Jumat, 31 Agustus 2012

NURSING CARE PATIENTS WITH PROBLEMS Benign prostate hypertrophy (BPH)

A. DEFINITION
BPH is the enlargement or prostate hypertropi. The prostate gland enlarges, stretching forward into the bladder and block the outflow of urine, can cause hydronefrosis and hydroureter. Prostate hypertrophy Benigna term is not really appropriate because the prostate gland is not enlarged or hypertrophic prostate glands periuretralah but experiencing hyperplasia (the cells multiply.
Prostate glands alone will be squashed and pressed called surgical capsule. Then in the literature on benign hyperplasia of the prostate gland or prostate adenoma, but was commonly used prostate hypertrophy.

B. Etiology
The causes of prostate hypertrophy Benigna is not certain. The prostate is an organ that depends on the endocrine and can also be considered an invitation (counter part). Therefore, the etiology is considered to be due to the absence of endocrine balance.
But according to Hidayat Syamsu and Wim De Jong in 1998 etiology of BPH are:
 The periuretral hyperplasia caused due to changes in the balance of testosterone and estrogen.
Ø
 endocrine imbalance.
Ø
 Factor age / age.
Ø
 Unknown / not known with certainty.
Ø

C. PATHOLOGY ANATOMY
Prostate gland is a gland fibro muscular Bledder circular neck and the proximal urethra. Weight of the prostate gland in adults approximately 20 grams with an average size: Length 3.4 cm, width 4.4 cm, thickness 2.6 cm. In embryological terdiro of 5 lobur: medial lobe 1 fruit, 1 fruit anterior lobe, posterior lobe 1 fruit, 2 pieces of lateral lobes.
During development medial lobe, the anterior lobe and posterior lobe would be cypress called medial lobes. In the cross-sectional medial lobes are sometimes not visible because it is too small and it looks homogeneous lobe gray, with small cysts filled with fluid milk, the cyst is called the prostate gland. In cross section the posterior urethra prostate gland consists of:
 anatomical Capsules
Ø
 Network stroma composed of fibrous and muscular tissue.
Ø Gland tissue were divided into 3 parts:
 The outside of the gland called the actual
-
 The middle section is called the sub mucosal glands, this layer is also known as zone adenomatus
-
 In periuretral gland around the urethra is called
-

The outlet of the three glands together with duct of the seminal vesicles forming united communist ejakulatoris duct which empties into the urethra. In older men the prostate has not been palpable on digital rectal examination, whereas in adult oran slightly palpable and the parents are usually easily palpable.
While on the cross-ridge on the prostate hyperplasia, prostate tissue is still good. Added elements gland produces reddish yellow color, soft and bounded clear konsisitensi with prostate tissue pressed white to gray in color and solid. If the bulge is pushed out liquid like milk.

When networks are growing bulge fibromuskuler gray, solid and fluid dispensing so unclear boundaries. This bulge can press the urethra from the urethral lumen resembles that lateral slit. Sometimes this can also cover the protrusion of urethral lumen, but glandular tissue fibrosis gradual contraction of the prostate and urged vesicles that can cause inflammation.

