Prostatic hypertrophy
Hypertrophy of the prostate is a gland hyperplasia of the periurethral prostate tissue which then forces the original to be peripheral and surgical hoops. (Jong, Wim de, 1998).EtiologyMany theories that explain the occurrence of an enlarged prostate gland, but until now there has been no agreement on the matter. There are several theories put forward why periurethral glands can undergo hyperplasia, namely:Stem cell theory (Isaacs 1984)Based on this theory prostate tissue in adults is in the balance between cell growth and cell death, the condition is called steady state. On prostate tissue contained stem cells that can proliferate more quickly, resulting in hyperplasia of the periurethral glands.Neal MC theory (1978)According to the MC. Neal, benign prostate enlargement starts from the transition zone of proximal located on both sides of the external spincter veromontatum in periurethral zone.In theory Hydro Testosterone (DHT)Testosterone is a male hormone that is produced by cells Leyding. Testosterone is produced by the majority of both testicles, so the incidence of prostate enlargement requires the existence of a normal testis. The amount of testosterone produced by the testes is approximately 90% of the entire production of testosterone, while the 10% is produced by the adrenal glands.Most of the testosterone in the body is in a state bound to proteins in the form of Serum Hormone Binding (SBH). Approximately 2% of testosterone is in a free state. Hormone-free is what plays a role in the process of enlargement of the prostate gland. Testosterone can freely enter into the prostate cells to penetrate the cell membrane into the cytoplasm of prostate cells to form DHT - receptor complex that will affect Ribo Nucleic Acid (RNA) that can lead to protein synthesis that can occur cell proliferation (MC Connel 1990). Changes in the balance of testosterone 50 years and over. ± and estrogen can occur with ageAnatomy and PhysiologySpincter externa surrounds the urethra below the bladder in women, but in men there is a prostate gland is located behind the urethra spincter cover. Excrete prostatic fluid into the urethra during ejaculation, prostatic fluid is giving food to sperm. The fluid enters the pars prostatic urethra from the vas deferens.Prostate bypassed by:a. Ejaculatory duct, consists of 2 pieces derived from the seminal vesica empties into the urethra.b. Urethra itself, whose length is 17-23 cm.Automatically prostate size is as follows:a. Transverse: 1.5 inchesb. Vertical: 1.25 inchesc. Anterior Posterior: 0.75 inchesThe prostate consists of 5 lobes, namely:a. Two lateral lobesb. The posterior lobec. The anterior lobed. The medial lobeThe prostate gland is about the size of a large walnut, located below the bladder.Normal prostate weight in adults is estimated to 20 grams.PathophysiologyUsually found symptoms and signs of obstruction and irritation. Presence of urinary obstruction means patients have to wait at the beginning of micturition, micturition interrupted, dripping at the end of micturition, micturition jets become weaker, and the flavor was not satisfied over micturition. Irritative symptoms caused by detrusor muscle hypersensitivity, meaning increased micturition frequency, nocturia, difficult micturition and dysuria arrested. Obstruction symptoms due to detrusor fails to contract with a strong enough or long enough so that the contract failed contraction disjointed. Irritative symptoms occur due to incomplete emptying during micturition or an enlarged prostate causes stimulation of the bladder, thus vesica often though not yet fully contracted. This situation makes the scoring system to determine the severity of prostate hypertrophy patients clinical complaints.If vesica become decompensated, urinary retention that would occur at the end of micturition still found residual urine in the bladder, and produces a sensation of incomplete at the end of micturition.If this situation continues, at some point there will be traffic jam, so people can no longer afford because of micturition urine production continues to happen then at some point bladder unable to hold urine, so the pressure continues meningakat vesicles. When the bladder pressure becomes higher than the pressure spincter and obstruction, urinary incontinence will occur causing chronic retention paradox vesicoureter reflux, hydroureter, hydronephrosis and renal failure. Process accelerated kidney damage if there is an infection.At the time of micturition the patient should always be straining so that over time cause a hernia or