinary drainage. A common postoperative complication that can be potentially life-threatening is bleeding, which will be seen in the urinary drainage.

The RN is monitoring the client and preparing him for surgery. Which task can the RN delegate PN to complete?

Prepare a client with renal failure for a scheduled dialysis treatment. This client is stable, and this task does not require the expertise of the RN. Lewis, Sharon. (2017). Medical-Surgical Nursing Assessment and Management of Clinical Practices (10th Edition), St. Louis, Missouri. Elsevier. P. 11.

Mr. Hamilton asks if he will need to have any more yearly rectal exams. How should the nurse respond?

Provide the client with written information explaining the need for yearly rectal exams and PSA screenings. Since the prostate gland is only partially removed during TURP, annual rectal exams and PSA screenings for prostate cancer should still be performed. Lewis, Sharon. (2017). Medical-Surgical Nursing Assessment and Management of Clinical Practices (10th Edition), St. Louis, Missouri. Elsevier. P. 1273 - 1274. Submit Previous Section

During the night, Mr. Hamilton reports increased bladder discomfort. The nurse's observation of the urinary drainage catheter indicates minimal output for the last 2 hours. What action should the nurse take?

Stop the CBI, and irrigate the catheter. The catheter is most likely obstructed by blood clots and should be manually irrigated with 30 to 50 ml of sterile, normal saline. The nurse should first check to make sure there are no kinks in the drainage tubing or other obvious signs of catheter obstruction! INCORRECT: Apply gentle pressure over the bladder. This action will increase Mr. Hamilton's discomfort without resolving the problem. Continue the CBI, and notify the HCP. Continuing the CBI may worsen the bladder distention. Gradually increase the flow rate of the CBI. The catheter is obstructed. Increasing the CBI may worsen the bladder distention.

Which assessment findings warrants immediate intervention by the nurse? (Select all that apply.)

Sudden painful inability to urinate. This is a sign of acute obstruction and requires an indwelling urinary catheter to allow urine to drain.Lewis, Sharon. (2017). Medical-Surgical Nursing Assessment and Management of Clinical Practices (10th Edition), St. Louis, Missouri. Elsevier. P. 1034, 1268-1269. Painful, frequent urination. This is a sign of urinary tract infection that requires antibiotic therapy as soon as possible.Lewis, Sharon. (2017). Medical-Surgical Nursing Assessment and Management of Clinical Practices (10th Edition), St. Louis, Missouri. Elsevier. P. 1034, 1268-1269.

Which instruction should the nurse provide to the client before starting the procedure?

While voiding into a special toilet, urine flow pressure will be monitored. The pressure of the urine flow is measured to determine the degree of obstruction.Lewis, Sharon. (2017). Medical-Surgical Nursing Assessment and Management of Clinical Practices (10th Edition), St. Louis, Missouri. Elsevier. P. 1024.

Management Issues: Client Care Assignments The client is scheduled to have emergency surgery. His partner is with him, and she is very anxious and upset. While the client is awaiting transport to the operating room, which nursing staff member should be assigned to his care?

An RN who has worked on the unit for 3 years. An RN experienced in the care of clients on this unit has the best expertise to monitor an unstable client.Crawford, Lynne. (2020). Fundamentals of Nursing (2nd Ed.), St. Louis, Missouri. Elsevier. P. 59. INCORRECT: A graduate nurse who has completed orientation. The graduate nurse might help provide support to the client's partner but this staff member does not have sufficient experience to care for this unstable client. An PN who formerly worked in the operating room. The PN might be assigned to assist the RN but this staff member should not be assigned to care for this client who has an unstable condition. An RN who transfered to the unit from a long-term care facility. An RN is the best member of the nursing staff to monitor the client at this time. However, a nurse with only long-term care experience does not have the expertise to monitor an unstable client.

The nurses discuss the components needed to prove professional negligence or malpractice. They discuss breach of duty. What action by the nurse would indicate a breech of duty.

