Case Study 3: John Wong's Essay On Transurethral Resection Of The Prostate.

Pathophysiology of John Wong's Condition

Case Study 3: John Wong (Transurethral Resection of the Prostate)

John Wong is an 80 year old male of Chinese origin. John’s medical history includes hypothyroidism and osteoporosis and he smokes 10 cigarettes per day. His gait has recently been increasingly unstable and he has difficulty with simple tasks, such as getting up his house stairs and getting up from chairs.

In the last 4 weeks, he has noticed that he has been having difficulty passing urine and some abdominal discomfort. His GP referred him to a urologist and a prostate biopsy was taken. This showed BPH (benign prostate hyperplasia) and it was recommended that he undergo a Transurethral Resection of the Prostate (TURP).

While conducting John’s pre-admission assessment it is noted that John is slightly hypertensive and is fidgeting and moving around the waiting room. After some education John states that he is pleased to have the surgery as he hopes it will relieve some of the discomfort he has been experiencing. John tells the nurse that he currently lives alone.

John’s surgery is uneventful during the intra-operative stage. On arrival to PACU John is placed in a supine position. He is drowsy and restless and oxygenated through a facemask on 02 at 5l/min. A wheeze and non-productive cough is noted. John has an IDC insitu with continuous bladder irrigation with output noted to be a reddish pink. A number of blankets are placed on top of him as he is shivering. His observations are T 36.5c, HR 90, RR 30, BP 150/90 and SpO2 91%.

John is transferred to the surgical ward after a 65 minute stay in PACU. John remains drowsy but easily rousable. He is oxygenated via intra-nasal cannulae at 2l/min and he states his pain is 3/10. He has 0.9% sodium chloride infusion running at 125ml/hr. Post-operative orders include IVF, analgesia (PRN Endone, 5mg 6hrly and Paracetamol, 1g 4-6hourly), strict FBC and continuous bladder irrigation for 24 hours, with an aim of rose urine output.

Four hours after John’s return to the ward he is observed to be in pain and distressed. He is diaphoretic and restless and states that his bladder feels full and he feels the urge to urinate. At this time, vital signs are noted to be: T 36.9c, HR 91, RR 28, BP 146/91 & SPO2 98%. On review of his documentation it is found that his fluid status has a positive 500ml balance and his urine is of red colour. There are blood clots in his urine.

Required:

1. In relation to your chosen patient, discuss the pathophysiology of their condition and using evidence based practice explore current treatment options for your patient’s condition, include any pharmacological and non-pharmacological considerations.

2. Critically discuss four (4) components of the PACU discharge criteria outlined in the Aldrete Scale. Utilize the scale provided on LEO as a resource in your case study.

3. Develop a discharge plan to support your patient on discharge. Include any education you deem relevant, any referrals to allied health professional/s required, and discuss your rationale.

Evidence-Based Treatment Options

1. According to the case study, John Wong is suffering from hypothyroidism, osteoporosis and is currently diagnosed with benign prostate hyperplasia. Hypothyroidism is said to be a condition, caused because of deficient thyroid hormone production from thyroid gland. The HPT or hypothalamic-pituitary-thyroid axis administers the secretion of thyroid hormone. Osteoporosis is said to be a progressive bone disease, where bone density and mass decrease and can cause an increased possibility of fracture. Benign prostate hyperplasia is considered as the condition of benign increase in prostate size (McEvoy, 2013). It includes hyperplasia of epithelial and stromal cells, giving rise to discrete, large nodule formation within the transitional zone of prostate. If these nodules grow sufficiently large they affect the urethra and resist urine flow from bladder. Both stromal and glandular epithelial cells, along with muscular fibers go through hyperplasia phase in benign prostate hyperplasia (Isaacs, 2008). Evidences have supported the fact that out of the two different tissues, stromal cell hyperplasia prevails but the accurate ratio is still not clear (Lin et al., 2007). Benign prostate hyperplasia is strongly related with prostate transitional zone and posterior urethral glands. The initial indications of this condition usually initiate between 30-50years of age in posterior urethral glands that are present next to proximal urethra. In this incident mostly the growth takes place in transition zone (Foster, 2000). Apart from these two recognized zones, another area called peripheral zone is believed to be involved with this condition, but to a slighter extent. Prostate cancer initiates in peripheral zone. To rule out the possibility of cancer, usually the nodules, which are formed in the transitional zone, are biopsied. The American Urological Association has stated that BPH is incurable; hence treatment should be focused on lessening the indications (Strope, Yang, Nepple, Andriole & Owens, 2012). The treatments depend upon the symptoms severity. A surgeon may recommend a patient for surgery, for example: transurethral needle ablation, transurethral resection of prostate or transurethral microwave therapy. BPH affects individual’s quality of life, so proper nursing care (non-phrmacological), apart from the pharmacological care is very much important (Mitropoulos et al., 2002). A nurse should convey the patient that he should not rush his urination, he should feel relaxed while using toilet. He should properly distribute his fluid intake throughout a day. Pharmacological considerations include application of drugs like alpha blockers, 5-alpha reductase inhibitors, phytotherapeutics and anticholinergics. These drugs are focused on complication prevention and change of disease progression, which are linked with BPH.

