Objectives

General:

After 2 weeks of application of nursing procedures pertaining to our patient’s situation

concerning prostate cancer, we would be able to gain understanding regarding the said disease

and increase notions in performing the desired nursing concerns and interventions suitable for

the health, wellbeing and optimum level of functioning of our patient.

Specific:

To establish rapport with the patient and the family members to ease their anxiety level

and to be able to gain necessary information needed for this study

To identify and assess actual and potential health problems of the patient

To be able to define Prostate cancer

To have the knowledge regarding the disease process and the possible complications of

the condition

To be able to discuss the normal and abnormal anatomy and physiology of the bodily

systems involved

To be able to formulate the most appropriate nursing management and interventions for

the patient

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Significance of the Study

Nursing Education

This case study will allow the student nurse to be able to have an understanding regarding

the disease proper. It will provide a new point of view and additional up-to-date information.

Students and other health practitioners will be able to exercise critical thinking and decision-

making relevant in the practice and also in the management of the said condition.

Nursing Practice

The actual performance of skills in the field will be defined by the knowledge that they

have gained. It is important to develop the competence of the practitioners due to the fact that

they will be in contact with the patient first-hand. The ability of the nurse to manage the patient

properly will be a factor in promoting his wellness.

Nursing Research

Nursing research has enormously contributed to the understanding of diseases, disease

processes and management. This will provide related studies that will be valuable for future

studies. It presents information that will help in the understanding on how to prevent and cure

prostate cancer in the future.

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Introduction

This case study was conducted in order to further understand the distinctive

characteristics of prostate cancer and its signs and symptoms. The focus is on an elderly patient

with Stage 4 prostate cancer.

Cancer is one of the leading causes of death in the world. There are a number of theories

on how this disease can be acquired. Prostate cancer is a common affliction among men. With

regards to this, it is important to be able to define properly the medical condition. Included in the

study are the risk factors, usual manifestations, different procedures to limit or cure the disease

as well as suggested nursing care management.

The main purpose of the case study is to provide an insight on how prostate cancer

afflicts the male human body. It is aimed at helping the students increase their knowledge and

skills and be able to handle patients suffering from prostate cancer with the most apt supervision.

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Patient’s History

A. present history

57 year old, Mr. Roberto Cruz Reyes, is a resident of Mapandan Pangasinan. He was admitted at Pangasinan Medical Center (PMC) in the morning of Nov.10, 2009 with primary complaints of deep pain felt in the lower abdomen, back and pelvis.

Due diagnostic test such as blood examinations and tissue sampling were made confirming the diagnosis of stage IV prostate cancer. Prostate cells are described as poorly differentiated and highly irregular in shape, invading the neighboring tissues in the male reproductive organ.

Thus, with the patient’s informed consent, a bilateral orchidectomy (removal of both testicles) is performed in the morning of the consecutive day (nov.11, 2009) prior to admission. This is to stop the progression of the said disease. Orchidectomy was chosen over hormone replacement therapy which is said to be more expensive than the surgical procedure.

Several days after the operation, the patient was discharged with records of stable vital signs and timely wound healing with negative erythema or purulent discharge in the incision site.

The patient is advised for follow up medical check-up.

B. Past History

In its early stages, prostate cancer usually does not cause symptoms. Upon recall by the patient, he concluded that the abnormalities he felt include difficulties starting his urine stream, frequency of urination, need to urinate at night and pain when urinating. However, medical institutions are not yet utilized at this time for reasons that the client thought that the symptoms maybe part of the aging process or signs of easily treatable infections such as UTI.

Two months before the orchidectomy procedure, hematuria (blood in the urine) and pain in the abdomen were added to the symptoms. A month after, the patient consulted for medical advice that revealed metastasizing advance prostate cancer. As a medical intervention, a transurethral resection prostatectomy (TURP) is performed on oct. 21, 2009 at PMC.

C. Family History

The patient stated no hereditary/familial origin of the disease as nobody in the family is diagnosed with prostate cancer.

D. Social History

Being a tricycle driver, the patient is exposed to heat as well as industrial carcinogens (pollution) that maybe factors in the development of cancers.