haemorhoid. Because there is always a residual urine sediment can form stones in the bladder. This stone can add to complaints cause irritation and hematuria. The stones can also cause cystitis and reflux can occur in case of pyelonephritis.There are 3 ways to measure the magnitude of hypertrophy of the prostate, namely (a) rectal grading (b) clinical grading and (c) intra-urethral grading.Rectal gradingRecthal grading or rectal toucher do in an empty jar. Because when a full bladder can occur errors in judgment. With rectal toucher estimated by several cm protruding into the lumen of the prostate and rectum. Prominence of the prostate can be determined in grade. Grade division as follows:0-1 cm ..........: Grade 01-2 cm ..........: Grade 12-3 cm ..........: Grade 23-4 cm ..........: Grade 3Over 4 cm .......: Grade 4Usually in grade 3 and 4 boundary of the prostate can not be touched because it bumps into the rectal cavity. By determining the grading of rectal got a great impression and prostate weight and it is also important to determine the kind of operation that will be performed. When small (grade 1), then a good therapy is TUR (Trans Urethral Resection) When prostate immense (grade 3-4) can do trans vesical prostatektomy open.Clinical gradingAt this measurement as a standard is the number of residual urine. This measurement is done in a way, the patient woke up the morning of the urinary asked to complete, and then inserted a catheter into the bladder to measure the residual urine.Residual urine Normal 0 cc .........................Residual urine 0-50 cc ................... Grade 1Residual urine 50-150 cc ................ Grade 2Residual urine> 150 cc ..................... Grade 3Urinary absolutely can not ...... Grade 4Intra urethra gradingTo see how far lateral lobe protrusion into the lumen of the urethra. These measurements should be viewed with penendoskopy and has become a field of urology specific.Effects that may occur due to prostate hypertropi:To the urethraWhen the medial lobes enlarged, usually resulting in an upward direction pars prostatic urethra lengthened, and therefore fixation ductus ejaculatorius then the extension will spin and cause blockages.To the bladderIn the bladder muscle hypertropi be obtained as a result of the compensation process, which is obtained thickened muscle fibro depressed section (curvature) are called diverticula potential.In the longer process of decompensation will occur in the muscles and as a result there are hypertropi atonia (no power) than the muscles.If the enlargement occurs on the medial lobe, it will form a post-prostatic pouch, this is the bag that contained the bladder behind the medial lobe.Prostatic Post is a source of formation of residual urine (urine is left) and the post prostatic pouch also always found the stones in the bladder.To the ureter and kidneyIf circumstances urethra valve vesica well, then strain into extra vesicles are not forwarded to the above, but if the valve is damaged then forwarded to the pressure, as a result the muscles calyces, pelvis, ureter own experience hipertropy and will lead to hydronephrosis and uremia due up.To sex organsInitially increased libido, decreased libido teatapi eventually.Clinical SymptomsDivided into 4 grades as follows:At grade 1 (congestic)1.) Patients at first difficult months or a few years and began straining bladder.2.) If micturition was satisfied.3.) Urine drips out and poor stream.4.) Nocturia5.) Urine out at night more than normal.6.) Longer than normal erections and more libido than normal.7.) In cytoscopy visible hyperemia of the internal urethral orifice. Occurs slowly bleeding varices could eventually happen (blooding)At grade 2 (residual)8.) When micturition is hot.9.) Dysuri nocturi gain weight.10.) Can not urinate (urinary dissatisfied).11.) Can occur because of residual urine infection.12.) There was high heat and may shiver.13.) Pain in the lumbar region (spreading to the kidneys).At grade 3 (urinary retention)14.) Ischuria paradosal.15.) Incontinensia paradosal.At grade 416.) Full bladder.17.) Patients feel pain.18.) Urine dripped periodically called over flow incontinensia.19.) On physical examination, palpation of the lower abdomen to feel there is a tumor, because of a great dam.20.) With an infection the patient may shiver and high heat about 40-410 C.21.) Then the patient can be coma.Diagnostic testClinical diagnosis of prostate enlargement can be established by examination as follows:a. Anamnesis goodb. Physical examinationCan be done with a toucher rectal examination, in which the