Prostate Cancer
Content
PROSTATE CANCER
1
CANCER OF THE PROSTATE: Cancer of the prostate is the most common cancer in men, the second most common cause of cancer deaths in American men older than 55, and the most prevalent cancer overall in African American men. About 1 in 5 men in the US develop prostate cancer. Risk factors include increasing age and possibly a high-fat diet. CLINICAL MANIFESTATIONS: Usually asymptomatic in early stage Nodule felt within the substance of the gland or extensive hardening in the posterior lobe Lesion is stony hard and fixed. Obstructive symptoms occur late in the disease: difficulty and frequency of urination, urinary retention, decreased size and force of urinary stream. Blood in urine or semen; painful ejaculation Cancer metastasis to bone, lymph nodes, brain, and lungs. Symptoms of metastases include backache, hip pain, perineal and rectal discomfort, anemia, weight loss, weakness, nausea, and oliguria; hematuria may result from urethral or bladder invasion. Sexual dysfunction ASSESSMENT AND DIAGNOSTIC METHODS: To promote early detection, all men over 50 years of age should have a digital rectal examination (DRE) as part of their regular health checkup. This is the key to a higher cure rate. The diagnosis is confirmed by histologic examination of tissue, transurethral resection, open prostatectomy, and fine-needle aspiration. Prostate- specific antigen (PSA) level, transrectal ultrasound. bone scan, radiographs, excretory urography, renal function tests, computed tomography (CT) scans, lymphangiography, or monoclonal antibody- based imaging may also be used.
Joyce Young Johnson, Handbook for Brunner and Suddarth’s Textbook of Medical- Surgical Nursing, 11th edition, pp 213- 220
Advanced Stage
PROSTATE CANCER
2
MEDICAL MANAGEMENT: Treatment is based on the stage of the disease and patient’s age and symptoms. PSA concentration is used to monitor patient’s response to cancer therapy and to detect local progression and early recurrence.
Radical Prostatectomy
Radiation Therapy
Removal of the prostate and seminal vesicles through suprapubic approach (greater blood loss), perineal approach (easily contaminated, incontinence, impotence, and rectal injury common), or retropubic approach (infection can readily start). This procedure is performed in patients who have potentially curable disease and life expectancy of 10 years of more. Sexual impotency and various degrees of urinary incontinence follow radical prostatectomy.
If cancer is in the early stage, treatment may be curative. For locally advanced cancer, hormonal treatments are given before and after radiation. Side effects, usually transitory, include inflammation of the rectum, bowel, and bladder. There is better preservation of sexual potency, and young patients may prefer this treatment. Hormone Therapy Method of control rather than cure. Accomplished by either orchiectomy or administration of estrogens. Diethylstilbestrol (DES) is the most widely used estrogen. Luteinizing hormone (LHRH) agonists and antiandrogen drugs such as flutamide and cyproterone are newer hormonal therapies. Other Therapies Transurethral resection of the prostate (TUR or TURP) or transurethral incision of the prostate (TUIP) for benign condition. Cyrosurgery for those who cannot physically tolerate surgery of for recurrence Chemotherapy (doxorubicin, cisplatin, and cyclophosphamide). Repeated TUR to keep urethra patient; suprapubic or transurethral catheter drainage when repeat TUR is impractical.
Joyce Young Johnson, Handbook for Brunner and Suddarth’s Textbook of Medical- Surgical Nursing, 11th edition, pp 213- 220
PROSTATE CANCER
3
Opioid or nonopioid medications (antiandrogen, prednisone, and mitoxantrone) to control pain with metastasis to bone. Blood transfusions to maintain adequate hemoglobin levels. Prosthetic penile implants or other options to create a penile erection for the patient with impotence. Laparoscopic radical prostatectomy (LAP): a new method, not widespread. NURSING PROCESS: The Patient Undergoing Prostatectomy:
Assessment
Take a complete history, with emphasis on urinary function and the effect of the underlying disorder on patient’s lifestyle. Note reports of urgency frequency, nocturia, dysuaria, urinary retention, hematuria, or decreased ability to initialize voiding. Note family history of cancer, heart disease, or kidney disease, including hypertension.
Diagnosis
Preoperative Nursing Diagnoses Anxiety related to inability to void. Acute pain related to bladder distention. Deficient knowledge of the problem and treatment protocol. Postoperative Nursing Diagnoses Acute pain related to surgical incision, catheter placement, and bladder spasms. Deficient knowledge about postoperative care. Collaborative Problems/ Potential Complications Hemorrhage and shock Infection Deep vein thrombosis Catheter obstruction Sexual dysfunction
Joyce Young Johnson, Handbook for Brunner and Suddarth’s Textbook of Medical- Surgical Nursing, 11th edition, pp 213- 220
PROSTATE CANCER
4
Planning and Goals
The major preoperative goals of the patient may include reduced anxiety and increased knowledge about the prostate problem and the perioperative experience. The major postoperative goals may include correction of fluid volume disturbances, relief of pain and discomfort, ability to perform self- care activities, and absence of complications.