High dietary fat intake is also claimed to be part of the clients diet influencing further progression of the disease as the stated diet is under observation to be one of the contributory factors that may cause prostate cancer.

The patient also stated that he drink minimal amounts of alcohol. However, alcohol do not show any direct effects to the said disease.

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Anatomy and Physiology

Male External Reproductive System

1. Penis — The penis is the male organ for sexual intercourse. It has three parts: the root, which attaches to the wall of the abdomen; the body, or shaft; and the glans, which is the cone-shaped end of the penis. The glans, which also is called the head of the penis, is covered with a loose layer of skin called foreskin. (This skin is sometimes removed in a procedure called circumcision.) The opening of the urethra, the tube that transports semen and urine, is at the tip of the glans penis. The penis also contains a number of sensitive nerve endings.

The body of the penis is cylindrical in shape and consists of three internal chambers. These chambers are made up of special, sponge-like erectile tissue. This tissue contains thousands of large spaces that fill with blood when the man is sexually aroused. As the penis fills with blood, it becomes rigid and erect, which allows for penetration during sexual intercourse. The skin of the penis is loose and elastic to accommodate changes in penis size during an erection.

Semen, which contains sperm, is expelled (ejaculated) through the end of the penis when the man reaches sexual climax (orgasm). When the penis is erect, the flow of urine is blocked from the urethra, allowing only semen to be ejaculated at orgasm.

2. Scrotum — The scrotum is the loose pouch-like sac of skin that hangs behind the penis. It contains the testicles (also called testes), as well as many nerves and blood vessels. The scrotum has a protective function and acts as a climate control system for the testes. For normal sperm development, the testes must be at a temperature slightly cooler than the body temperature. Special muscles in the wall of the scrotum allow it to contract and relax, moving the testicles closer to the body for warmth and protection or farther away from the body to cool the temperature.

3. Testicles (testes) — The testes are oval organs about the size of large olives that lie in the scrotum, secured at either end by a structure called the spermatic cord. Most men have two testes. The testes are responsible for making testosterone, the primary male sex hormone, and for generating sperm. Within the testes are coiled masses of tubes called seminiferous tubules. These tubules are responsible for producing the sperm cells through a process called spermatogenesis.

Male Internal Reproductive System

Vas deferens — The vas deferens is a long, muscular tube that travels from the epididymis into the pelvic cavity, to just behind the bladder. The vas deferens transports mature sperm to the urethra in preparation for ejaculation.

Epididymis — The epididymis is a long, coiled tube that rests on the backside of each testicle. It functions in the transport and storage of the sperm cells that are produced in the testes. It also is the job of the epididymis to bring the sperm to maturity, since the sperm that emerge from the testes are immature and incapable of fertilization. During sexual arousal, contractions force the sperm into the vas deferens.

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Ejaculatory ducts — These are formed by the fusion of the vas deferens and the seminal vesicles. The ejaculatory ducts empty into the urethra.

Urethra — The urethra is the tube that carries urine from the bladder to outside of the body. In males, it has the additional function of expelling (ejaculating) semen when the man reaches orgasm. When the penis is erect during sex, the flow of urine is blocked from the urethra, allowing only semen to be ejaculated at orgasm.

Seminal vesicles — The seminal vesicles are sac-like pouches that attach to the vas deferens near the base of the bladder. The seminal vesicles produce a sugar-rich fluid (fructose) that provides sperm with a source of energy and helps with the sperms’ motility (ability to move). The fluid of the seminal vesicles makes up most of the volume of a man’s ejaculatory fluid, or ejaculate.

Prostate gland — The prostate gland is a walnut-sized structure that is located below the urinary bladder in front of the rectum. The prostate gland contributes additional fluid to the ejaculate. Prostate fluids also help to nourish the sperm. The urethra, which carries the ejaculate to be expelled during orgasm, runs through the center of the prostate gland. Another function of the prostate gland is to help control urination by pressing directly against the part of the urethra that it surrounds

Bulbourethral glands — The bulbourethral glands, or Cowper’s glands, are pea-sized structures located on the sides of the urethra just below the prostate gland. These glands produce a clear, slippery fluid that empties directly into the urethra. This fluid serves to lubricate the urethra and to neutralize any acidity that may be present due to residual drops of urine in the urethra.