D. Pathophysiology
According to Hidayat Syamsu and Wim De Jong 1998 is this disorder generally occurs after middle age due to hormonal changes. The best part in the formation of enlarged prostate adenoma spread. Progressive enlargement of the adenoma pressing or urgent normal prostate tissue to produce a true capsule capsule surgery. This surgical capsule and adenoma withstand expansion tend to grow inward toward lumennya, which restricts urine output. Finally, increased emphasis is needed to empty the bladder. Destrusor muscular fibers respond hypertrophy, resulting trabekulasi in the bladder.
In some cases if obsruksi out too great, there is a bladder decompensation flasid structure, dilated and able to contract effectively. Because there is the urine, there is an increase in infections and bladder stones. Increased back pressure can cause hydronephrosis.
The progressive retention of water, sodium, and urea can cause severe edema. Edema is respond quickly with catheter drainage. Postoperative diuresis can occur in patients with severe edema and hydronephrosis after obstruksinya removed. At first the water, electrolyte, urine and load solutlainya increase diuresis, eventually the progressive loss of fluid can damage the kidneys' ability to concentrate and retain water and sodium from loss of excessive fluid and electrolyte can cause hipovelemia.
According to Arif in 2000 Mansjoer prostate enlargement occurs slowly in the urinary tract, occurs slowly. In the early stages of prostate enlargement occurs, causing physiological changes that cause the prostate urethral resistance, detrusor neck vesicles then cope with the contractions stronger.
As a result, the fiber will become thicker detrusor and detrusor fiber protrusion into the bladder mucosa appear as beams tampai (trabekulasi). When viewed from the vesicles with sitoskopi, mucosal vesicles may break out between the detrusor fibers, forming small protrusions called mucosa which, if and to the extent sakula called diverkel. Detrusor thickening phase is the phase in an ongoing detrusor compensation will be tired and eventually suffer decompensation and no longer able to contract, resulting in total urinary retention which can lead to hydronephrosis and upper urinary tract dysfunction.

E. CLINICAL
Although prostate hypertrophy Benigna always occurs in older people, but not always accompanied by clinical symptoms, this happens because of two things:
1. Narrowing of the urethra causing difficulty urinating
2. Retention of urine in the bladder causing the bladder dilatation, hypertrophy of the bladder and cystitis.
The signs and symptoms seen in patients with Benigna Prostate Hypertrophy:
a. Retention of urine
b. Lack of or weak urinary stream
c. Micturition were not satisfied
d. Increased frequency of urination, especially at night (nocturia)
e. At night micturition must push
f. Hot, painful or around the time of micturition (dysuria)
g. Mass in the lower abdomen
h. Hematuria
i. Urgency (urgent and sudden urge to remove urine)
j. Difficulty initiating and ending micturition
k. Renal colic
l. Weight loss
m. Anemia
Sometimes without a known cause, the patient is unable to urinate so it must be removed with the catheter. Because urine is always filled in the bladder, it is easy to happen cystitis and kidney damage membranes.

G. DIAGNOSTIC EXAMINATION
In patients with prostate hypertrophy Benigna general examination:
1. Laboratory
Includes urea (BUN), creatinine, electrolyte, urine culture and sensitivity test
2. Radiological
Intravenous pylografi, BNO, sistogram, retrograde, ultrasound, Ct Scanning, cystoscopy, abdominal plain. Indications sistogram retrogras do when bad kidney function, ultrasound can be performed trans-abdominal or trans rectal examination (TRUS = Trans Rectal Ultra Sonography), in addition to knowing ultra sonography enlarged prostate can also specify volume pot, mengukut residual urine and other pathological conditions such as difertikel, tumors and stones (Syamsuhidayat and Wim De Jong, 1997).
3. Retro pubic prostatectomy
Making an incision in the lower abdomen, but the bladder is not opened, simply drawn and adematous prostate tissue removed through an incision in the anterior capsule of the prostate.
4. Prostatectomy Parineal
That is the prostate gland surgically removed through the perineum.

H. COMPLICATIONS
Complications that can occur in prostate hypertrophy is
a. Chronic retention can cause vesico-ureteric reflux, hidroureter, hydronephrosis, renal failure.
b. The process accelerated kidney damage in the event of an infection at the time of micturition
c. Hernia / hemorrhoids
d. Because there is always a residual urine, causing stone formation
e. Hematuria
f. Cystitis and pyelonephritis

I. FOCUS ASSESSMENT
From the data gathered in patients with BPH: Post Prostatectomy writers can be grouped into:
a. Subjective data:
 The patient complained of pain at the incision.
Ø
 The patient said he could not have sex
Ø
 Patients always ask the actions taken
Ø
 Patients say pee imperceptible.
Ø
b. Objective Data:
 There incision
Ø
 Tachycardia
Ø
 Restless
Ø
 increased blood pressure
Ø
 Expression w ajah fears
Ø
 Installed catheter
Ø

J. Nursing Diagnosis
1. Impaired sense nyamam: pain associated with muscle spasm spincter
2. Changes in the pattern of elimination: urinary retention associated with secondary obstruction
3. Sexual dysfunction associated with loss of body function
4. Potential occurrence of infection associated with port de entrée microorganisms through catheterization
5. Lack of knowledge related to the lack of information about the disease, its treatment.