Preoperative Nursing Interventions
Reducing Anxiety Provide privacy, and establish a trusting and professional relationship. Encourage patient to discuss feelings and concerns. Clarify the nature of the surgery and expected postoperative outcomes. Preparing Patient for Treatment Explain diagnostic tests, surgery procedure, and drainage system. Answer questions and provide support. Establish a private time for patient to review the anatomy and function of affected parts. Explain rationale for use of preoperative compression stockings. Administer enema, if ordered.
Postoperative Nursing Interventions
Relieving Discomfort While patient is on bed, administer analgesic agents; initiate measures to relieve anxiety. Monitor voiding patterns; watch for bladder distention. Insert indwelling catheter if urinary retention is present or if laboratory tests results indicate azotemia. Prepare patients for a cystostomy if urinary catheter is not tolerated. Caring for Patient After Treatment Distinguish cause and location of pain, including bladder spasms. Give analgesic agents for incisional pain and smooth muscle relaxants for bladder spasm. Monitor drainage tubing and irrigate drainage system to correct any obstruction.
Joyce Young Johnson, Handbook for Brunner and Suddarth’s Textbook of Medical- Surgical Nursing, 11th edition, pp 213- 220
PROSTATE CANCER
5
Secure catheter to leg or abdomen. Monitor dressings, and adjust to ensure they are not too snug or not too saturated or are improperly placed. Provide stool softener, prune juice, or an enema, if prescribed. Monitor for electrolyte imbalances (eg. hyponatremia). Monitoring and managing Complications Hemorrhage: observe catheter drainage, note bright- red bleeding with increased viscosity and clots; monitor input and output and vital signs; administer medications, intravenous fluids, and blood as prescribed. Provide explanations and reassurance to patient and family. Infection: assess for urinary tract infection and epididymitis; administer antibiotics as prescribed. Provide sitz bath and heat lamps to promote healing after sutures are removed. Use aseptic technique with dressing changes; avoid rectal thermometers, tubes and enemas. Thrombosis: assess for deep vein thrombosis and pulmonary embolism; apply compression stockings. Assist patient to progress from dangling the day of surgery to ambulating the next morning; encourage patient to walk but not sit for long periods of time. Monitor the patient receiving heparin for excessive bleeding. Obstructed catheter: observe lower abdomen for bladder distention. Provide for patient drainage system; perform gentle irrigation as prescribed to remove blood clots. Sexual dysfunction: erectile dysfunction, decreased libido, and fatigue may be a concern soon or months after surgery. Medications, surgically placed implants or negative- pressure devices may help restore function. Reassurance that libido usually returns and fatigue diminishes after recuperation may help. Providing privacy, confidentiality, and time to discuss issues of sexuality is important. Referral to a sex therapist may be indicated. NURSING ALERT! Urine leakage around the wound may be noted after catheter removal.
Joyce Young Johnson, Handbook for Brunner and Suddarth’s Textbook of Medical- Surgical Nursing, 11th edition, pp 213- 220
PROSTATE CANCER
6
Promoting Home and Community- Based Care Teaching Patients Self- Care Teach patient and family how to manage drainage system; monitor urinary output, perform wound care, and use strategies to prevent complications. Inform patient about signs and symptoms that should be reported to the physician (eg. blood in the urine, decreased urine output, fever, change in wound drainage, or calf tenderness). Teach perineal exercises to help regain urinary control. As indicated, discuss possible sexual dysfunction (provide a private environment) and refer for counseling. Instruct patient not to perform Valsalva maneuver for 6 to 8 weeks because it increases venous pressure and may produce hematuria. Urge patient to avoid long car trips and strenuous exercise, which increases tendency to bleed. Inform patient that spicy foods, alcohol, and coffee can cause bladder discomfort. Encourage fluids to avoid dehydration and clot formation. Continuing Care Refer to home care as indicated. Remind patient that return of bladder control may take time.
Evaluation
Expected Preoperative Patient Outcomes Demonstrates reduced anxiety. States pain and discomfort are decreased. Relates understanding of surgical procedure and postoperative care (perineal muscle exercises and bladder control techniques). Expected Postoperative Patient Outcomes Relates relief of discomfort. Performs self- care measures. Remains free of complications. Exhibits fluid and electrolyte balance. Reports understanding of changes in sexual function.