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The entire male reproductive system is dependent on hormones, which are chemicals that stimulate or regulate the activity of cells or organs. The primary hormones involved in the functioning of the male reproductive system are follicle-stimulating hormone (FSH), luteinizing hormone (LH) and testosterone.

FSH and LH are produced by the pituitary gland located at the base of the brain. FSH is necessary for sperm production (spermatogenesis), and LH stimulates the production of testosterone, which is necessary to continue the process of spermatogenesis. Testosterone also is important in the development of male characteristics, including muscle mass and strength, fat distribution, bone mass and sex drive.

Etiology

Prostate cancer is classified as an adenocarcinoma, or glandular cancer, that begins when normal semen-secreting prostate gland cells mutate into cancer cells. It is considered as androgen-dependent and is usually androgen sensitive. The region of prostate gland where the adenocarcinoma is most common is the peripheral zone. Initially, small clumps of cancer cells remain confined to otherwise normal prostate glands, a condition known as carcinoma in situ or prostatic intraepithelial neoplasia (PIN). Although there is no proof that PIN is a cancer precursor, it is closely associated with cancer. Over time, these cancer cells begin to multiply and spread to the surrounding prostate tissue forming a tumor. Eventually, the tumor may grow large enough to invade nearby organs such as the seminal vesicles or the rectum, or the tumor cells may develop the ability to travel in the bloodstream and lymphatic system. Prostate cancer is considered a malignant tumor because it is a mass of cells that can invade other parts of the body. This invasion of other organs is called metastasis. Prostate cancer most commonly metastasizes to the bones, lymph nodes, rectum, and bladder.

Testosterone, the male hormone, directly stimulates the growth of both normal prostate tissue and prostate cancer cells. This hormone is thought to be involved in the development and growth of prostate cancer. The important implication of the role of this hormone is that decreasing the level of testosterone should be effective in inhibiting the growth of prostate cancer.

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PATHOPHYSIOLOGY OF PROSTATE CANCER

Tricycle Driver Man aged 57 y/o High fat-diet & exposure to carcinogens (Occupational Factor) (Gender & Age Factor) (Lifestyle Factor)

Testicles exposed to heat Toxins enter via ingestion & inhalation (pollution)

Death of testicular cells Travel through BV

Necrosis Reach prostate glands

Necrotic cells absorbed by seminal tubules

Reach prostate glands

Infection in the peripheral zone of prostate

Normal semen-secreting gland cells mutate

Development into cancer cells

Cancer cells can avoid apoptosis

Multiplication of cancer cells

Formation of small clumps of cancer cells (asymptomatic stage)

Spread to surrounding tissues (stroma)

Formation of tumor

Compression of urethra

Weak urine stream hematuria dysuria hematospermia polyuria

Inability to urinate nocturia

Metastasize

Invades seminal vesicles

Infects testicles

Deep pain in the lower abdomen, back, & pelvis

PROSTATE CANCER

Transurethral Resection Prostatectomy (TURP) Orchidectomy

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Risks for Prostate Cancer:

1. AgeAge is a risk factor for prostate cancer, especially men age 50 and older. More than 70 percent of all prostate cancers are diagnosed in men over the age of 65.

2. RaceProstate cancer is nearly 60 percent more common among African-American men than it is among Caucasian-American men. Japanese and Chinese men native to their country have the lowest rates of prostate cancer. Interestingly, when Chinese and Japanese men immigrate to the US, they have an increased risk and mortality rate from prostate cancer, when compared to their native populations. In Japan, the incidence of prostate cancer has increased as Western diets and lifestyles have been adopted.

3. Environmental exposuresStudies show an increased chance for prostate cancer in men who are farmers, or those exposed to the metal cadmium while making batteries, welding, or electroplating. The risk of developing prostate cancer is also increased with those who are exposed to altered temperature or trauma in the groin area. Presence of harmful chemicals found in the environment also increases the risk of prostate cancer.