Initial blood transfusion rate 10 mL/min for the first 15 minutes. Blood should be transfused at approximately 2 mL/minute (120mL/hour) for 1st 15 minutes, then increase rate to infuse over 1 to 2 hours (150-250 mL/hr), or as ordered. Do NOT hang longer than 4 hours. Breach of duty is the failure to perform according to established standards, such as those define in the Infusion Nursing Society. Crawford, Lynne. (2020). Fundamentals of Nursing (2nd Ed.), St. Louis, Missouri. Elsevier. P. 987.

Mr. Hamilton tells the nurse that he is uncomfortable, because he constantly feels like he has to urinate. The nurse explains that this is the result of the oversize balloon putting pressure on the sphincter of the bladder. Which nursing intervention best promotes effective communication?

Instruct the client to try not to bear down around the catheter. The client could damage the urinary sphincter if he tries to void around the catheter. Bearing down to try to urinate will create more pressure on the sphincter.

Aware of the client's partner's body language, what action should the nurse implement?

Let the client's partner know that you will be glad to answer any questions she may have. This response gives the partner the opportunity to choose any further interaction, which include avoidance of physical touch between persons who are not close. INCORRECT: Ask the partner if she would like you to stay with her for a while. Although this response demonstrates offering of self, the partner may feel that a response of "no" would be disrespectful to the nurse.Lewis, Sharon. (2017). Medical-Surgical Nursing Assessment and Management of Clinical Practices (10th Edition), St. Louis, Missouri. Elsevier. P. 26-27. Acknowledge that you can see that she is uncomfortable. The partner's behaviors and verbalization may have been misinterpreted. Take the partner's hand and offer silent support. The partner may be uncomfortable with physical contact.

What does Mr. Hamilton need to know about taking finasteride (Proscar)?

Liver function studies (LFTs) need to be monitored frequently. Finasteride (Proscar) can cause hepatic dysfunction, so liver function tests results should be reviewed periodically. Most clients see significant change in BPH symptoms in 4 months. It may take 12 weeks to 6 months to achieve the desired response. Protect the medication from light. Finasteride (Proscar) should be protected from the light. Clients can experience breast enlargement. One of the adverse effects of finasteride (Proscar) is breast enlargement and tenderness.

The nurse initiates the infusion of 0.9% sodium chloride and informs the HCP of the client's signs and symptoms of a blood transfusion reactions. The HCP determines that the client is having an acute hemolytic reaction. The nurse instructs the UAP to place the emergency cart bedside. What is the next action the nurse should implement?

Notify the laboratory of the transfusion reaction. The next step in managing the transfusion reaction is to notify the lab so they can begin the transfusion reaction workup. Crawford, Lynne. (2020). Fundamentals of Nursing (2nd Ed.), St. Louis, Missouri. Elsevier. P. 987.

Mr. Hamilton is scheduled for a digital rectal exam, serum prostate-specific antigen (PSA) level, urinalysis, serum creatinine, and blood urea nitrogen (BUN). He states that he has had the rectal exam and PSA levels done before for prostate screening. He asks why the other lab tests (creatinine and BUN levels) are necessary. Which information should be included in the nurse's explanation?

Prostate enlargement may result in renal damage, causing a decreased of urine production in the kidneys, which these tests will evaluate. Prostate enlargement may result in kidney damage, which can cause a change in urine production. When the prostate gland is blocking the flow of urine, some degree of kidney damage that can be detected with these tests. As the flow of urine is blocked by the enlarged prostate gland, gradual dilation of the ureters (hydroureter) and kidneys (hydronephrosis) can occur, resulting in increased creatinine and BUN levels. Advise the client that it is protocol for the healthcare provider (HCP) to conduct then recheck tests to compare previous results. It is important to monitor progression and degree of kidney damage.Lewis, Sharon. (2017). Medical-Surgical Nursing Assessment and Management of Clinical Practices (10th Edition), St. Louis, Missouri. Elsevier. P. 1268-1269.

Ethical-Legal Issues: Malpractice It is determined that the client experienced an acute hemolytic transfusion reaction. This type of reaction occurs when there is an antigen-antibody reaction due to ABO or Rh incompatibilities. In addition to stopping the transfusion, the nurse sends the blood bag, tubing, and a urinalysis to the lab, and administers an antipyretic medication. The nurse is concerned that the client experienced a transfusion reaction and expresses her fear of being sued with the charge nurse. Which nursing intervention best promotes effective communication by the charge nurse?