2. Patients do recover in post anesthetic care unit (PACU), requires proper airway management and accurate monitoring to avoid post operative difficulties (Litwack, 2009). The Aldrete scale is said to be a recovery measurement scale which is used after anaesthesia. This scale includes estimating consciousness, respiration, blood pressure and activity. In the care unit after anesthesia, the nurse anesthesia, anesthesiologist and the nurse anesthetist involves patient condition, surgery performed; type of given anesthesia, blood loss, total fluid input and urine output during surgery (Tzeng, 2000).  The PACU nurse should note if any surgical complications are present, including differences in blood circulation stability. Evaluation of patient’s airway openness, consciousness level, vital signs are considered as the fundamental priorities after admission to the post anesthetic care unit. Apart from that other assessment categories are surgical site, body temperature (hyperthermia/hypothermia), patency of drainage tubes, rate of intravenous fluids, sensation in extremities after surgery, sensation level after local anesthesia, vomiting pain status. Surgical site assessment includes intact dressings without any indications of bleeding. Assessment of drainage tube patency means that checking proper opening of tubes.

Components of PACU Discharge Criteria

A patient can only be discharged from care unit when he/she meets set up discharge criteria, as identified by the Aldrete scale. This scale scores patient’s respiratory status, mobility, pulse oximetry, conscious and circulation. The importance of Aldrete scale includes checking consciousness after anesthesia. Not only that this will also help the nurses to understand a patient’s current health condition after a surgery and anaesthesia. The assigned score is also responsible for checking blood pressure, respiration and activity. According to Aldrete score an individual patient should score nine or more for confirmed recovery. If the patient do not meet the scoring criteria then he/she should not be released to general ward. This is because his/her condition might deteriorate after surgery.

Aldrete scoring:

Activity:

• four extremities:
• Two extremities:
• No extremities:

Respiration:

• Deep breathing and freely coughing
• Shallow, dyspnoea or limited breathing:
• Apnoea:

Circulation:

• Blood pressure within 20mm Hg prior surgery
• Blood pressure within 20-50mmHg prior surgery
• Blood pressure +/-50mm Hg prior surgery

Consciousness

• Fully awake
• Arousal on calling
• Unresponsive

Oxygen saturation

• Saturation>92%
• Requires oxygen to retain saturation>90%
• Saturation<90% with oxygen

Based on surgery types and patient’s condition, he/she may be admitted to intensive care unit or general surgical ward. After anesthesia patient may still be in sedative condition, hence patient safety is a fundamental goal. Patients may be discharged from care unit to general ward or home after their proper urination, capacity to moving out of bed and have development of oral intake capacity.

In this case study it is seen that after arrival to PACU John is placed in a supine position. This is a good approach to ensure that patient is under good airway management. Airway management is said to be a medical process to make sure that there is open passageway between outside world and patient lungs along with diminishing aspiration risk (Løvstad, Granhus & Hetland, 2000). John is restless, drowsy and oxygenated through a facemask. Oxygenated mask is an additional process which assists smooth air passage. This would help John to avoid the condition of hypoxaemia or low oxygen level in blood. John has a normal body temperature, yet he is shivering, which might be because of pain after surgery, hence monitoring of his body temperature is significant.

During pre-admission it is recorded that John is hypertensive and also after the surgery his blood pressure is 150/90, which is more than the standard blood pressure level. Elevated blood pressure can worsen John’s complications. It is mentioned that John is drowsy after surgery, so grading consciousness is important with the help of Glasgow Coma Scale. It is a neurological scale which gives an objective and reliable way of documenting conscious state of an individual for primary assessment as well as following assessment. An individual is evaluated against the scale criteria and results provide that individual a score between3-15. This scale is used not only to determine consciousness level after head injury, this scale is also used to monitor chronic patient in intensive care unit. Hence, it is justified to use GCS in John’s case (Sartorius et al., 2010). This scale mainly indicates the state of central nervous system of an individual. It is considered as one of the most important system of human system that receives signals, coordinates and influence activity of all parts of the human system. Therefore, checking the status of central nervous system for level of consciousness and activity is very much needed. John has an indwelling catheter with nonstop bladder irrigation, his urine output noted to be reddish pink. So, the PACU nurse should check whether this is because the presence of any kind of infection or because John recently undergone TURP. John has undergone a TURP surgery; therefore, it is common to see some reddish pink colored blood in urine after the operation. The nurse should have the understanding that, if urine represents much bright reddish color for more than 48hours, they should inform the doctor for further advice. John’s heart rate is 90, which might represent his painful condition immediately after surgery.