4. Diet Epidemiological data suggests that the diet consumed in Western industrialized countries may be one of the most important contributory factors for developing prostate cancer. Consider the following information regarding diet and its effect on the risk for prostate cancer: fat

Studies suggest that men who eat a high-fat diet may have a greater chance of developing prostate cancer. Fat intake from dairy products increases calcium, itself a proposed risk factor. Calcium can suppress the circulating levels of dihydroxyvitamin D, a possible protective factor for prostate cancer. A low intake of dietary fiber and high protein are associated with increased risk of prostate cancer. Low dietary levels of selenium are also associated with increased risk of prostate cancer.

Preservatives

Increased amounts of preservatives found in food increases the chance of cancer in the body. These chemicals are said to affect the normal reproduction cells in the body.

In prostate cancer, the cells that have mutated are often found in the outer portion of the gland. Cancer cells are abnormally fast-reproducing and compete with normal cells for nutrients. How and why normal cells mutate is still unknown but there are many theories that may suggest the answer.

The exposure of the patient to the risk factors has increased the likelihood of developing prostate cancer. His age predisposes him to acquiring the said disease. The pollution present in the surroundings may also have contributed to this. His diet of high fat and his vices also added to him being at risk for prostate cancer. His occupation as a tricycle driver raised his chances as well due to the fact that the drivers’ groin are subjected to high temperatures and trauma.

Tesosterone is the major circulating androgen. It breaks down into Dihydrotestosterone (DHT) and estradiol. DHT has a higher affinity for prostate tissues compared to testosterone. In

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order for testosterone ot be converted, it needs androgen-metabolizing enzymes. However, these enzymes are age-dependent. As one grows older, there is a significant decrease in these enzymes and the levels of DHT is significantly decreased. The presence of testosterone alone is weakly carcinogenic compared to testosterone and estradiol. This high ratio of estrogen and androgen is highly carcinogenic.

The cells in the prostate gland now mutate ad rapidly divide. The abnormal cells are usually found in the outer region of the prostate. Since cancer cells have genetically-altered DNA, they do not follow the life cycle of a normal cell. They do not die and thus continue to rapidly multiply. Tumors are clumps of cancer cells within the tissue. The presence of tumors will then alter the normal anatomy and cause the signs and symptoms of prostate cancer.

The normal passageway of the urine will now be compressed ad impeded due to the presence of the tumor. There will be pain felt during urination because of the blockage created by the tumor. This leads to dysuria, nocturia and inability to urinate. It causes the presence of blood in the semen or hematospermia. It may be due to the breaking of the capillaries due to the pressure exerted by the tumor.

Metastasis of prostate cancer usually involves the other male reproductive organs. This is due to its proximity. In the case of the patient, the cancer spread to his seminal vesicles and testicles. Nerves in the groin area are now compressed and affected. This leads to the lower back, lower abdomen and pelvic pain felt by the patient.

To stop the spread of cancer cells and its growth, several treatments can be utilized. Orchidectomy or the removal of testicles is done in order to lower the testosterone level. This is because the hormone affects the growth of the cancer cells. By eliminating the main source of androgens in the body, it limits the cancer cells’ activities. Transurethral Resection Prostatectomy is done to removing tissue in the prostate to reduce its size and also eliminate cancer cells. This will improve the patient’s ability to urinate.

Laboratory Results10

HEMATOLOGY Hemoglobin (N: 135-180): 99 gms/LRBC (N: 4.6-6.2): 3.54x10 to the 9th power/L WBC (N: 5-10): 5.1x10 to the 9th power/LSegmenters (N: .58-.66): .64Lymphocytes (N: .21-.30): .27Monophils (N: .04-.10): .05Eosinophils (N: .02-.06): .04Total Neutrophils (N: .68-.70): .64Hematocrit (N: .40-.50): .30 BLOOD CHEMISTRY Creatinine (N: .5-1.7): 1.8mg/dlPotassium (N: 3.4-5.3): 4.83mEq/LSodium (N: 135-152): 143.2 mEq/L

Hemoglobin is the protein found in the red blood cell that oxygen attach to. The hematocrit count calculates the percentage of red blood cells per micro liter of blood. It represents the cells present in the whole blood.

The lab result of the patient shows that both the hemoglobin and hematocrit are low. The low hemoglobin may be due to the low number of red blood cells in the blood. The patient is not receiving the adequate supply of oxygen because of this.