Review blood transfusion interventions with the nurse. This is an assertive response by the charge nurse and offers both nurses an opportunity to review the situation to determine variations from policy and any evidence of negligence. Crawford, Lynne. (2020). Fundamentals of Nursing (2nd Ed.), St. Louis, Missouri. Elsevier. P. 146.

Discharge Teaching The client is transported to the operating room for emergency surgery to stop the hemorrhage. Following surgery, the client is transferred to the surgical critical care unit. Once hemodynamically stable, the client is transferred to the surgical nursing unit, where his condition continues to improve. The client prepares for discharge. The nurse is teaching the client how to perform pelvic floor muscle exercises. The instructions include contracting the pelvic floor muscles for 5 seconds, then relaxing for 5-10 seconds. Which nursing intervention best promotes effective communication while teaching the client about contracting pelvic floor muscles?

Squeeze as if stopping the flow of urine. This best describes how to contract the pelvic floor muscles. After holding the contraction for 5 seconds, the client should relax for 5-10 seconds, and repeat 15-20 times TID. These exercises are also called Kegel exercises. Lewis, Sharon. (2017). Medical-Surgical Nursing Assessment and Management of Clinical Practices (10th Edition), St. Louis, Missouri. Elsevier. P. 1275.

The nurse recognizes that nonverbal behavior such as eye should not be ignored. What action is most important for the nurse to take regarding the partner's minimal eye contact?

Tell the partner you noticed she appeared to look away when you were speaking. Avoiding eye contact or engaging in minimal eye contact should be addressed. This would be a common response when someone is uncomfortable and not handling a stressfull or unknown situation.Lewis, Sharon. (2017). Medical-Surgical Nursing Assessment and Management of Clinical Practices (10th Edition), St. Louis, Missouri. Elsevier. P. 21.

Test results, along with urodynamic flow studies, indicate that Mr. Hamilton's prostate gland is significantly enlarged, and treatment is recommended. Mr. Hamilton elects to try medical management of his symptoms. He receives prescriptions for oral finasteride (Proscar) and terazosin (Hytrin). The nurse provides instructions about these medications. What information should be included when teaching Mr. Hamilton about terazosin (Hytrin)?

This medication can cause dizziness so it should be taken at night. Terazosin (Hytrin) is an alpha-adrenergic blocking agent and is likely to cause orthostatic hypotension and dizziness, especially when the client first starts the medication. It is recommended to take the medication at night.

The client continues to take his medications for 8 months, but his symptoms do not improve significantly and he is scheduled for a uroflowmetry study. The client arrives at the clinic early for the uroflowmetry test and is asking the nurse to explain the procedure. Which nursing intervention best promotes effective communication?

Uroflowmetry is a non-invasive exam to measure the volume and flow of urine. Uroflowmetry is a simple non-invasive procedure that measures the flow of urine which can indicate the extent of blockage the prostate is creating.Goldman MD, Lee and Schafer MD, Andrew. (2020). Goldman-Cecil Medicine (26th ed.), St. Louis, Missouri. Elsevier. Pg. 794Lewis, Sharon. (2017). Medical-Surgical Nursing Assessment and Management of Clinical Practices (10th Edition), St. Louis, Missouri. Elsevier. P. 1269.

Administration of a Blood Transfusion The aminocaproic acid (Amicar) infusion successfully stops the bleeding without complications. Mr. Hamilton's hemoglobin and hematocrit drop as the result of the bleeding, and the HCP prescribes the administration of 1 unit of packed red blood cells. Which action should the nurse implement to reduce the risk for a hemolytic transfusion reaction?

Verify the blood type and Rh factor with another nurse. Acute hemolytic reactions are the result of the infusion of incompatible blood products. This risk is reduced if two nurses verify and compare the label on the blood with the client's identification band and the blood bank form. In addition, the transfusion should be started slowly, and the client should be observed carefully during the first 15 to 30 minutes of the transfusion.