HESI case study - Benign Prostatic Hyperplasia - Bob Hamilton

Ethical-Legal Issues: Malpractice It is determined that Mr. Hamilton experienced a febrile transfusion reaction. This type of reaction is caused by the body's sensitivity to components in the donor blood such as WBCs, platelets, or plasma proteins. In addition to stopping the transfusion, the nurse sends the blood bag, tubing, and a urinalysis to the lab, and administers an antipyretic medication until Mr. Hamilton is once again afebrile. The nurse is upset that Mr. Hamilton experienced a transfusion reaction and the nurse talks with the charge nurse about the situation. The nurse states, "I never thought I would get sued for malpractice. Do you think I will be sued because of this?" What is the best initial response by the charge nurse?

"Describe everything you did that is related to the transfusion." This is an assertive response by the charge nurse and offers both nurses an opportunity to review the situation to determine if malpractice occurred.

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

"You will still need 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.

Mr. Hamilton continues to take his medications for 8 months, but his symptoms do not improve significantly. He is scheduled for residual catheterization at the clinic. Which catheter should the nurse select to perform the procedure?

12 French straight catheter. Residual urine measurement does not require an indwelling catheter, so a small, straight catheter is the best choice. If the nurse is unable to insert a small, straight catheter, a curved, Coudé-tip catheter may be used to successfully pass the enlarged prostate gland. Ultrasound techniques may soon eliminate the need for invasive residual urine catheterizations. *************************************************** INCORRECT: 8 French catheter with a 5 mL balloon. This is a small indwelling catheter and is not the appropriate size for an adult. 16 French catheter with a 5 mL balloon. This indwelling catheter is not necessary to measure residual urinary retention. 12 F metal catheter. A metal catheter would only be used by a urologist.

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

The nurse recognizes that nonverbal behavior such as eye contact varies in different cultures. How can the nurse best interpret Mrs. Hamilton's minimal eye contact, in light of Mrs. Hamilton's cultural background?

A cultural practice based on recognition of someone's social status. In Korean culture, avoiding eye contact or engaging in minimal eye contact, is based on recognition of a person's status. This would be a common response to engagement in a conversation with an HCP, who would be seen as an authority figure by most Korean laypersons.

The nurses discuss the components needed to prove professional negligence or malpractice. They discuss "Breach of Duty."

A nurse's actions do not meet established standards. Breach of duty is the failure to perform according to established standards, such as those defined in state Nurse Practice Acts.

Which nursing diagnosis has the highest priority when implementing care?

Altered cardiac output. Hemorrhage has resulted in decreased cardiac output, resulting in hypovolemic shock. This is the highest priority.

While Mr. Hamilton is awaiting transport to the Operating Room (OR), 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.

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.

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.

Which instruction should the nurse provide to Mr. Hamilton before starting the procedure?

Empty your bladder completely. The purpose of residual catheterization is to determine the amount of urine remaining in the bladder after voiding.

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 nurse administers oxygen per face mask, ensures that the IV is patent, and notifies the HCP that Mr. Hamilton is experiencing overt bleeding and manifestations of hypovolemic shock. Specimens for stat blood work and arterial blood gases are drawn. Which lab value would the nurse question?

Hemoglobin 15.0 g/dL. Since Mr. Hamilton is experiencing hypovolemic shock secondary to hemorrhage, both the hemoglobin and hematocrit would decrease.

Which additional manifestations would the nurse expect in clients with BPH?

Hesitancy when starting the urine stream. This is a common manifestation in men with BPH, along with nocturia, frequency, post-void dribbling, and hematuria. Decrease in the size and force of urine stream. It is common for men with BPH to experience a decrease in the size and force of the urine stream, rather than an increase, due to the obstruction of the urethra caused by the enlarged prostate gland. Frequent urination, including nocturia. Besides hesitancy and decrease in size and force of urine stream, frequency and nocturia are also common manifestations of BPH.

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 normal saline solution through separate IV tubing. After stopping the blood transfusion, the nurse should next infuse normal saline through a separate IV tubing to maintain IV patency. Mr. Hamilton may experience shock and may need additional fluids and medications.

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 a physical examination to further investigate Mr. PerryHamilton's symptoms. Which assessment finding would indicate that Mr. Hamilton is experiencing urinary retention?

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.

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.

While the nurse is monitoring Mr. Hamilton closely, which additional responsibility is best to assign to the LPN?

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.

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.

What analogy can the nurse use to describe how to contract the 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.

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.

In what position should the nurse place Mr. Hamilton?

Supine with feet elevated at a 45 degree angle. Elevating the feet above heart level promotes venous return, increasing the circulatory volume. The client's head may also be elevated to 30 degrees. INCORRECT: High-Fowler's position with feet lowered. This position will increase the client's hypotension. Semi-Fowler's position with feet flat. This position may be desirable in cardiogenic shock to prevent venous return from taxing the heart, but it is not desirable in hypovolemic shock. Trendelenburg position with feet elevated. In the Trendelenburg position, the head is lowered. This is not desirable in shock, because cardiovascular and respiratory function may be compromised.

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.

"Do not try to void 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.

What is the best response by the nurse?

"I will be glad to answer any questions you may have." This response gives Mrs. Hamilton the opportunity to choose any further interaction and respects the practices of her culture, which include avoidance of physical touch between persons who are not close. INCORRECT: "Do you want me to stay here with you for a while?" Although this response demonstrates offering of self, persons of Korean background may feel that a response of "no" would be disrespectful to the nurse. "I can see you are comfortable, but call if I can help you." Mrs. Hamilton's behaviors and verbalization may be reflective of a cultural response that the nurse has misinterpreted. Take Mrs. Hamilton's hand and offer silent support. Mrs. Hamilton may be uncomfortable with physical contact.

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.

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? 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.

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

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.