will of benign prostate enlargement palpable mass in front of the rectum that dining chewy consistency, which is not too big if it can achieve an upper limit to the fingertips, while an upper limit has not palpable prostate tissue is usually more of 60 gr.c. Examination of residual urined. Examination of ultra sonography (ultrasound)Can be done from the supra pubic or transrectal (Trans Rectal Ultra Sonography: TRUS). For clinical purposes supra pubic and large enough to estimate prostate anatomy, whereas TRUS is usually needed to detect malignancy.e. Examination EndoskopyWhen the toucher rectal examination, not too obtrusive but very clear prostatismus symptoms or to know the size of the prostate that protrude into the lumen.f. Radiological examinationWith radiology examinations such as abdominal plain radiography and intravenous pyelografi often called IVP (Intra Venous Pyelografi) and BNO (Buich Nier Oversich). On the other examination of prostate enlargement can be seen as a defect lesion contrast wedge at the base of the bladder and ureter distal end turned up shaped like a hook / fishing (FISA hook appearance).g. A CT-Scan and MRIComputed Tomography Scanning (CT-Scan) can provide a snapshot of the enlarged prostate, whereas magnetic resonance imaging (MRI) can provide a picture of the prostate in the transverse plane and sagittal slices in many areas, but this is rarely done because pameriksaan expensive.h. Examination sistografiPerformed if the history was found on examination of urine or hematuria was found mikrohematuria. This examination can illustrate the possibility of a tumor in the bladder or the source of the bleeding if the blood coming from the mouth of the ureter or radiolucent stones in the vesica. Additionally sistoscopi can also provide information about prostate by measuring the length of the urethra pars prostatic protrusion prostatica and look into the urethra.i. Another inspectionSpecifically for the inspection of benign prostate enlargement have not been there, there is the examination of a tumor marker for prostate carcinoma is the examination Prostatic Specific Antigen (PSA), PSA cut-off rate is 4 nanograms / ml.Differential diagnosisBy due process of micturition depends on detrusor contraction strength, elasticity bladder neck resistance to tone muscles and urethra which is a factor in the difficulty of micturition. Detrusor weakness caused by neurological disorders (neurologic bladder) such as: spinal cord lesions, the use of sedatives. Vesica neck stiffness caused by the process of fibrosis, whereas urethral resistance caused by an enlarged prostate benign or malignant, tumors in the bladder neck, stones in the urethra or urethral stricture.TreatmentEach micturition difficulties arising from any of the factors such as reduced detrusor contraction strength or elasticity decrease vesica neck, the treatment measures aimed at reducing the volume of the prostate, reducing tone vesica neck or urethra opening pars prostatica and detrusor contraction strength in order to increase the micturition process becomes easy.Treatment for prostate hipertropy there are 2 kinds:a.Konsevatifb.OperatifIn this treatment was based on prostate size distribution, ie the degree of 1-4.I a.DerajatDo conservative treatment, for example with fazosin, prazoin and terazoin (for smooth muscle relaxation).b.Derajat IIIndications for surgery. Usually recommended endoscopic resekesi through the urethra.c.Derajat IIIEstimated prostate big enough and the action taken to open surgery through the transvesical, retropubic or perianal.d.Derajat IVFreeing people from total urinary retention by placing a catheter, for further examination in the implementation of the plan surgery.Conservative.Conservative treatment aims to slow the growth of prostate enlargement. Action performed when surgical treatment can not be done, for example: refuse surgery or any contra-indications for surgery.Conservative therapeutic measures, namely:a.Mengusahakan so suddenly enlarged prostate not due to secondary infection with antibiotics.b.Bila done Catheterisasi urinary retention.OperativeSurgery is the primary treatment in benign prostatic hypertrophy (BPH), prostate gland during surgery and removed intact soft tissues that have an enlarged tissue removed through four ways: (a) transurethral (b) suprapubic (c) retropubic and (d) perineal.Transurethral.Implemented when enlargement occurs in the medial lobes immediately surrounds the urethra. Resected tissue only slightly so there is no bleeding and surgical time is not too long. Rectoscope connected