BPH Quiz
symptoms of enlarged prostate
- increased urinary frequency - decreased force of urine stream - "double" or "triple" voiding - dysuria - hematuria - nocturia -hematospermia
The nurse is preparing a discharge teaching plan for a client who has had a prostatectomy. Which of the following would be appropriate to include?
Perform perineal exercises frequently throughout the day
A client comes to the clinic reporting urinary symptoms. Which statement would most likely alert the nurse to suspect benign prostatic hyperplasia (BPH)?
"I've had trouble getting started when I urinate, often straining to do so."
azotemia
(excessive) urea and nitrogenous substances in the blood -> kidney failure
causes of BPH
- DHT is a critical mediator to cell growth in BPH - slow and insidious, develops over time - men gain elevated estrogen levels - hypertrophy of prostate can obstruct the bladder neck or urethra, causing incomplete emptying and urinary retention - can cause dilation of ureters (hydroureters) and kidney (hydronephrosis) - can cause UTI's r/t retention
assessment of patient TURP
-assess underlying disorder (BPH or prostate cancer) has the patient had any activity level or tolerance changes? what is the presenting urinary problem? has the patient had a decreased force of urinary flow? any decreased ability to initiate voiding, urgency, frequency, etc? -obtain a family history of cancer
relieve discomfort
-bed rest is prescribed -analgesics -monitor voiding patterns, watch for bladder distention, assist with catheterization -insert an indwelling catheter if patient has continuous urinary retention -prepare patient for cystotomy if they cannot tolerate a catheter
potential catheter problems post-turp
-obstruction -irrigation
Medical management of BPH includes pharmacologic therapy. Which of the following medications would the nurse expect the health care provider to prescribe for this diagnosis?
Alpha-adrenergic blocker
Bright red bleeding following prostate surgery indicates which of the following?
Arterial bleed
Which is inconsistent with a digital rectal examination (DRE)?
Can reveal a hydrocele
special indications alpha-adrenergic blockers BPH
DO NOT COMBINE W/ ANY OTHER SNS MED FOR ERECTILE DYSFUNCTION (-afil), will cause a DANGEROUS DROP IN BLOOD PRESSURE or any other anti-HTN medication
Which of the following would the nurse expect to be done to assess the size of the prostate?
DRE
A patient experiences hypotension, lethargy, and muscle spasms while receiving bladder irrigations after a transurethral resection of the prostate (TURP). What is the first action the nurse should take?
Discontinue the irrigations
A client is ordered continuous bladder irrigation at a rate of 60 gtt/minute. The nurse hangs a 2 L bag of sterile solution with tubing on a three-legged IV pole. She then attaches the tubing to the client's three-way urinary catheter, adjusts the flow rate, and leaves the room. Which important procedural step did the nurse fail to follow?
Evaluating patency of the drainage lumen
Which of the following is an immediate danger after a prostate surgery?
Hemorrhagic shock
A 65-year-old man complains to his health care provider that, when he urinates, he has to start and stop several times over a period of minutes in order to fully empty his bladder. The nurse is aware that this is not uncommon in men over the age of 60. This "double voiding" is directly related to which of the following?
Hyperplasia of the prostate gland
MONITOR I/O!
If we do not get out what we put in, there is a problem (obstruction)
A client has presented at the clinic with symptoms of benign prostatic hyperplasia. What diagnostic findings would suggest that this client has chronic urinary retention?
Increased BUN
After a radical prostatectomy for prostate cancer, a client has an indwelling catheter removed. The client then begins to have periods of incontinence. During the postoperative period, which intervention should be implemented first?
Kegel exercises
The nurse is providing care to a client who has had a transurethral resection of the prostate. The client has a three-way catheter drainage system in place for continuous bladder irrigation. The nurse anticipates that the catheter may be removed when the urine appears as which of the following?
Light yellow and clear
BPH
NONCANCEROUS enlargement or hypertrophy of the prostate - one of the most common disease in men 90% of men have this by age of 85
saw palmetto and african plum
NOT recommended by medical experts but are COMMONLY used function by interfering with conversion of testosterone to DHT, saw palmetto may directly block the ability of DHT to stimulate prostate cell growth DO NOT USE WITH ESTROGEN CONTAINING MEDS!! don't want to drop testosterone too much
A client with benign prostatic hyperplasia doesn't respond to medical treatment and is admitted to the facility for prostate gland removal. Before providing preoperative and postoperative instructions to the client, the nurse asks the surgeon which prostatectomy procedure will be done. What is the most widely used procedure for prostate gland removal?
TURP
Which is the most common type of prostate surgery?
TURP
most common surgery for BPH?
