Recognition of clinical deterioration and abnormal signs is among the most important aspects of clinical assessment. The current paper is a discussion of a case study of Peter Harris, a 72-year-old male patient, who presented with urinary signs and symptom, admitted for surgical correction of benign prostatic hyperplasia. He has a past medical history of chronic obstructive airway disease and type 2 diabetes mellitus. A diagnosis of BPH was made and surgical correction was done by transurethral resection of the prostate. He was later transferred to the ward for post-operative recovery. His vitals were: the respiratory rate of 30 breaths per minute, blood pressure of 100/60, heart rate of 128 bpm, the temperature of 35oC and a pain score of 0/10. He had continuous bladder irrigation via a three-lumen catheter and it was noticed that the urine contained large blood clots. He also had a peripheral line running fluids at 8 hourly rates. The paper will outline the pathophysiology of BPH, etiology, and pathophysiology of abnormal vitals post-operative, priorities of care including nursing interventions and the multidisciplinary team that will help him excluding the primary nurse, surgical team or physician.
BPH is an enlargement of the prostate gland with or without urinary symptoms (Kumar, Abbas, & Aster, 2017). This is evidenced by microscopic prostatic stromal and epithelial hyperplasia that is almost always in the transitional and periurethral zones of the prostate (Williams & O'Connell, 2013). The pathophysiology is not clearly understood but is postulated to involve age and hormonal influences. Age is the single most important risk factor for BPH as the incidence increases with advancing age. This lead to the postulation of the mesenchymal theory of BPH, which states that BPH is due to slowed apoptosis of cells in favor of cell proliferation (Williams & O'Connell, 2013).
The other correlation postulates a link between BPH and hormonal imbalance. There is an interplay between imbalanced testosterone, estrogen, prolactin and growth factors. It is hypothesized that since testosterone levels decrease with age and estrogen levels do not equally decrease, the effects of unopposed estrogen on stromal and epithelial cells cause BPH. Intermediate peptide growth factors are also thought to play a role in the pathology (Chughtai et al., 2016).
The close proximity to the prostatic urethra and the bladder will present with urinary symptoms (Roehrborn, 2011). Up to 80% of men more than 60 have histological evidence of BPH but only about 40% of them will develop symptomatic BPH. This makes it the most prevalent urological problem in the world (Roehrborn, 2011).
Signs and symptoms of BPH are due to either the outflow obstruction or the physiologic response of the bladder to outflow resistance (Sarma & Wei, 2012). The muscles of the bladder hypertrophy to overcome outflow obstruction and there is increased blood flow to these muscles leading to prominent vasculature that is prone to bleeding and hematuria. The bladder becomes more irritable and less compliant with detrusor instability. The urethra becomes narrowed and lengthened and may change curvature and become distorted (Sarma & Wei, 2012). The prostatic stroma has smooth muscles with a vast adrenergic nerve supply. Hypertrophy leads to increased autonomic tone that is set on the prostatic urethra.
Lower urinary tract symptoms are either irritative or obstructive. Irritative symptoms include increased frequency, nocturia, urge incontinence and dysuria. Obstructive symptoms include straining during voiding, poor urine stream, incomplete voiding with dribbling, and hesitancy or intermittency (Lewis, Dirksen, & McLean, 2013). Other symptoms and complications of BPE include hematuria, lower urinary tract infections with fever and dysuria, acute urinary retention, chronic urine retention, and renal failure in severe cases (Hinkle & Cheever, 2013).
Treatment of BPH can be medical or surgical. Medical treatment employs drugs such as alpha blockers that reduce the adrenergic tone. The preferred surgical procedure for correction of BPE is a transurethral resection of the prostate (Williams & O'Connell, 2013). This is the procedure that the patient underwent. It involves resecting the bladder in small “chips” and the pieces of the prostate removed (Williams & O'Connell, 2013).
The patient showed abnormal vital signs on assessment in the ward. Normal vital signs include heart rate between 60 to 100 beats per minute, blood pressure of between 90/60 to 130/85 mmHg with a pulse pressure of 30-50 mmHg, temperature between 36.5 to 37.2OC and respiratory rate of between 12 to 20 breaths per minute (Australian Commission on Safety and Quality in Health Care, 2012). The patient had a tachycardia of 128 bpm, a tachypnea of 30 breaths per minute and a hypothermia of 35OC.
The reasons for abnormal vitals are hypovolemic shock due to hemorrhage. A complication of TURP is hematuria. It occurs in 6% of patients undergoing TURP. In the patient, this was evidenced by heavy bleeding seen as large clots during continuous bladder irrigation. Shock progresses through four stages, an initial stage, a compensatory stage, progressive stage and a refractory stage (Lewis, Dirksen, & McLean, 2013).