K. Nursing Plan
1. Impaired sense of comfort: pain related to muscle spasm spincter
Objectives: After 3-5 days of treatment for the patient is able to maintain the adequate degree of comfort.
Expected outcomes:

 Verbally expressing pain patients reduced or lost
Ø
 Patients can rest in peace.
Ø
Intervention:
a. Monitor and record the presence of pain, location, duration and trigger factors and pain relievers.
b. Observation of non-verbal signs of pain (anxiety, forehead wrinkle, increased blood pressure and pulse)
c. Give warm ompres the abdomen, especially the lower abdomen
d. Instruct patient to avoid stimulants (coffee, tea, smoking, abdominal strain)
e. Adjust the position of the patient as comfortable as possible, teach relaxation techniques
f. Perform aseptic therapeutic treatments. Report to your doctor if pain increases
2. Changes in the pattern of urinary elimination: urinary retention associated with secondary obstruction.
Purpose:
 After 5-7 days of treatment for patients not experiencing urinary retention
Ø
Criteria:
 Patients can urinate regularly free of bladder distension.
Ø
Intervention:
a. Perform irrigation catheter periodically or continuously with sterile technique
b. Adjust the position of the catheter and urine bag hose suitable gravity is closed
c. Observe for signs of shock / hemorrhage (hematuria, cool, moist skin, tachycardia, dyspnea)
d. Maintaining sterility drainage system wash your hands before and after using the tool and observation of urine flow and the presence of blood clots or tissue
e. Monitor urine every hour (the first day of the operation) and every 2 hours (starting the second day post-surgery)
f. Measure fluid intake output
g. Give intake action / oral intake 2000-3000 ml / day, if there are no contra indications]
h. Provide perineal exercises (Kegel training) 15-20x/jam for 2-3 weeks, encourage and motivate the patient to do so.
3. High risk of sexual dysfunction associated with ejaculatory duct obstruction, loss of bodily functions
Purpose:
After perawatn for 1-3 days the patient was able to maintain sexual function
Expected outcomes:
a. Patients are aware of the situation and will start again intaraksi sexual and activities optimally.
b. Intervention:
c. The motivation of patients to express feelings associated with changes
d. Answer any questions the patient with appropriate
e. Give the patient the opportunity to discuss their feelings about the effects of prostatectomy on sexual function
f. Involve my family / wife in the treatment of sexual function problems pmecahan
g. Give important explanation:
h. Impotence occurs in radical procedure
i. The possibility of returning to normal sexual function
j. A setback ejaculation
k. Instruct patient to avoid intercourse for 1 month (3-4 weeks) after surgery.
4. The risk of infection associated with port de entrée ikroorganisme through catheterization
Purpose:
After 1-3 days treatment for patients free from infection

Expected outcomes:
 Vital signs are within normal limits
Ø
 There is no swelling, aritema, pain
Ø
 the incision wound healed well
Ø
Intervention:
a. Perform bladder irrigation with sterile solution.
b. Observation incision (induration, and catheter drainage), (the blockage, leakage)
c. Perform maintenance incision aseptically, keep the skin around the catheter and drainage
d. Monitor bandage wounds, use a fastener to ensure a T perineal dressing
e. Monitor signs of sepsis (weak pulse, hypotension, increased breathing, cold)
5. Lack of knowledge related to the lack of information about the disease, its treatment
Purpose:
After treatment for 1-2 days
Criteria:
In verbal patients understand and be able to express and demonstrate care
Intervention:
a. Motivation of the patient / family to express a statement about the disease, nurses
b. Provide education to the patient / family about:
c. Wound care, nutrition, irrigation fluids, catheters
d. Care at home
e. Signs of hemorrhage


May be useful....................................

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