Joyce Young Johnson, Handbook for Brunner and Suddarth’s Textbook of Medical- Surgical Nursing, 11th edition, pp 213- 220
1
CANCER OF THE PROSTATE: Cancer of the prostate is the most common cancer in men, the second most common cause of cancer deaths in American men older than 55, and the most prevalent cancer overall in African American men. About 1 in 5 men in the US develop prostate cancer. Risk factors include increasing age and possibly a high-fat diet. CLINICAL MANIFESTATIONS: Usually asymptomatic in early stage Nodule felt within the substance of the gland or extensive hardening in the posterior lobe Lesion is stony hard and fixed. Obstructive symptoms occur late in the disease: difficulty and frequency of urination, urinary retention, decreased size and force of urinary stream. Blood in urine or semen; painful ejaculation Cancer metastasis to bone, lymph nodes, brain, and lungs. Symptoms of metastases include backache, hip pain, perineal and rectal discomfort, anemia, weight loss, weakness, nausea, and oliguria; hematuria may result from urethral or bladder invasion. Sexual dysfunction ASSESSMENT AND DIAGNOSTIC METHODS: To promote early detection, all men over 50 years of age should have a digital rectal examination (DRE) as part of their regular health checkup. This is the key to a higher cure rate. The diagnosis is confirmed by histologic examination of tissue, transurethral resection, open prostatectomy, and fine-needle aspiration. Prostate- specific antigen (PSA) level, transrectal ultrasound. bone scan, radiographs, excretory urography, renal function tests, computed tomography (CT) scans, lymphangiography, or monoclonal antibody- based imaging may also be used.
Joyce Young Johnson, Handbook for Brunner and Suddarth’s Textbook of Medical- Surgical Nursing, 11th edition, pp 213- 220
Advanced Stage
PROSTATE CANCER
2
MEDICAL MANAGEMENT: Treatment is based on the stage of the disease and patient’s age and symptoms. PSA concentration is used to monitor patient’s response to cancer therapy and to detect local progression and early recurrence.
Radical Prostatectomy
Radiation Therapy
Removal of the prostate and seminal vesicles through suprapubic approach (greater blood loss), perineal approach (easily contaminated, incontinence, impotence, and rectal injury common), or retropubic approach (infection can readily start). This procedure is performed in patients who have potentially curable disease and life expectancy of 10 years of more. Sexual impotency and various degrees of urinary incontinence follow radical prostatectomy.
If cancer is in the early stage, treatment may be curative. For locally advanced cancer, hormonal treatments are given before and after radiation. Side effects, usually transitory, include inflammation of the rectum, bowel, and bladder. There is better preservation of sexual potency, and young patients may prefer this treatment. Hormone Therapy Method of control rather than cure. Accomplished by either orchiectomy or administration of estrogens. Diethylstilbestrol (DES) is the most widely used estrogen. Luteinizing hormone (LHRH) agonists and antiandrogen drugs such as flutamide and cyproterone are newer hormonal therapies. Other Therapies Transurethral resection of the prostate (TUR or TURP) or transurethral incision of the prostate (TUIP) for benign condition. Cyrosurgery for those who cannot physically tolerate surgery of for recurrence Chemotherapy (doxorubicin, cisplatin, and cyclophosphamide). Repeated TUR to keep urethra patient; suprapubic or transurethral catheter drainage when repeat TUR is impractical.
Joyce Young Johnson, Handbook for Brunner and Suddarth’s Textbook of Medical- Surgical Nursing, 11th edition, pp 213- 220
PROSTATE CANCER
3
Opioid or nonopioid medications (antiandrogen, prednisone, and mitoxantrone) to control pain with metastasis to bone. Blood transfusions to maintain adequate hemoglobin levels. Prosthetic penile implants or other options to create a penile erection for the patient with impotence. Laparoscopic radical prostatectomy (LAP): a new method, not widespread. NURSING PROCESS: The Patient Undergoing Prostatectomy:
Assessment
Take a complete history, with emphasis on urinary function and the effect of the underlying disorder on patient’s lifestyle. Note reports of urgency frequency, nocturia, dysuaria, urinary retention, hematuria, or decreased ability to initialize voiding. Note family history of cancer, heart disease, or kidney disease, including hypertension.
Diagnosis
Preoperative Nursing Diagnoses Anxiety related to inability to void. Acute pain related to bladder distention. Deficient knowledge of the problem and treatment protocol. Postoperative Nursing Diagnoses Acute pain related to surgical incision, catheter placement, and bladder spasms. Deficient knowledge about postoperative care. Collaborative Problems/ Potential Complications Hemorrhage and shock Infection Deep vein thrombosis Catheter obstruction Sexual dysfunction
Joyce Young Johnson, Handbook for Brunner and Suddarth’s Textbook of Medical- Surgical Nursing, 11th edition, pp 213- 220
PROSTATE CANCER
4
Planning and Goals
The major preoperative goals of the patient may include reduced anxiety and increased knowledge about the prostate problem and the perioperative experience. The major postoperative goals may include correction of fluid volume disturbances, relief of pain and discomfort, ability to perform self- care activities, and absence of complications.