with an electrical current then entered into the urinary urethra.Kandung rinse continuously during the procedure berjalan.Pasien got the tools for the future of the electric shock was given a metal plate placed in lube under paha.Kepingan soft tissue in the waste sliced and bleeding spots on the lid with a cauterized.After TURP in pairs of three-channel Foley catheter equipped balloon catheter balloon 30 ml.Setelah developed, catheter in the pull down so the balloon is in the works as the prostate fossa hemostat.Ukuran large catheter in pairs to facilitate the expenditure of blood clots from bladder urine.Bladder irrigated continue with a three-point drop with salt fisiologisatau another solution in use by expert bedah.Tujuan of constant irrigation is to free the bladder from that block the flow of blood ekuan kemih.Irigasi constant bladder was stopped after 24 hours if not kemih.Kemudian clot out of the bladder catheter can be rinsed usual every 4 hours until the catheter once the lift is usually 3 to 5 days after catheter operasi.Setelah in lifting patients should measure the amount of urine and micturition time every time.Suprapubic Prostatectomy.Method of open surgery, resection of the prostate gland supra pubic removed from the bladder through the urethra.Retropubic ProstatectomyAt retropubic prostatectomy, an incision is made in the lower abdominal but not the bladder is opened.Perianal prostatectomy.Performed on suspicion of prostate cancer, an incision made between the scrotum and rectum.Complicationa.Perdarahanb.Inkotinensiac.Batu bladderd.Retensi urinee.Impotensif.Epididimitisg.Haemorhoid, hernia, rectal prolapse from strainingh.Infeksi urinary tract caused by Catheterisasii.HydronefrosisThings that should be performed in patients after discharge from the hospital is;weight training, weight lifting and sexual intercourse be avoided for 3 weeks after the home.Should not take the vehicle.Straining during defecation should be avoided, faeces should be mushy if necessary medication to soften faeces.Recommends plenty of water to prevent infection and to make static and soft faeces.Basic Concepts of NursingNursing care of patients with prostatic hypertrophy through the nursing process approach consisting of nursing assessment, nursing planning, implementation and evaluation of nursing.Nursing AssessmentThe data collectionBasic data related to postoperative prostate hypertrophy. Classifying data is a step taken after holding data collection obtained as follows:Pain in the surgery area.Dizziness.Changes in urinary frequency.Urgency.DysuriaNegative flatus.Wound surgery on the prostate region.Retention, the bladder is full.IncontinenceDry lips.Fasting.Bowel sounds negative.Grimacing facial expressions.Installation of permanent catheter.Restless.Less information.Reddish-colored urine.Nursing diagnosesNursing diagnoses in order of priority problems in patients post surgery prostate hypertrophy, is as follows:Changes in urinary elimination related to mechanical obstruction: blood clots, edema, trauma, surgical procedures, pressure and irritation of the catheter / balloon.Risk of lack of fluid volume related to the area of vascular surgery: difficulty controlling bleeding.The risk of infection related to invasive procedures: a tool for surgery, catheter, bladder irrigation often, tissue trauma, surgical incisions.Impaired sense of comfort: pain related to irritation of the bladder mucosa: a reflex spasm of muscles in connection with surgical procedures and / bladder pressure of the balloon.Risk of sexual dysfunction associated with crisis situations (incontinence, urine leakage after removal of the catheter, the involvement of the genital area).Anxiety associated with lack of knowledge, incorrect interpretation of information, do not know the source of information.Planning NursingChanges in urinary elimination related to mechanical obstruction: blood clots, edema, trauma, surgical procedures, and pressure irrigation catheter / balloon, characterized by:Pain in the surgery area.Changes in urinary frequency.Urgency.Dysuria.Installation of permanent catheter.The existence of wound surgery on the prostate region.Reddish-colored urine.Objective: The client said no complaints, with the following criteria:Catheter remained patent at tempatntya.There is no blockage of blood flow through the catheter.Without excessive urination flow.Retention does not occur during irrigation.Intervention:Assess urine output and system catheter / drainage, especially during bladder irrigation.Rational:Retention may occur due to the surgical area