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Peter Harris is 72-year-old man who was admitted to hospital for surgery following urinary symptoms that led to a diagnosis of benign prostatic hyperplasia (BPH). He has a history of COPD and Type 2 diabetes. Peter lives alone but his adult son is with him on admission and reports that his father likes his beer and can drink up to six stubbies per night and does not eat well. Peter currently weighs 70kgs. 

Peter was taken to surgery and underwent a transurethral resection of the prostate (TURP) under spinal anaesthesia. 
After 1 hour in the post-anaesthetic recovery room (PARU) and an uneventful recovery, he was transferred to the ward, where you have been allocated to his care.

On return to the ward, Peter's observations are as follows: 

• Respirations 30 breaths per minute

• BP 100/60mmHg

• Pulse 128bpm

• Temperature 35.0°C.

• Pain score 0/10

• He has a continuous bladder irrigation via a three lumen urethral catheter. His urine contains large blood clots.

• Peter has IV therapy via peripheral line running at an 8-hrly rate. 

It is planned for Peter to be discharged after two days on the ward.

Questions To Be Addressed  In relation to Peter Harris: 

• Discuss the aetiology and pathophysiology of the patient's presenting condition

• Critically discuss the underlying pathophysiology of the patient's post-operative deterioration. Prioritize, outline and justify the appropriate nursing management of the patient during this time

• Identify three (3) members of the interdisciplinary healthcare team, apart from the primary medical and nursing team, who you would involve in the care of the patient before their discharge and provide justification for their involvement.

Overview of Peter Harris' case

A very important aspect for effective PARU care planning and delivery is the correct and adequate analysis of the exact disease process and how the disease develops along with the aetiological process so that the care plan that is going to be devised for the patient can be optimally individualized (Patel & Parsons, 2014). Along with aetiology, understanding the pathophysiology of the post-operative deteriorations is also extremely important for the nurses so that they can easily recognize the anomalies and the root cause behind the development of them before developing the care plans for the patients and addressing to their care needs. This essay will attempt to explore and analyse the aetiology and pathophysiology of the disease, post-operative deteriorations, and the exact nature of the postoperative deteriorations to be able to provide adequate and safe patient centred care.

The case study represents a 72 year old patient named Peter Harris who had to undergo the surgical procedure of transurethral resection of the prostrate or TURP under spinal anaesthesia due to the benign prostatic hyperplasia that he had. Benign prostatic hyperplasia can be defined as the histological diagnosis that is associated with unregulated proliferation of the connective tissue, glandular epithelium and the smooth muscles. It is a more or less common health disorder that affects the men in the older age, and is generally considered to be a disorder that is associated with old age (Nayak et al., 2017). In order to discuss the aetiology and pathophysiology of the disease, it has to be mentioned that BPH is a common progressive condition that is characterized by not just prostate enlargement that is also accompanied by lower urinary tract symptoms as well. Exploring further, BPH arises in the peri-urethral and transitional zones of the prostate glands and many authors have argued BPH and its associated lower urinary tract symptoms to be an inescapable phenomenon for the ageing male population. The estimated percentage of men over the age of 50 years that have reported symptoms of BPH to be arising is 75% and along with that, 20-30% of men between the age group of 70 to 80 that have BPH reported to be needing surgical intervention. Although, the disease is fairly common, the pathogenesis and aetiology of the disease is still largely unresolved (Roper, 2017). Although, there are various different theories that have been introduced to attempt to decipher the aetiological course of the development of BPH that indicate hormonal alteration, inflammation and metabolic syndrome to be the most important causal factors. First and foremost, ageing has been discovered as the most potent risk factor this disease, several studies have been successful in drawing reference between the physiological process of ageing and the markers of BPH progression.

In support, Goren and Gat (2018), have stated that there is a significant tissue remodelling process that occurs in the ageing males, especially in the transition zones. Exploring further, there is also an interference in the stability of the growth factor signalling pathways as well which alters the fate of the divisible cells in the region, especially the basal cells. These basal cells undergo changes in intracellular metabolic pathways becoming hypertrophic and enlarged and when accompanied by age derived changes in the stromal epithelial interactions, there is a benign volume enlargement of the prostate. However changes in the male hormone levels and metabolic syndromes that are facilitated due to age are also contributing factors to the etiology of the disease. The signs and symptoms of this disease is mainly the LUTS which Peter had been suffering from such as incomplete emptying of blabber, nocturia, urinary incontinence, need to strain while urinating, painful urination and haematuria. The type 2 diabetes also has a significant link to the occurrence of BPH facilitated by the link between glycaemic control and prostate enlargement, however, the impact of the dynamic glycaemic control is more linked to LUTS symptoms as compared to the BPH (Roper, 2017).

