Case Study
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. Postoperative 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.
Please refer to the rubric on page 14 on the Unit Outline for full marking criteria
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 nonpharmacological 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?
1: As referred to in the case study, the old man named John Wong has been suffering from hypothyroidism and osteoporosis previously. Now that he is diagnosed with benign prostrate hyperplasia. The disorder of hypothyroidism refers to a condition that is caused due to deficient formation of thyroid hormone from the thyroid gland. The hypothalamic-pituitary-thyroid axis is said to administer the secreting of thyroid hormone (Menon, 2014). The disorder of osteoporosis is referred to as a progressive disease of bone whereby the bone density as well as mass declines to a great level resulting in an elevated possibility of fracture. The problem of benign prostate hyperplasia refers to the condition of increasing size of prostate. This involves hyperplasia of epithelial as well as stromal cells that give rise to large discrete nodule development in the transitional portion of prostate. When the nodules grow adequately big, these start affecting the urethra as well as restrict flow of urine from bladder (Petkov, Saltirov & Petkova, 2011). Both grandular as well as stromal epithelial cells including that of muscular fibers pass through the phase of hyperplasia into benign prostate hyperplasia. Various evidences support the matter that from two various tissues, the one named stromal cell hyperplasia exists; however exact ratio still lacks. This problem disorder is associated strongly with prostate transitional area as well as posterior urethral glands. Symptoms of this disorder at the initial stage arise amidst 30 and 50 years of age within the prostate glands which exist next to the proximal urethra. Here, the growth is said to occur mostly during the transitional zone. Besides the recognized areas, another zone named peripheral zone is also engaged in the condition to a small level. Prostate cancer starts at the peripheral area (Shigemi, Yoshida, Tanaka & Suzuki, 2012). For ruling out the chances of cancer, specifically the nodules that are formed within the transitional zone are to be biopsied. It has been stated by the American Urological Association that this disorder of benign prostate hyperplasia is incurable, and so due treatment must be laid upon reducing the indications. Process of treatment relies upon the severity of symptoms. Often a surgeon may recommend any patient for a surgery for instance, transurethral resection of prostate, transurethral needle ablation or transurethral microwave therapy. Normally BPH affects quality of life of a patient. Hence, adequate nursing care is a must besides pharmacological care. A nurse is supposed to convey the advice to the patient to rush to the washroom for urination (Tsukamoto, Masumori, Rahman & Crane, 2007). This would make him feel relaxed. He is required to distribute properly his intake of fluid throughout the day. Considerations regarding pharmacology include applying of drugs such as alpha blockers, phytotherapeutics, 5-alpha reductase inhibitors, and anticholinergics. All these drugs are meant to prevent complication as well as changing disease progression that are related to BPH. Also, it is important to consider non-pharmacological treatment as well where patients need to administer self-treatment as well in order to recover soon.
2: Patients generally recover at the post anesthetic care unit (PACU). However, it requires appropriate airway management as well as exact monitoring to avoid difficulties in the process. The Aldrete scale is referred to as a scale that measures recovery used after anaesthesia. This scale involves estimation of consciousness, blood pressure, respiration, and activity. Within the care unit just after anaesthesia, the anesthesiologist, nurse anesthesia, and nurse anesthetist includes patient condition, performed surgery; forms of given anesthesia, fluid input, blood loss and excretion of urine during the time of surgery (Tsukamoto, Masumori, Rahman & Crane, 2007).. The nurse engaged at the PACU unit must note the presence of any sort of complications, including variance in stability in blood circulation. Evaluating airway openness of patients, level of consciousness, important signs are regarded as the basic priorities after admission in the care unit. Besides that, few different other categories include body temperature, surgical site, rate of intravenous fluids, drainage tube patency, extreme sensation post surgery, status of vomiting pain, and level of sensation post local anesthesia (Baniahmad, 2012). Assessing surgical site involves proper dressings with no sign of bleeding. Assessing patency of drainage tube refers to the proper check for tube opening.it may be decided to admit him to the intensive care unit or at the general surgical ward.
A patient is normally discharged from the care unit once he or she is perfectly fine and meets every criteria of discharge as indicated in the Aldrete scale (Shigemi, Yoshida, Tanaka & Suzuki, 2012). The scale is used for scoring respiratory status of patients, their mobility, consciousness, circulation, and pulse oximetry. Depending upon types f surgery as well as that of conditions of patients, post anesthesia, patient often remains in a sedative state, and so safety of patient is an essential goal. Often patients are shifted from intense care unit to that of general ward or even home after urination, moving out of bed and when the patient is capable of taking oral intakes.
In the given case scenario, it has been observed that once arrived to the intense care unit, John has been kept in a supine posture. It is an effective approach for ensuring that he is under proper airway management. Airway management refers to a medical process for ensuring existence of an open passageway amidst outside world as well as patient lungs with lowering risk of aspiration. John has been observed to be quite restless, drowsy, and so he had been oxygenated by a facemask. This oxygenated mask happens to be a process that assists easy passage of air. It would enable John to ignore condition of hypoxaemia or that of low level of oxygen within blood (Cohen, 2010). He has normal body temoperature but still he shivered. That might be due to the surgical pain. So, monitoring his body constantly is quite essential.