edema, blood clots and spasms of the bladder.Note the time, the number and size of urinary stream after the catheter is removed.Rational:Catheter is usually removed 2-5 days after surgery, but voiding can continue to be a problem for some time due to edema and loss of urethral tone.Encourage clients when it feels the urge to urinate but not more than 2-4 hours.Rational:Urge to urinate with to prevent retention, urine. Limitations to urinate every 4 hours (if tolerated) increased bladder tone and helps the bladder retraining.Measure residual volume when there is a supra pubic catheter.Rational:Monitor the effectiveness of the bladder to empty. More than 50 ml residue indicates the need for continuity catheter until the bladder muscle tone improves.Push 3000 ml fluid intake as tolerated.Rational:Maintain adequate hydration and renal perfusion to the flow of urine.Medical collaboration for bladder irrigation as indicated in the early postoperative period.Rational:Bladder wash of blood clots and to maintain catheter patency / flow of urine.Risk of lack of fluid volume related to the area of vascular surgery: difficulty controlling bleeding, characterized by:Dizziness.Negative flatus.Dry lips.Fasting.Bowel sounds negative.Reddish-colored urine.Objective: There is a shortage of fluid volume, with the following criteria:Normal vital signs.Palpable peripheral pulse.Good capillary refill.Mucous membranes well.Appropriate urine output.Intervention:Immerse catheter, avoiding manipulation berlenihan.Rational:Withdrawal / catheter movement can cause bleeding or blood clot formation.Keep an eye on fluid intake and expenditure.Rational:Indicator fluid balance and replacement needs. On bladder irrigation, estimated blood loss and the watch accurately assess urine output.Evaluation of color, komsistensi urine.Rational:To indicate the presence of bleeding.Keep an eye on vital signsRational:Dehydration / hypovolemia requires rapid intervention to prevent continued to shock. Hypertension, bradycardia, nausea / vomiting showed TURP syndrome, requiring immediate medical intervention.Collaboration for laboratory tests as indicated (hemoglobin / hematocrit, red blood cell count)Rational:Useful in the evaluation of blood loss / replacement needs.The risk of infection associated with surgical procedures, catheter, bladder irrigation often, tissue trauma, surgical incisions, characterized by:Regional pain surgery.Dysuria.Wound surgery on the prostate region.Installation of permanent catheter.Purpose: Shows no signs of infection, with the following criteria:No visible signs of infection.Incontinence is not the case.Surgical wound dry quickly.Intervention:Provide care in a sterile catheter remains.Rational:Prevent the introduction of bacteria and infection / cross infection.Ambulation dependent drainage bag.Rational:Avoid turning reflex urine, which can include bacteria to the bladder.Keep an eye on vital signs.Rational:Clients who are at risk for TUR surgical shock / septic connection with instrumentation.Change the bandage with frequent, cleaning and drying of the skin over time.Rational:Wrap wet can cause irritation, and provide a medium for bacterial growth, increased risk of infection.Medical collaboration for the delivery of antibiotic drug classes.Rational:Can kill pathogenic bacteria causing the infection.Impaired sense of comfort; pain associated with irritation of the bladder mucosa: reflex muscle spasm associated with surgical procedures and / pressure of the balloon bladder, characterized by:Pain in the surgery area.Wound surgery.Grimacing facial expressions.Retention of urine, so that the bladder is full.Intervention:Assess the level of pain.Rational:Knowing the level of perceived pain and facilitate our clients in providing the action.Maintain the position of the catheter and drainage system.Rational:Maintain the function of the catheter and drainage system, reduce the risk of distension / bladder spasm.Teach relaxation techniques.Rational:Merileksasikan muscles so the blood supply to the tissues is met / adequate, so the pain is reduced.Give sitz baths when indicated.Rational:Increase tissue perfusion and edema repair and promote healing.Medical collaboration for the provision of anti-spasmodic and analgesic.Rational:Class of anti-spasmodic drugs to relax the smooth muscle, to give / reduce spasm and pain.Classes of analgesic drugs can inhibit pain receptors so not transmitted to the brain and the pain is not felt.Risk of sexual dysfunction associated with crisis situations (incontinence, urine leakage after removal of the catheter, the