Aetiology and pathophysiology of Benign Prostatic Hyperplasia

Peter had underwent a transurethral resection of the prostate as a surgical management of the BPH symptoms he had been suffering from. Although the patient has had an uneventful recovery after the surgery, the vital signs that the patient has documented in the PARU unit indicates varied degree of anomaly. First and foremost, his respiratory rate is at 30 breaths per minute, which is extremely high for the patient which is a considerable post-operative deterioration. As per Novosad (2016), the normal respiratory rates are 12 to 16 breaths per minute for an adult. Hence, the respiratory rate for this patient is almost double of the normal rates, which indicates at post-operative deterioration. A high respiratory rate after a surgical procedure is often indicative of a massive medical emergency such as cardiac arrhythmia or even sepsis. In order to discuss the cause behind the respiratory distress, Nakahira et al. (2017), have mentioned that in the post-surgical condition, the increased resistance to the airway flow, increased tissue resistance, and increased thoracic resistance causes a significant impact on the development of the respiratory distress. Along with that, it has to be mentioned that the patient had been suffering from COPD which indicates at possibility of bronchial restriction or airway collapse which can be further aggravated due to the surgery.

The next deterioration is blood pressure and pulse rate which also indicates at the post-operative deteriorations as well. The normal range of blood pressure is 120/80 mmHg for a healthy adult and the normal pulse rate is 100 beats per minute (Novosad, 2016). On the other hand, the patient had a blood pressure of 100/60 mmHg which indicates hypotension and pulse rate at 128 bpm which indicates arrhythmia. As per Nag et al. (2018), the impact of anaesthesia is often the most important contributing factor that has a significant impact on the blood pressure of the patient, septic shock or the chances of a severe surgical site infections can also be a considerable reason behind the drop in the blood pressure along with vasodilation. The elevated heart rate or tachycardia can be associated with a cardiac risk and should be addressed to avoid any myocardial injury (Cimino et al., 2017). The most plausible contributing factor to the increased heart rate can be the anaesthesia and the oxygen therapy, used in the surgery. As Peter had a previous history of COPD, the chances of the heavy dose oxygen therapy on increasing the heart rate is highly likely. The patient has 35 degree body temperature which is indicative of risk of perioperative hypothermia which is mainly caused by decreased peripheral blood flow as a result of the anaesthesia; the patient had not been feeling any pain at all which can also be due to high block of anaesthesia. Lastly the patient had blood clots in the urine, which indicates at perioperative haematuria; although the occurrence of blood or clots in the urine is considered normal after a TURP surgery due to the wound healing and bladder scab being loosened, care should be taken to stop the bleeding (Goren & Gat, 2018). In case all of her presenting post-operative symptoms are taken into consideration, the patient might be at a risk of septic shock. In this case, the patient is already having high pulse and RR, a blood test should be carried out to ascertain whether the WBC count of the patient is abnormally high or low to confirm risk of sepsis (Rhodes et al., 2017).

Post-operative deteriorations experienced by Peter Harris

The first care priority will be to manage the risk of sepsis, the immediate nursing responsibility will be to administer antibiotics with oxygen and fluids by vein. In the next step the nurse must provide bronchodilators to the patient to minimize the respiratory rate, in case the issue persist, the patient should also be given the aid of external oxygen therapy. Followed by which the patient should be given anti-hypotension medication and medication for tachycardia along with electrolyte therapy to regain hemodynamic stability in his body. In this case, the nursing management for Peter will be to perform bladder irrigation for flushing out any remaining blood clots so that there is no risk of blockage or infection. The nurse will also have to encourage the patient to enhance fluid intake to flush out any remaining blood. To manage the body temperature, the nursing management will be provide warm blankets and electrolytes to enhance the body temperature back to normal and check the anaesthesia levels in the body (Haese & Sotelo, 2018).

Three other interdisciplinary health care team that will need to be involved in the care for Peter includes firstly a dietician. Peter is a type two diabetic, which is a disorder that comes with a variety of different dietary restrictions. Hence, it is very important for the patient to understand his dietary intake after discharge which will also help him to recover and meet all his nutritional requirements, but will also help in performing glycaemic control for him (Mahomoodally, Ruhee & Holmes, 2016). Hence, it is imperative for his care plan to involve a dietician or a nutritional expert who will help him develop a diet chart with his collaboration to best assist in his recovery. The second member will be a community support nurse, as Peter is living alone and has no one to care for him, there are certain self-care risks including medication adherence, surgical wound management, mobility, fall risk and even certain self-care activities. Hence, Peter will require assistance from a community health and social care support network to provide him with 24*7 assistance (Deek et al., 2016). Lastly, alcohol addiction is considerable issue for Peter which can lead to severe consequences for the patient post discharge and affect his recovery. Hence, an addiction relief psychotherapist will also be involved in his care who will not only help him cope with his surgery and post-surgical restrictions but will also help him overcome his alcohol addiction through rehabilitation care programs (Yokell et al., 2014).