Preoperative Nursing Interventions
Reducing Anxiety Provide privacy, and establish a trusting and professional relationship. Encourage patient to discuss feelings and concerns. Clarify the nature of the surgery and expected postoperative outcomes. Preparing Patient for Treatment Explain diagnostic tests, surgery procedure, and drainage system. Answer questions and provide support. Establish a private time for patient to review the anatomy and function of affected parts. Explain rationale for use of preoperative compression stockings. Administer enema, if ordered.
Postoperative Nursing Interventions
Relieving Discomfort While patient is on bed, administer analgesic agents; initiate measures to relieve anxiety. Monitor voiding patterns; watch for bladder distention. Insert indwelling catheter if urinary retention is present or if laboratory tests results indicate azotemia. Prepare patients for a cystostomy if urinary catheter is not tolerated. Caring for Patient After Treatment Distinguish cause and location of pain, including bladder spasms. Give analgesic agents for incisional pain and smooth muscle relaxants for bladder spasm. Monitor drainage tubing and irrigate drainage system to correct any obstruction.
Joyce Young Johnson, Handbook for Brunner and Suddarth’s Textbook of Medical- Surgical Nursing, 11th edition, pp 213- 220
PROSTATE CANCER
5
Secure catheter to leg or abdomen. Monitor dressings, and adjust to ensure they are not too snug or not too saturated or are improperly placed. Provide stool softener, prune juice, or an enema, if prescribed. Monitor for electrolyte imbalances (eg. hyponatremia). Monitoring and managing Complications Hemorrhage: observe catheter drainage, note bright- red bleeding with increased viscosity and clots; monitor input and output and vital signs; administer medications, intravenous fluids, and blood as prescribed. Provide explanations and reassurance to patient and family. Infection: assess for urinary tract infection and epididymitis; administer antibiotics as prescribed. Provide sitz bath and heat lamps to promote healing after sutures are removed. Use aseptic technique with dressing changes; avoid rectal thermometers, tubes and enemas. Thrombosis: assess for deep vein thrombosis and pulmonary embolism; apply compression stockings. Assist patient to progress from dangling the day of surgery to ambulating the next morning; encourage patient to walk but not sit for long periods of time. Monitor the patient receiving heparin for excessive bleeding. Obstructed catheter: observe lower abdomen for bladder distention. Provide for patient drainage system; perform gentle irrigation as prescribed to remove blood clots. Sexual dysfunction: erectile dysfunction, decreased libido, and fatigue may be a concern soon or months after surgery. Medications, surgically placed implants or negative- pressure devices may help restore function. Reassurance that libido usually returns and fatigue diminishes after recuperation may help. Providing privacy, confidentiality, and time to discuss issues of sexuality is important. Referral to a sex therapist may be indicated. NURSING ALERT! Urine leakage around the wound may be noted after catheter removal.
Joyce Young Johnson, Handbook for Brunner and Suddarth’s Textbook of Medical- Surgical Nursing, 11th edition, pp 213- 220
PROSTATE CANCER
6
Promoting Home and Community- Based Care Teaching Patients Self- Care Teach patient and family how to manage drainage system; monitor urinary output, perform wound care, and use strategies to prevent complications. Inform patient about signs and symptoms that should be reported to the physician (eg. blood in the urine, decreased urine output, fever, change in wound drainage, or calf tenderness). Teach perineal exercises to help regain urinary control. As indicated, discuss possible sexual dysfunction (provide a private environment) and refer for counseling. Instruct patient not to perform Valsalva maneuver for 6 to 8 weeks because it increases venous pressure and may produce hematuria. Urge patient to avoid long car trips and strenuous exercise, which increases tendency to bleed. Inform patient that spicy foods, alcohol, and coffee can cause bladder discomfort. Encourage fluids to avoid dehydration and clot formation. Continuing Care Refer to home care as indicated. Remind patient that return of bladder control may take time.
Evaluation
Expected Preoperative Patient Outcomes Demonstrates reduced anxiety. States pain and discomfort are decreased. Relates understanding of surgical procedure and postoperative care (perineal muscle exercises and bladder control techniques). Expected Postoperative Patient Outcomes Relates relief of discomfort. Performs self- care measures. Remains free of complications. Exhibits fluid and electrolyte balance. Reports understanding of changes in sexual function.
Joyce Young Johnson, Handbook for Brunner and Suddarth’s Textbook of Medical- Surgical Nursing, 11th edition, pp 213- 220