TURP (transurethral resection of the prostate)
After having transurethral resection of the prostate (TURP), a client returns to the unit with a three-way indwelling urinary catheter and continuous closed bladder irrigation. Which finding suggests that the client's catheter is occluded?
The client reports bladder spasms and the urge to void
The client states to the nurse that he is very anxious about having prostate cancer ever since his prostate-specific antigen (PSA) test came back elevated. The client asks, "Which diagnostic test produces definitive results if cancer is present?" The nurse is most correct to state which of the following?
Tissue biopsy
antibiotics given for what
UTI's and epididmyitis post surgery
A client underwent a transurethral resection of the prostate gland 24 hours ago and is on continuous bladder irrigation. Which nursing intervention is appropriate?
Use sterile technique when irrigating the catheter.
names of alpha-adrenergic blockers BPH
alfuzosin (Uroxatral) terazosin (Hytrin) doxazosin (Cardura) tamsulosin
what should be withhled prior to TURP
all clotting defects must be corrected and medications for anticoagulation must be withheld since bleeding is a complication
what should patient avoid post-turp
anything that produces valsava effect (straining, heavy lifting) since it can lead to hematuria avoid long motor trips, strenous exercise DRNK ENOUGH FLUIDS
Bright red bleeding with increased viscosity and numerous clots
arterial bleed
anticholinergics used for
bladder spasms
educate family on s/s to report to provider
blood in urine decreased urine output fever change in wound drainage calf tenderness
observe the lower abdomen to ensure the catheter has not become obstructed
distinct, rounded swelling above the pubis indicates an overdistended bladder (use a bladder scan to confirm)
range for PSA test
less than 4mg/dL = normal
alpha-adrenergic blockers BPH (-ZOSIN!!!)
relax smooth muscle of the bladder neck and prostate, improving urine flow and relieving symptoms of BPH - cause dilation in arterioles/veins, relaxes SNS effects on urinary tract, tx HTN
arterial hemorrhage
requires surgery, bright red
what are the names of the herbal supplements for BPH
saw palmetto and african plum
what can happen with urine post-turp
urinary incontinence will occur for up to a year, DRIBBLING
5-alpha-reductase inhibitors (testosterone blockers) (-ERIDE)
used to prevent the conversion of testosterone to DHT and decrease prostate size - shrinks prostate by blocking reproduction of prostate cells
Furosemide (Lasix)
used to promote urination and initiate post-operative diuresis
dark and less viscous blood
venous bleed
how do you treat a patient with mild to moderate symptoms of BPH?
watchful waiting, monitored ANNUALLY but receive no interventions
venous hemorrhage
can be controlled by applying traction to the catheter, so that the balloon applies pressure to the prostatic fossa TAPE CATHETER TO THIGH FOR TRACTION, MUST STAY IN TRACTION TO WORK
educate patient on s/s of infection
fever chills sweating dysuria urinary frequency urgency
names of 5-alpha-reductase inhibitors BPH
finasteride (Proscar) dutasteride (Avodart)
infection complication
first dressing is changed by surgeon on first day post-op, watch for technique and nurse changes every other one from there on out aseptic technique
AFTER TURP, catheter must drain well
if obstructed, produces distention of the prostatic capsule and hemorrhage as a result, along with bladder spasms
if patient is admitted as an emergency r/t being unable to void, what occurs?
immediately catheterized ordinary catheter may not work, thin wire may be inserted by UROLOGIST to prevent collapsing when meeting resistance MAKE SURE THE PT DOES NOT PULL THIS OUT
cystotomy
incision into the urinary bladder may be necessary to provide drainage
if patient c/o pain
inspect tubing, irrigate with 50mL of fluid to clear obstructions
3-way irrigation system
irrigation goes in, while irrigation and urine come out into collection bag, balloon must be inflated to keep the catheter in place
educate patient on exercises to help regain urinary control
kegel exercises -tension on the perineal muscles by pressing buttocks together, hold, then relax (10 to 20 times an hour) -try to interrupt the urinary stream after starting to void, wait, then continue
Which of the following would a nurse include in a teaching plan for a client with benign prostatic hyperplasia who is not yet a candidate for surgery?
maintain optimal bladder emptying
what should patients do with BPH prior to surgery?
maintain optimal bladder emptying
home visits
may need home-care if -older patient with comorbidities -does not have strong support system -lives alone -family unable to provide care just b/c they live with someone does not mean they have adequate support, so address this may still even need help with a support system
educate patient on dribbling
may occur for up to a year after surgery
what should be monitored closely post-op TURP?