Conservative Management11

No treatment maybe indicated in men over age 70 because prostate cancer maybe slow growing and it is expected that many men will die from other causes. It is commonly recommended that this patient followed closely with periodic PSA (serologic marker of prostate cancer) determination and examination for evidence of metastasis.

Symptom controlled for advance prostatic cancer in which treatment is not effective:

a. Analgesics and opioids to relieve pain.

b. Short course of radio therapy for specific sites of bone pain.

c. IV administration of beta-emitter agent (strontium, chloride 89) delivers radio therapy directly to sites of metastasis.

d. TURP to remove obstructing tissue if a bladder outlet obstruction occurs.

e. Suprapubic catheter placement

Surgical Management

Radical Prostatectomy

A radical prostatectomy (removal of the prostate and seminal vesicles) remains the standard surgical procedure for patients who have early stage, potentially curable disease and a life expectancy of 10 years or more. Sexual impotence follows radical prostatectomy and may have various degrees of urinary incontinence.

Transurethral Resection of the Prostate

Transurethral resection of the prostate (also known as TURP, plural TURPs and as a transurethral prostatic resection TUPR) is a urological operation. It is used to treat benign prostatic hyperplasia (BPH). As the name indicates, it is performed by visualizing the prostate through the urethra and removing tissue by electrocautery or sharp dissection. This is considered the most effective treatment for BPH. This procedure is done with spinal or general anesthetic. A large triple lumen catheter is inserted through the urethra to irrigate and drain the bladder after the surgical procedure is complete. Outcome is considered excellent for 80-90% of BPH patients.

It is the most common procedure used, can be carried out through endoscopy. The surgical and optical instrument is introduced directly through the urethra of the prostate, which can then be viewed directly. The gland is removed in small chips with an electrical cutting loop. This procedure, which requires no incision, may be used for glands of varying size and is ideal for patients who have small glands and those who are considered poor surgical risks.

This approach usually requires an overnight stay in the hospital stay. Strictures are more frequent, and repeated procedures may be necessary because the residual prostatic tissue can grow back. TURP rarely causes erectile dysfunction, but it may cause retrograde ejaculation

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because removing the prostatic tissue at the bladder neck can cause the seminal fluid to flow backward into the bladder rather than forward through the urethra during ejaculation.

Suprapubic Prostatectomy

It is a surgical procedure involving a skin incision and enucleation of the prostatic adenoma, through the prostatic capsule (RPP-retropubic prostatectomy) or through the bladder (SPP-suprapubic prostatectomy). It is reserved for extremely large prostates. Both techniques have advantages and disadvantages, with the suprapubic technique being a better choice is patients with prostate volumes that are much larger.

Perineal Prostatectomy

In this operation, the surgeon makes the incision in the skin between the anus and scrotum (the perineum), as shown in the picture below. This approach is used less often because the nerves cannot easily be spared and lymph nodes can't be removed. But it is often a shorter operation and might be an option if you don't want the nerve-sparing procedure and you don't require lymph node removal. It also might be used if you have other medical conditions that make retropubic surgery difficult for you. It can be just as curative as the retropubic operation if done correctly.

Retropubic approach                Perineal approach

Radical retropubic prostatectomy

This is the operation used by most urologic surgeons (urologists). You will be either under general anesthesia (asleep) or be given spinal or epidural anesthesia (numbing the lower half of the body) along with sedation during the surgery. For this operation, the surgeon makes a skin incision in your lower abdomen, from the belly button down to the pubic bone. If there is a reasonable chance the cancer may have spread to the lymph nodes (based on your PSA level, DRE, and biopsy results), the surgeon may remove lymph nodes from around the prostate at this time. If any of the nodes contain cancer cells, which means the cancer has spread, they often will not continue with the surgery because it is unlikely that the cancer can be cured.

Transurethral Incision of the Prostate

Transurethral incision of the prostate (TUIP) is a simple surgical procedure that can relieve the symptoms of an enlarged prostate gland. The prostate gland is part of a man's reproductive system. It is normally a little bigger than a walnut. It is located between the base of

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the bladder and the beginning of the penis. It surrounds the upper part of the urethra. (The urethra carries urine from the bladder out through the penis.) The prostate gland produces a fluid that is ejaculated with sperm.