Discharge Plan for John Wong

3. Discharge planning is considered as an important part of health care to maintain patient care quality at home and to avoid readmissions (Eliopoulos, 2010). Hence for John, a proper and effective discharge planning need to be prepared. The following discharge plan is important for John in terms of holistic nursing (Nsameluh, 2005). The nurse should make the patient understand about each and every detail mentioned in the discharge plan. John is an 80years old male so it is quite obvious for him to forget various information regarding his health status. Hence, the hospital should arrange a nurse aide for him, who can continue his treatment and care at his residence. It is also mentioned in the case study that John lives alone, so assisting him with a nurse aide is very much significant for John. John should be referred to a dietician and physician. This is because he has recently undergone a surgery and to maintain his health condition he should consume adequate amount of liquid. He is suffering from poor gait; this is because of osteoporosis and also the uncomfortable feeling from BPH. After surgery to improve his movement light aerobic exercises are very much important to recommend for John. This might include leg exercises for short period of time in every hour. With proper nursing care, intervention and discharge plan, health care professionals can accomplish their care goal and thus can improve the quality of life of the patient and their wellbeing.

References

Eliopoulos, C. (2010). Gerontological nursing. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins.

Foster, C. (2000). Pathology of benign prostatic hyperplasia. Prostate, 45(S9), 4-14. doi:10.1002/1097-0045(2000)45:9+3.0.co;2-q

Isaacs, J. (2008). Prostate stem cells and benign prostatic hyperplasia. Prostate, 68(9), 1025-1034. doi:10.1002/pros.20763

Lin, V., Wang, S., Vazquez, D., C. Xu, C., Zhang, S., & Tang, L. (2007). Prostatic stromal cells derived from benign prostatic hyperplasia specimens possess stem cell like property. Prostate, 67(12), 1265-1276. doi:10.1002/pros.20599

Litwack, K. (2009). Clinical coach for effective perioperative nursing care. Philadelphia: F.A. Davis.

Løvstad, R., Granhus, G., & Hetland, S. (2000). Bradycardia and asystolic cardiac arrest during spinal anaesthesia: A report of five cases. Acta Anaesthesiologica Scandinavica, 44(1), 48-52. doi:10.1034/j.1399-6576.2000.440109.x

McEvoy, L. (2013). Fast Facts: Benign Prostatic Hyperplasia. - By Roger Kirby & Peter J. Gilling. Int J Urol Nurs, 7(2), 117-117. doi:10.1111/j.1749-771x.2012.01173.x

Mitropoulos, D., Anastasiou, I., Giannopoulou, C., Nikolopoulos, P., Alamanis, C., Zervas, A., & Dimopoulos, C. (2002). Symptomatic Benign Prostate Hyperplasia: Impact on Partners’ Quality of Life. European Urology, 41(3), 240-245. doi:10.1016/s0302-2838(02)00041-6

Nsameluh, K. (2005). Discharge planning.

Sartorius, D., Le Manach, Y., David, J., Rancurel, E., Smail, N., & Thicoïpé, M. et al. (2010). Mechanism, Glasgow Coma Scale, Age, and Arterial Pressure (MGAP): A new simple prehospital triage score to predict mortality in trauma patients*. Critical Care Medicine, 38(3), 831-837. doi:10.1097/ccm.0b013e3181cc4a67

Strope, S., Yang, L., Nepple, K., Andriole, G., & Owens, P. (2012). Population Based Comparative Effectiveness of Transurethral Resection of the Prostate and Laser Therapy for Benign Prostatic Hyperplasia. The Journal Of Urology, 187(4), 1341-1345. doi:10.1016/j.juro.2011.11.102

Tzeng, J. (2000). Dexamethasone for prophylaxis of nausea and vomiting after epidural morphine for post-Caesarean section analgesia: comparison of droperidol and saline. British Journal Of Anaesthesia, 85(6), 865-868. doi:10.1093/bja/85.6.865