Patient Peter is at the compensatory stage of hypovolemic shock. Hypoperfusion due to reduced intravascular volume leads to end-organ dysfunction. At this stage, the body tries to improve perfusion by having a fight or flight response (Lewis, Dirksen, & McLean, 2013). The sympathetic nervous system is activated leading to increased heart rate and vasoconstriction. Vasoconstriction improves peripheral resistance and keeps the blood pressure within normal while sympathetic effects on the heart cause tachycardia (Kreimeier, 2016). Peripheral vasoconstriction is, however, selective as blood is shunted to vital organs from organs such as kidneys, skin, and the gastrointestinal tract. Hypothermia is due to shunting of blood from the skin, resulting in cold, clammy hands. Urine output also reduces as renal blood flow is reduced due to vasoconstriction (Hinkle & Cheever, 2013). Reduced perfusion causes the body to reverts to anaerobic respiration, releasing lactic acid as a byproduct and producing a metabolic acidosis necessitating the patient to hyperventilate (respiratory rate of 20-30) to remove excess acid (Hinkle & Cheever, 2013). The high respiratory rate could also be due to his underlying chronic obstructive pulmonary disease. The pain score is at 0/10 due to the persistence of spinal anesthesia used during the procedure and will wear off gradually upon complete reversal of anesthesia.
Clinical problems in this patient that should be a priority include inadequate fluid volume in circulation, acute pain and risk of infection in disability (Hinkle & Cheever, 2013). Inadequate fluid volume is related to hemorrhage in hypovolemic shock and is evidenced by signs of bleeding and tachycardia of 128 beats per minute, and increased respiratory rate of 30 breaths per minute. Acute pain is related to surgery while the risk of infection is related to surgery and underlying diabetes mellitus.
The goals of interventions for inadequate fluid volume include maintaining the patients circulating volume evidenced by normalization of vital signs including blood pressure and pulse rate, normalization of urine output and skin warm and dry. The nursing interventions include monitoring trends in vital signs including heart rate, blood pressure, temperature, and level of consciousness. These show clinical deterioration to worse stages of shock or response to intervention (Kyriacos, Jelsma, & Jordan, 2011). Administration of fluids as indicated is the next recommended action. Crystalloids should be used to improve fluid volume in the initial stages of shock as this is enough to correct the deficit and improve perfusion (Perel, Roberts, & Ker,2013). More blood loss of more than 30% of body weight should necessitate blood transfusion as the fluid of choice for a replacement (Gutierrez, Reines & Wulf-Gutierrez, 2014).
The goals of care in acute pain management include patient to be pain-free in 24 hours as evidenced by verbalization of pain-free period and relaxed posture and uninterrupted sleep. The nursing interventions for acute pain intervention include assessing the patient’s pain including reports of the duration, severity, intensity, character, onset and associated factors (Vadivelu, Mitra, & Narayan, 2010). The pain is rated on a scale of 1-10. This helps in guiding intervention or assessing improvement. The second intervention provision of comforting means such as a pleasant environment, back rub, position changes and other means such as music (Gelinas, Arbour, Michaud, Robar, & Côté, 2013). These measures sooth the patient and reduce anxiety and pain. Finally, administer analgesics as charted. Post-operative pain management with analgesics has been shown to reduce hospital stay and improve morbidity (Turk & Melzack, 2011).
The risk of infections should be adequately combated as post-operative infection following TURP is a concern (Rosenberger, Politano, & Sawyer, 2011). The rate of infection in these patients is increased in those with unsterile urine, and catheterization. Septicemia can occur shortly after the operation. This patient is at an increased risk due to his type 2 diabetes. The goal is for the patient to remain free of infection evidenced by the absence of signs of infection and normal vitals during the 3 days post-operative. Interventions include monitoring the patient’s lab works for signs of infection such as raised white blood cells, ESR, CRP or positive urine cultures (Hinkle & Cheever, 2013). Clinical signs of infection should also be monitored for including fever, draining pus from surgical wounds or a catheter site. Patient handling should be done using aseptic techniques to avoid infection spread. This encompasses the safe care campaign that aims at reducing surgical infections by promoting strict infection control measures such as hand washing. Medications should be administered as indicated including prophylactic antibiotics (Hinkle & Cheever, 2013).
A multidisciplinary approach is important in the management of this patient. Other team members apart from the primary nurse, surgical team, anesthesia team and physician include a social worker, dietitian, and a psychologist. Social workers help in the follow-up of the patient ensuring there is social support through the family and the community. A psychologist is able to help the patient with coping with chronic illness, aging and perceived health deterioration by the patient. A dietitian is also needed as nutritional support for a post-surgical patient is ideal to facilitate healing and prevent infection and other complications. This referral is also indicated since the patient is diabetic, requiring special nutritional support (Hinkle & Cheever, 2013).
In conclusion, clinical deterioration in this patient post TURP was due to hypovolemic shock due to hematuria. This presented with deranged vital signs and reduced urine output. Priorities of care included correcting the inadequate fluid volume, managing post-surgical pain and preventing post-operative infection. The multidisciplinary team recommended to be involved in the care of the patient include a dietitian, psychologist and social worker.
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