On a concluding note, Post-operative care delivery is dependent upon a variety of different factors, and the condition that the patient is in and how to provide care to the patient. As a result the nurses are required to undertake a thorough assessment and analysis of the patient and his presenting symptoms to be able to plan and implement patient centred and safe care. This essay had been successful in discovering all the key post-operative deterioration that Peter had been suffering from and has discussed adequate priority based interventions. Along with that, this essay has also outlined three interdisciplinary health care members to help him recovery completely after discharge and be able to attain a state of optimal health and wellbeing with adequate support and assistance.

References:

Cimino, S., Voce, S., Palmieri, F., Favilla, V., Castelli, T., Privitera, S., ... & Morgia, G. (2017). Transurethral resection of the prostate (TURP) vs GreenLight photoselective vaporization of benign prostatic hyperplasia: analysis of BPH6 outcomes after 1 year of follow-up. International journal of impotence research, 29(6), 240.

Deek, H., Noureddine, S., Newton, P. J., Inglis, S. C., MacDonald, P. S., & Davidson, P. M. (2016). A family?focused intervention for heart failure self?care: conceptual underpinnings of a culturally appropriate intervention. Journal of advanced nursing, 72(2), 434-450.

Goren, M., & Gat, Y. (2018). Varicocele is the root cause of BPH: Destruction of the valves in the spermatic veins produces elevated pressure which diverts undiluted testosterone directly from the testes to the prostate. Andrologia, 50(5), e12992.

Haese, A., & Sotelo, R. (2018). Simple prostatectomy. In Complications in Robotic Urologic Surgery (pp. 239-251). Springer, Cham.

Mahomoodally, M. F., Ruhee, C. D., & Holmes, T. F. M. (2016). A qualitative study of healthcare professionals' perceived trust in and willingness to recommend alternative medicines for the management of diabetes mellitus. African Journal of Diabetes Medicine, 24(1).

Nag, D. S., Chatterjee, A., Samaddar, D. P., & Agarwal, A. (2018). Perioperative stroke following transurethral resection of prostate: high index of suspicion and stabilization of physiological parameters can save lives. Revista brasileira de anestesiologia, 68(4), 388-391.

Nakahira, J., Nakano, S., Sawai, T., Ishio, J., Ono, N., & Minami, T. (2017). Factors Causing Post-Anesthetic High Respiratory Resistance in Patients Undergoing Transurethral Resection of Bladder Tumors. Anesthesiology and pain medicine, 7(2).

Nayak, B. S., Sinanan, K., Sharma, S., Shripat, V., Sidat, R., Siddiqui, S., ... & Sieunarine, S. (2017). Investigating the link between benign prostatic hypertrophy, BMI and type 2 diabetes mellitus. Diabetes & Metabolic Syndrome: Clinical Research & Reviews, 11, S627-S630.

Novosad, S. A. (2016). Vital signs: epidemiology of sepsis: prevalence of health care factors and opportunities for prevention. MMWR. Morbidity and mortality weekly report, 65.

Patel, N. D., & Parsons, J. K. (2014). Epidemiology and etiology of benign prostatic hyperplasia and bladder outlet obstruction. Indian journal of urology: IJU: journal of the Urological Society of India, 30(2), 170.

Rhodes, A., Evans, L. E., Alhazzani, W., Levy, M. M., Antonelli, M., Ferrer, R., ... & Rochwerg, B. (2017). Surviving sepsis campaign: international guidelines for management of sepsis and septic shock: 2016. Intensive care medicine, 43(3), 304-377.

Roper, W. G. (2017). The prevention of benign prostatic hyperplasia (bph). Medical hypotheses, 100, 4-9.

Tai, S., Xu, L., Zhang, L., Fan, S., & Liang, C. (2015). Preoperative risk factors of postoperative delirium after transurethral prostatectomy for benign prostatic hyperplasia. International journal of clinical and experimental medicine, 8(3), 4569.

Yokell, M. A., Camargo, C. A., Wang, N. E., & Delgado, M. K. (2014). Characteristics of United States emergency departments that routinely perform alcohol risk screening and counseling for patients presenting with drinking–related complaints. Western journal of emergency medicine, 15(4), 438.

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