meticulous I&O must be monitored, amount of fluid being irrigated should equal amount of fluid leaving
relieving pain post-operatively (ambulation)
patient is assisted to sit and dangle legs over side of bed on DAY OF SURGERY assist to ambulate NEXT DAY
sexual dysfunction
patient may experience erectile dysfunction, decreased libido, and fatigue PDE-5 inhibitors may be used if neurovascular bundles are preserved to restore erection allow patient to verbalize concerns
PLISSIT
permission, limited information, specific suggestions, intensive therapy - mode of sexual assessment to provide framework for nurses - ask the patient permission (P) to discuss sexual functioning - limited information (LI) may be provided to the patient - specific suggestions (SS) for the patient as the convo progresses - intensive therapy (IT) w/ a sex counselor
special indications 5-alpha-reductase inhibitors BPH
- FEMALES MUST WEAR GLOVES WHEN HANDLING - MALES CANNOT DONATE BLOOD/FERTILIZE DURING AND FOR 6 MONTHS AFTER TAKING THESE MEDICATIONS
postoperative nursing interventions BPH
-maintain fluid balance -relieve pain -monitor/manage complications -educate patient on self care
A patient is having a DRE in the physician's office and the nurse is to assist in the examination. What can the nurse instruct the client to do to decrease the discomfort from the exam?
Take a deep breath and exhale when the physician inserts a gloved finger into the rectum.
urinary incontinence
preventing incontinence involves increasing voiding frequency, avoiding positions that encourage voiding, and decreasing fluid intake prior to activities PELVIC FLOOR EXERCISES absorbent pads and extra clothes
heat lamp
promotes healing post TURP
A client asks the nurse what PSA is. The nurse should reply that it stands for:
prostate-specific antigen, which is used to screen for prostate cancer.
monitor drainage bag for what
bloody urine changes of urine from pink to amber = decreased bleeding
BETTER
bringing up the topic, explaining, telling, timing, educate about treatment r/t side effects, recording - developed to assist HCP to include sexuality in the assessment of the patient with cancer
prostate-specific antigen test
cells produce this protein (PSA), not specific to prostate cancer - increased levels = POTENTIAL prostate cancer - can be elevated with age, race, and prostate size (BPH will cause a high level due to more cells) - many false positives in young men, can be high after ejaculation serum PSA + DRE are more accurate together than separate
urine may be
cloudy for a few weeks
A client is scheduled for a transurethral rescection of the prostate (TURP). Which statement demonstrates that the expected outcome of "client demonstrates understanding of the surgical procedure and aftercare" has been met?
"The surgeon is going to insert a scope through my urethra to remove a portion of the gland."
how often/what men should get a DRE?
- annually for every man older than 50 - age 45 for men at high risk (family Hx) or African american men
factors r/t health history topics for BPH
- chronic illnesses - use of meds that affect sexual function - stress - alcohol - patient's openness to discuss sexual function
side effects of 5-alpha-reductase inhibitors BPH
- decreased libido and ejaculatory dysfunction - erectile dysfunction - gynecomastia - flushing
generalized symptoms of BPH
- fatigue - anorexia - nausea/vomiting - pelvic discomfort
transurethral resection of the prostate (TURP)
-can be done endoscopically -prostate is removed in small chips with an electrical cutting loop -eliminates risk of transurethral resection syndrome -overnight hospital stay -repeated surgery may be needed -rarely causes erectile dysfunction, may trigger retrograde ejaculation
hemorrhage = #1 complication of TURP
-discontinue aspirin, NSAIDs, and platelet inhibitors 10 TO 14 DAYS before surgery to prevent excessive bleeding -prostate gland is very vascular -blood clots can occur which will obstruct urine outflow DRAINAGE NORMALLY BEGINS AS REDDISH-PINK AND THEN CLEARS TO A LIGHT PINK WITHIN 24 HOURS AFTER SURGERY
post-op turp care
-maintenance of fluid volume balance (3- way drainage system) -relief of pain and discomfort -ability to perform self care activities -absence of complications -bladder spasms (controlled w/ antispasmodics)
pre-operative nursing interventions
-reduce anxiety -relieve discomfort -provide education -prepare the patient
provide education pre-op
-review anatomy/structures -explain what will take place during the surgery/diagnostic tests -reinforce any information given by the surgeon
relieving pain post-operatively (bladder spasms)
-urgency to void, feeling of pressure/fullness in bladder GIVE ANTISPASMODICS: Flavoxate (Urispas) and oxybutynin (Ditropan) WARM COMPRESS OR SITZ BATHS HELP TOO
When assessing a client with benign prostatic hyperplasia, which of the following would the nurse expect the client to report as the initial complaint?
Increased effort to void
IPSS
International Prostate Symptom Score questionarre to give to patients
Which statement is accurate regarding sildenafil?
Its side effects include headache, flushing, and dizziness.