involvement of the genital area) is characterized by:Prostate gland surgery.Objective: Sexual function can be maintained, the criteria:Patients can discuss their feelings about sexuality with people nearby.Intervention:Provide information about the expectations of the return of sexual function.Rational:Physiological Impotence: occurs when a nerve is cut for perineal radical surgical procedures: in other approaches, sexual activity can be carried out as normal in 6-8 weeks.Discuss basic anatomy.Rational:Nerve plexus controls the flow to the prostate through the posterior capsule. On procedures that do not involve the prostate capsule, impotence and sterility is usually not the case.Instruct perineal exercises.Rational:Improve muscle control increased urinary continence and sexual function.Collaboration advisor to sexuality / sexology as indicated.Rational:For further require professional intervention.Anxiety associated with lack of knowledge, incorrect interpretation of information, do not know the source of information, characterized by:Restless.Less informationObjective: The client expressed anxiety resolved, with the following criteria:Clients are not restless.RelaxedIntervention:Assess the level of anxiety.Rational:Knowing the level of anxiety experienced by the client, making it easier to give further action.Observation of vital signs.Rational:Indicators in knowing the client experienced an increase in anxiety.Provide clear information about the action procedure to be performed.Rational:Understand / understand the disease process and the actions provided.Provide support through a spiritual approach.Rational:That the client has the spirit and not in a desperate run for the healing treatmentImplementation of Nursing.At this step, nurses provide nursing care, the nursing plan based implementation that has been adjusted in the previous step (planning nursing actions).Evaluation of Nursing.Nursing care in the form of changes in patient behavior is the focus of an objective evaluation, the evaluation of nursing with postoperative prostate hypertrophy is as follows:Urinary elimination pattern can be normal.Outcomes:Demonstrate behaviors to control bladder reflexes.Bladder emptying in the absence of suppression / distended bladder / urinary retention.The requirement for fluids.Outcomes:Normal vital signsGood peripheral pulse / palpable.Good capillary refill.Mucous membranes moist.Appropriate urine output.Prevent infection.Outcomes:Achieve healing and showed no signs of infection.Pain reported lost / controlled.Outcomes:Demonstrate the use of relaxation skills and activities appropriate therapeutic indications and individual situations.Looks relaxed.Sexual function can be maintained.Outcomes:Expressed understanding of individual situationsDemonstrate problem solving skills.Clients know / understand about the disease.Outcomes:Participate in the treatment program.Perform the necessary behavior changes.Perform the necessary procedures correctly and explain the reasons for the action.
bibliography
1.Basuki B Purnomo, 2000, Basics of Urology, National Library, Catalog-in-Publication (KTD), Jakarta.2.Doenges, Marilynn E, 1999, Nursing Care Plan - Guidelines for Planning and Documenting Patient Care, Interpreting: I Made Kariasa, Ni Made Sumarwati, Editor: Monica Ester, Yasmin Asih, Edition: Third, EGC; Jakarta.3.Guyton, Arthur C., 1997, Textbook of Medical Physiology, Editor, Irawati. S, Edition: 9, EGC, Jakarta.
Hypertrophy of the prostate is a gland hyperplasia of the periurethral prostate tissue which then forces the original to be peripheral and surgical hoops. (Jong, Wim de, 1998).EtiologyMany theories that explain the occurrence of an enlarged prostate gland, but until now there has been no agreement on the matter. There are several theories put forward why periurethral glands can undergo hyperplasia, namely:Stem cell theory (Isaacs 1984)Based on this theory prostate tissue in adults is in the balance between cell growth and cell death, the condition is called steady state. On prostate tissue contained stem cells that can proliferate more quickly, resulting in hyperplasia of the periurethral glands.Neal MC theory (1978)According to the MC. Neal, benign prostate enlargement starts from the transition zone of proximal located on both sides of the external spincter veromontatum in periurethral zone.In theory Hydro Testosterone (DHT)Testosterone is a male hormone that is produced by cells Leyding. Testosterone is produced by the majority of both testicles, so the incidence of prostate enlargement requires the existence of a