At the time of pre-admission, it was identified that John suffers from hypertension. His blod pressure is quite high far beyond normal standard. Increased blood pressure may worsen his condition and complications. Already it has been mentioned that he is drowsy post surgery. Hence, grading consciousness is essential through Glasgow Coma Scale. This is a scale used in the neurology that refers to a reliable way to document conscious status of a patient to conduct primary as well as henceforth assessment (Ehab, 2009). A patient is usually evaluated against criteria in the given scale along with the result that varies between 3 and 15. The scale is used to determine level of consciousness post head injury and also for monitoring chronic patients within intensive unit. Thus, in case of John it would be justified to use such a scale. It mainly shows the status of central nervous system of a patient. This scale is also referred to as the key human system which receives various signals, coordinates them and also affects activities of various parts of human system. So, it is increasingly important to check the status of central nervous system in case of consciousness as well as activity level (Okeke, George, Ogunbiyi & Wachtel, 2012). John has been provided with an indwelling catheter with continuous bladder irrigation. Since his urine has been observed to be pinkish in color, PACU nurse must check if that is due to infection that he has recently undergone. The heart rate of John is 90 and this may exhibit his painful situation post surgery.
3: Process discharge planning forms an important part of health care process of a patient to bring about quality care at home for avoiding readmission to health care center. In case of John, an effective discharge plan is required. The plan is described as below (Kim, Lee, Paick & Lho, 2006).
The nurse at PACU must make patient understand properly about the details his discharge plan. Since John is an aged man he may forget several things at this age about his health status. So, the health care unit must give efforts to arrange someone who may stay beside him constantly, provide information about his health to medical professionals whom John is admitted under, and also deliver care at his home. It has been stated that John resides alone and so a nurse staying by his side is very essential (Martino & Strejilevich, 2015). He must be referred to a physician as well as a dietician since he has recently undergone a surgery and that he needs to maintain his health post surgery. He also has feeble gait due to osteoporosis.
Post surgery for improving his movement slight aerobic exercises may be beneficial for John. This can include exercises of legs for some period of time every hour. With effective nursing care, through intervention as well as discharge plan, medical professionals may accomplish their objectives of healthcare and thus may enhance the quality of patient life as well as their wellbeing.
Discharge Plan
Name: John Wong Age: 80 Sex: Male Religion: Chinese origin
Diagnosis: Benign Prostate Hyperplasia Surgery: Transurethral Resection of the Prostate
Hospital: The CB Hospital Ward no. : 5
Physician: Ms. Amelia
A. Objectives: pain management, lung congestion prevention and blood clot prevention.
B. 1. Medications: analgesics
2 Exercise: light aerobic exercise, walking for 10-15minutes
3. Treatment: prescribed medicines as scheduled
4. Health teachings: Clinical follow-ups (√)
Use of alternative drugs ()
Understanding what to do in case of drug side effects (√)
Relapse prevention (√)
Others ()
5. a. Observed indications that required reporting: presence of blood clot in urine
b. Interventions:
6. Diet: increasing fluid intake, fibrous diet to avoid constipation.
7. Psychological and spiritual needs: Spiritual counseling (√)
Family therapy ()
Supportive counseling (√)
Anger management (√)
Discharge details
Date and time of discharge: 10am. 13th March, 2015.
Accompanied by: nurse aide
Transportation mode: hospital vehicle
Signature of patient: Signature of nurse: Clinical instructor:
References
Cohen, P. (2010). From benign prostatic hyperplasia to benign chronic prostatopathy. Medical Hypotheses, 74(4), 760. doi:10.1016/j.mehy.2009.04.033
Ehab, R. (2009). Transurethral Electrovaporization of the Prostate as an Alternative to Transurethral Resection: A Five-Year Follow-up. Urotoday International Journal, 02(06). doi:10.3834/uij.1944-5784.2009.12.12.ref1
Kim, H., Lee, B., Paick, S., & Lho, Y. (2006). Efficacy of Bipolar Transurethral Resection of the Prostate: Comparison with Standard Monopolar Transurethral Resection of the Prostate. Korean Journal Of Urology, 47(4), 377. doi:10.4111/kju.2006.47.4.377
Martino, D., & Strejilevich, S. (2015). Subclinical hypothyroidism and neurocognitive functioning in bipolar disorder. Journal Of Psychiatric Research, 61, 166-167. doi:10.1016/j.jpsychires.2014.12.016
Menon, B. (2014). Hypothyroidism and bipolar affective disorder: Is there a connection?. Indian J Psychol Med, 36(2), 125. doi:10.4103/0253-7176.130966
Petkov, T., Saltirov, I., & Petkova, K. (2011). S27 TRANSURETHRAL RESECTION OF PROSTATE IN SALINE (TURIS) VERSUS STANDARD MONOPOLAR TRANSURETHRAL RESECTION OF PROSTATE. European Urology Supplements, 10(9), 583. doi:10.1016/s1569-9056(11)61468-1
Shigemi, H., Yoshida, Y., Tanaka, K., & Suzuki, M. (2012). Hoarseness, Articulation Disorder and Hearing Impairment in Subjects with Hypothyroidism. Pract.Otol. (Kyoto), 105(2), 159-165. doi:10.5631/jibirin.105.159
Tsukamoto, T., Masumori, N., Rahman, M., & Crane, M. (2007). Change in International Prostate Symptom Score, prostrate-specific antigen and prostate volume in patients with benign prostatic hyperplasia followed longitudinally. International Journal Of Urology, 14(4), 321-324. doi:10.1111/j.1442-2042.2007.01596.x
Baniahmad, A. (2012). Benign Prostate Hyperplasia Meets Liver X Receptor. Endocrinology, 153(8), 3558-3560. doi:10.1210/en.2012-1474
Okeke, L., George, A., Ogunbiyi, A., & Wachtel, M. (2012). Prevalence of linea nigra in patients with benign prostatic hyperplasia and prostate carcinoma. International Journal Of Dermatology, 51, 41-43. doi:10.1111/j.1365-4632.2012.05564.x
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