VTE complication
assess patient frequently for manifestations of VTE TED hose prior to surgery Lovenox medication SCD's - especially if patient was in lithotomy position during surgery (knees bent)
drainage of bladder is done using GRAVITY through a three-way drainage system to irrigate the bladder and prevent clot formation
continuous irrigation may be used gentle irrigation (50mL) can be prescribed to remove clots
after patient is ambulatory, what should you remind them to do?
do not sit for long periods of time as it can increase intra-abdominal pressure and cause discomfort/bleeding
planning and goals TURP
goals pre-op = reduce anxiety and learning about the prostate disorder goals post-op = maintain fluid balance, relieve pain and discomfort, assess the ability to perform self care activities, and absence of complications
do not use these after TURP
rectal thermometers, rectal tubes, and enemas - can cause injury and bleeding
side effects of alpha-adrenergic blockers BPH
- dizziness, headache - asthenia/fatigue - postural hypotension - rhinitis - sexual dysfunction
what are causes for urinary incontinence in older men?
- medications - neurologic disease - BPH - erectile dysfunction
assessment/diagnostics of BPH
- health history: urinary tract, previous surgeries, health issues, family history of prostate disease, any possible surgery - voiding diary to record frequency/amount - DRE: large, rubbery, nontender - urinalysis: hematuria/UTI - PSA level: can be elevated (also with age, urinary retention, prostatitis, recent ejaculation) - urinary flow rate/residual measurement - ultrasound - cardiac/respiratory status - ELEVATED BUN = CHRONIC URINARY RETENTION
medical management (goals) of patient with BPH
- improve quality of life - improve urine flow - relieve obstructions - prevent disease progression - minimize complications
digital rectal examination (DRE)
- screening for prostate cancer
testicular examination
- self exam - palpated for nodules, masses, or inflammation/any other abnormalities - can reveal hydrocele, hernia, torsion, or tumors - START DURING ADOLESCENCE!!!!
risk factors for BPH
- smoking - alcohol consumption - obesity - poor exercise - HTN/heart disease - diabetes - western diet (high in animal fat/protein, refined carbs, low in fiber)
how much fluid should be given for irrigation of bladder?
50mL of fluid MAKE SURE SAME AMOUNT IS RECOVERED IN DRAINAGE RECEPTABLE SECURE TUBING TO LEG TO RELIEVE TENSION
tissue analysis
6-12 biopsies from all 4 zones are obtained to screen for cancer
TURP
- involves surgical removal of the inner portion of the prostate through an endoscope inserted through the urethra NO EXTERNAL INCISION IS MADE - performed with ultrasound guidance, tissue either vaporizes or becomes necortic/sloughs - usually OUTPATIENT or OVERNIGHT, less post-op bleeding than traditional prostatectomy, along with less risk for infection
what are the positions for DRE?
- leaning over examination table - side lying with knees to chest - supine with legs in stirrups - point toes inward - deep breath and exhale slowly while finger is inserted
with age, what happens to the male reproductive system?
- the prostate gland enlarges - prostate secretion decreases - scrotum hands lower - testes decrease in weight, atrophy, and soften - pubic hair becomes sparse
clinical manifestations of BPH
- urinary frequency, urgency - nocturia - hesitancy in starting urination - decreased or intermittent force of stream and the sensation of incomplete bladder emptying - abdominal straining w/ urination - decreased volume/force of stream - dribbling - acute urinary retention (>50mL) and recurrent UTI's - urinary residual can lead to azotemia (accumulation of nitrogenous waste) and kidney failure
reduce anxiety
-assess patients understanding of surgery -clarify any expectations -provide privacy/develop a trusting relationship
discharge instructions
-gravity bag v leg bag -empty bag in toilet, never raise above bladder -no baths -clean catheter site with mild soap and water -no ointments/creams
patient/family education
-how to manage the drainage system -how to assess for complications -how to promote recovery -how to monitor urinary output -wound care
continuous bladder irrigation
-bladder spasms can make it feel like you need to urinate -the more the patient bleeds, the faster the drip rate -infusion rate based on the urine (amount and color) -amount of drainage in bag must = amount being infused, if not it could be staying in the bladder due to a kink or obstruction
how does an examiner perform a DRE?
- used a lubricated, gloved finger into the rectum to assess the size, symmetry, shape, and consistency of the posterior surface of the prostate gland - assessing for tenderness on palpation and for the presence of nodules
preparing the patient for surgery
-antiembolism stockings before surgery r/t VTE -enema given at home the night before to prevent post operative straining (can increase risk for bleeding)
nursing diagnosis TURP
-anxiety -acute pain -deficient knowledge -risk for fluid imbalances -hemorrhage -infection -shock -VTE -catheter obstruction -urinary incontinence -sexual dysfunction
DRE results for a client with BPH
large, rubbery, and nontender prostate gland tender would mean it is cancer (mass)