Normal vital signs and their reference values
The current paper is a discussion of clinical deterioration with reference to a case study of Peter Harris. He is a 72-year-old male patient, who was admitted to the ward for correction of benign prostatic hyperplasia after presenting with urinary symptoms. He is a known diabetic type 2 and a COPD patient. The correction was done by a transurethral resection of the prostate (TURP). The pathophysiology of BPH will be outlined in this paper. The clinical situation of the patient post-operative will also be discussed with rationales for his abnormal vitals. Nursing care priorities will be set followed by evidence-based nursing interventions. Finally, to ensure continuity of care, three members of the multidisciplinary team excluding the surgical and primary nursing team will be mentioned with their roles in the care of the patient.
BPH is the most prevalent of the urological conditions in the world. It is a non-malignant enlargement of the prostate gland with or without presentation of urinary symptoms (Kumar, Abbas, & Aster, 2017). It starts as microscopic hyperplasia of epithelial components with stromal hyperplasia usually in the periurethral transitional zone of the prostate (Williams & O’Connell, 2013). It is mostly seen in the elderly, with more than 80% of men more than 60 years having evidence of BPH histologically. This sets up age as the most important risk factor for developing BPH (Roehrborn, 2011).
The exact etiology and pathophysiology is not clearly understood and is an area of intense research. However, it is postulated to involve an interplay of age and hormonal imbalance. The incidence increases with age, providing the clue that processes in old age lead to its formation. This is termed the mesenchymal theory which postulates that BPH is due to a slowed apoptosis process leading to cells turnover in the prostate to lean towards cell proliferation (Williams & O’Connell, 2013).
Hormones have been implicated in the pathogenesis of BPH including estrogen, testosterone, prolactin and growth factors. The theory links BPH to an imbalance in these hormones. Testosterone levels decrease with age but the others do not especially estrogen. Unopposed effect of estrogen on epithelial and stromal cells is thought to lead to cellular proliferation (Thor, 2015).
BPH is a histological diagnosis and does not necessarily mean it will cause symptomatology. In fact, of the 80% of men over 60 who present with BPH, only 40 % will develop the urinary symptoms (Roehrborn, 2011). The pathology will progress from prostatic hyperplasia to prostatic enlargement that will finally lead to benign outflow obstruction. This progression is, however, not definite as the size of the prostate poorly correlates with the symptoms present.
Outflow obstruction presents the most important pathology leading to symptoms in BPH (Sarma & Wei, 2012). However, other mechanisms exist to bring about symptoms. One is the physiologic response of the bladder to outflow obstruction. The detrusor muscle hypertrophies become less compliant and increase the blood supply. These new vessels are prone to rupture causing hematuria in BPH. Another dynamic mechanism is the hypertrophy of prostatic smooth muscles. These muscles have a rich adrenergic nerve supply hence hypertrophy increases the adrenergic tone that is set on the prostatic urethra, worsening the obstruction (Sarma & Wei, 2012).
Pathophysiology of BPH and its link to urinary symptoms
Lower urinary tract symptoms are characteristic in BPH and can either be obstructive or irritative. Obstructive ones range from poor urine stream, dribbling, incomplete voiding, straining, intermittency, and hesitancy. Irritative symptoms include nocturia, dysuria, urge incontinence, and increased frequency (Lewis, Dirksen, & McLean, 2013). Other possible presentations include acute urine retention that causes suprapubic pain, chronic urine retention that is painless, hematuria, lower urinary tract infections and renal failure in some cases (Hinkle & Cheever, 2013).
Treatment of BPH depends on the presentation and if the symptoms are severe enough to cause impairment. This can be calculated using a severity score termed the international prostate symptom score (IPSS) that uses the symptoms to give the patient a score and guide management (Vignozzi et al., 2014). Interventions can be surgical by prostatectomy or medical, by using drugs such as alpha blockers, 5 alpha reductase inhibitors, and Phosphodiesterase-5 Inhibitors. The patient underwent a prostatectomy, specifically a TURP. It involves resecting the prostate in small “chips” and the pieces of the prostate removed through the urethra (Williams & O’Connell, 2013).
The patient presented to the ward with abnormal vital signs. Normal vital signs include, blood pressure of between 90/60 to 130/85 mmHg and pulse pressure of 30-50 mmHg, heart rate between 60 to 100 beats per minute, temperature between 36.5 to 37.2OC and respiratory rate of between 12 to 20 breaths per minute (Australian Commission on Safety and Quality in Health Care, 2012). The patient’s vitals were deranged with a tachypnea of 30 breaths per minute, a tachycardia of 128 bpm, and a hypothermia of 35OC.
The vital signs are deranged because the patient is in shock, specifically hypovolemic shock. The underlying reason for hypovolemic shock is hemorrhage due to complications of the TURP. This complication is hematuria which is present in about 6% of patients who undergo a TURP. This was shown by the continuous bladder irrigation in this patient presenting with large clots representing heavy hematuria.