Laparoscopic Radical Prostatectomy

Laparoscopic Radical Prostatectomy is a method recently developed in France/ although not yet widespread in the US, it is anticipated that this procedure will be widely used in place of more extensive surgery for patients with localized prostatic cancer. The laparoscopic approach provides better visualization of the surgical site and surrounding areas. Preliminary data suggest that patients who undergo this procedure have less bleeding and reduced need for blood transfusion, a shorter hospital stay, less postoperative pain, and more rapid return to normal activity compared to open radical prostatectomy. An orchidectomy (also called orchiectomy) is done to help control the growth of prostate cancer. It is an operation to remove your testicles (testes). Prostate cancer needs testosterone in order to grow. Testosterone is the male sex hormone produced by the testicles, or testes. If the testicles are removed, the level of testosterone in your blood will fall dramatically. And in 9 out of 10 cases (90%) the prostate cancer will stop growing and start to shrink.

Orchidectomy

Orchidectomy is not used very often these days as the hormone treatments that are available now work in the same way.  Some men choose to have an orchidectomy.  They like the fact that it is one treatment compared to the injections which you have either monthly or 3 monthly.  Others don't like the fact that it is not reversible and worry about how they will feel about themselves after having their testicles removed.  It is important to talk through with your doctor about the pros and cons of having an orchidectomy.

It is a simple operation. The surgeon makes a small cut in your scrotum (the sac which holds your testicles). After removing your testicles, your surgeon may put in plastic balls (fake testicles or prostheses) to keep the look and shape of your scrotum the same.

MEDICAL MANAGEMENT

( Attached )

NURSING MANAGEMENT

( Attached )

Discharge Plan

Medication:

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Cefixime 400 mg BID for 6 days

Mefenamic acid 500mg for pain PRN

Exercise:

Exercise should include walking at a quick pace for 15 to 20 minutes four to five days a week, and once or twice a week at a slower pace for 20 to 25 minutes. A “quick pace” was defined as a training heart rate of 70 to 85 percent of a person’s maximum heart.

During this time you should not lift heavy objects, drive a car or take long car rides, perform strenuous exercise, or engage in sexual intercourse. Minimize severe straining during bowel movements by using a laxative if necessary.

Treatment:

You may expect frequency of urination and/or urgency and perhaps even more getting up at night. This will usually resolve or improve slowly over the healing period. You may see some blood in your urine over the first six weeks. Do not be alarmed, even if the urine was clear for a while. Refrain from strenuous activity and push fluids until clearing occurs.

Pharmacological and other conservative treatments should be observed. Anything observed out of the usual should be reported as soon as possible to the physician. This may indicate infection or aggravating of the current condition.

Health Teachings:

Use aseptic technique in cleaning wounds Observe proper diet

Follow proper schedule of medication

Educate the patient regarding changes in sexual functions such as “dry ejaculation and difficulty having erections within 3-12 mos. after surgical intervention

Eliminate vices and adapt healthy lifestyle

Advice taking of multi-vitamins with selenium

Out-Patient Follow-up:

Advice the patient to visit a hospital or a physician when:

-patient experiences severe pain that does not diminish

-patient observes hematuria and dysuria after 5 days of surgery

-patient develops fever, swelling and purulent discharge in the incision area

Inform the patient to take the scheduled follow up consultations with his physician regarding his condition.

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Diet:

Eat 5 to 9 servings a day of fruits and vegetables without sauce or dressing. Eating at least 5 servings each week of cruciferous vegetables, particularly broccoli, mighthelp you decrease your risk of developing prostate cancer. Size-wise, this translates intoabout a half cup of cooked vegetables per serving

Eat at least two servings a week of tomato sauce roughly a half cup per serving.

Drinking 8 oz of pomegranate juice daily might slow the rate at which prostate cancer progresses

Any anti-cancer effects of green tea requires drinking six or more cups per day

Reduce eating red meat. Do not grill food

Increased consumption of soy-based foods would seem to be beneficial in slowing the disease process. However, because not all soy-based foods are high in isoflavones and some preparations can be high in fat and low in nutritious value, be sure to discuss the value of adding different types of soy-based foods into your diet with your doctor and/or qualified nutritional consultant.

Eat more fish

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