The stages of shock depend on the amount of hemorrhage and include initial, compensatory, progressive and refractory or irreversible stage (Lewis, Dirksen, & McLean, 2013). Peter appears to be in the compensatory stage where the body has been able to maintain blood pressure through an effective sympathetic reflex. The sympathetic system is usually activated in times of fight or flight or in this case, stress (Lewis, Dirksen, & McLean, 2013). It causes the increased heart rate to maintain cardiac output (Vincent & De Backer, 2013). It also causes vasoconstriction to maintain perfusion to vital organs such as the brain and the heart. The non-vital organs such as the kidneys, the skin, and the gut have blood shunted away from them. kidney hypoperfusion will cause a reduction in urine output while shunting of volume away from the skin causes hypothermia with cold clammy skin (Hinkle & Cheever, 2013). Hypoperfusion drives cellular respiration into anaerobic respiration with the production of lactic acid. Removal of lactic acid is impaired due to renal impairment. The pain score of 0/10 can be attributed to the persistence of spinal anesthesia used for the procedure.
Influence of co-morbidities and lifestyle on vital signs and their effects
Assessment of airway, breathing, circulation, and disability is paramount to identify clinical problems. In this patient, they include inadequate fluid volume, acute pain, and risk of infection (Hinkle & Cheever, 2013). The inadequate fluid volume is related to hypovolemic shock due to hemorrhage as evidenced by a tachycardia of 128 and tachypnea of 30. Acute pain is related to the TURP surgical procedure. The risk of infection is related to the post-operative state and underlying immunosuppression due to diabetes mellitus.
The goal of interventions for inadequate fluid volume is achieving an adequate circulating volume in the patient as evidenced by stable vital signs, normal urine output and dry warm skin. The patient’s vitals should be monitored frequently include his blood pressure, pulse rate, respiratory rate, and temperature. Any changes should be noted. The changes might represent a clinical improvement or clinical deterioration and progression of shock (Mok, Wang, Cooper, Ang, & Liaw, 2015)). Fluids should be administered to expand the intravascular volume and improve perfusion (Myburgh, & Mythen, 2013). Fluids include crystalloids or in severe cases of more than 30% blood loss, a blood (Gutierrez, Reines & Wulf-Gutierrez, 2014).
The goal of care in acute pain management is in a pain-free state during the shift as evidenced by the patient being relaxed, sleeping well and verbalizing pain relief. The patient’s pain should be assessed by investigating reports of pain and documenting site, onset, character, aggravating factors, radiation and alleviating factors (Costantini, Affaitati, Fabrizio, & Giamberardino, 2011)). Pain rating is then done to subjectively obtain the severity of pain. the patient is asked to rate their pain on a scale of 1-10. This guides intervention and evaluates for improvement. Non-pharmacologic modules of pain management should be tried include providing a calming environment, instructing staff to be empathetic and cordial to the patient, providing tools such as warm or cold compresses, music and providing back rubs as indicated (Abdulla et al., 2013). Analgesics should then be administered as indicated including NSAIDs and opioids among others. This improves recovery and reduces in-hospital stay period (Turk & Melzack, 2011).
Post-operative infection is a legitimate risk in this patient. The risk factors include unsterile urine prior to the surgery, and in this patient, diabetes mellitus and catheterization (Rosenberger, Politano, & Sawyer, 2011. The goal is for the patient to be infection free post-operative evidenced by the absence of signs of infection and normal vitals. The patient’s laboratory tests should be monitored routinely including white blood cell count, CRP, ESR, and urine or blood cultures. Positive indices for infection establish a diagnosis and guide intervention (Hinkle & Cheever, 2013). Signs of infection should also be monitored as a clinical diagnosis can be used to guide empirical treatment. They include fever, purulent discharge from wounds and catheter site. Safe care should be employed including hand washing, proper disposal of sharps, using aseptic techniques during procedures and wound dressing and care. Prophylactic antibiotics can be administered as prescribed in situations where the risk of infection is high (Hinkle & Cheever, 2013).
Causes of all symptoms taken together
The patient will benefit from a multidisciplinary team. This ensures continuity of care and best care practice. The other members of the care team include a nutritionist, a social worker, and a psychologist. A nutritionist is needed due to the strict diet needs of this patient. The patient is postoperative and diabetic hence needs extra nutritional support. A social worker is needed in follow u of the patient in the community. This ensures that the patient has social support in accordance with the social determinants of health. A psychologist is needed to help the patient cope with chronic illness and the perceived risk of harm or death (Hinkle & Cheever, 2013).
In conclusion, the patient was suffering from BPE, the most prevalent of the urologic condition in the elderly. Clinical deterioration in this patient post-operative was due to manifestations of hypovolemic shock due to post-operative hematuria. The care priorities identified include correcting the hypovolemia, reducing the risk of infection and controlling the patient’s pain. it was identified that the multidisciplinary team that will facilitate continuity of care post discharge include a nutritionist, psychologist, and a social worker.
References
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