normal testis. The amount of testosterone produced by the testes is approximately 90% of the entire production of testosterone, while the 10% is produced by the adrenal glands.Most of the testosterone in the body is in a state bound to proteins in the form of Serum Hormone Binding (SBH). Approximately 2% of testosterone is in a free state. Hormone-free is what plays a role in the process of enlargement of the prostate gland. Testosterone can freely enter into the prostate cells to penetrate the cell membrane into the cytoplasm of prostate cells to form DHT - receptor complex that will affect Ribo Nucleic Acid (RNA) that can lead to protein synthesis that can occur cell proliferation (MC Connel 1990). Changes in the balance of testosterone 50 years and over. ± and estrogen can occur with ageAnatomy and PhysiologySpincter externa surrounds the urethra below the bladder in women, but in men there is a prostate gland is located behind the urethra spincter cover. Excrete prostatic fluid into the urethra during ejaculation, prostatic fluid is giving food to sperm. The fluid enters the pars prostatic urethra from the vas deferens.Prostate bypassed by:a. Ejaculatory duct, consists of 2 pieces derived from the seminal vesica empties into the urethra.b. Urethra itself, whose length is 17-23 cm.Automatically prostate size is as follows:a. Transverse: 1.5 inchesb. Vertical: 1.25 inchesc. Anterior Posterior: 0.75 inchesThe prostate consists of 5 lobes, namely:a. Two lateral lobesb. The posterior lobec. The anterior lobed. The medial lobeThe prostate gland is about the size of a large walnut, located below the bladder.Normal prostate weight in adults is estimated to 20 grams.PathophysiologyUsually found symptoms and signs of obstruction and irritation. Presence of urinary obstruction means patients have to wait at the beginning of micturition, micturition interrupted, dripping at the end of micturition, micturition jets become weaker, and the flavor was not satisfied over micturition. Irritative symptoms caused by detrusor muscle hypersensitivity, meaning increased micturition frequency, nocturia, difficult micturition and dysuria arrested. Obstruction symptoms due to detrusor fails to contract with a strong enough or long enough so that the contract failed contraction disjointed. Irritative symptoms occur due to incomplete emptying during micturition or an enlarged prostate causes stimulation of the bladder, thus vesica often though not yet fully contracted. This situation makes the scoring system to determine the severity of prostate hypertrophy patients clinical complaints.If vesica become decompensated, urinary retention that would occur at the end of micturition still found residual urine in the bladder, and produces a sensation of incomplete at the end of micturition.If this situation continues, at some point there will be traffic jam, so people can no longer afford because of micturition urine production continues to happen then at some point bladder unable to hold urine, so the pressure continues meningakat vesicles. When the bladder pressure becomes higher than the pressure spincter and obstruction, urinary incontinence will occur causing chronic retention paradox vesicoureter reflux, hydroureter, hydronephrosis and renal failure. Process accelerated kidney damage if there is an infection.At the time of micturition the patient should always be straining so that over time cause a hernia or haemorhoid. Because there is always a residual urine sediment can form stones in the bladder. This stone can add to complaints cause irritation and hematuria. The stones can also cause cystitis and reflux can occur in case of pyelonephritis.There are 3 ways to measure the magnitude of hypertrophy of the prostate, namely (a) rectal grading (b) clinical grading and (c) intra-urethral grading.Rectal gradingRecthal grading or rectal toucher do in an empty jar. Because when a full bladder can occur errors in judgment. With rectal toucher estimated by several cm protruding into the lumen of the prostate and rectum. Prominence of the prostate can be determined in grade. Grade division as follows:0-1 cm ..........: Grade 01-2 cm ..........: Grade 12-3 cm ..........: Grade 23-4 cm ..........: Grade 3Over 4 cm .......: Grade 4Usually in grade 3 and 4 boundary of the prostate can not be touched because it bumps into the rectal cavity. By determining the grading of rectal got a great impression and prostate weight and it is also important to determine the kind of operation that will be performed. When small (grade 1), then a good therapy is TUR (Trans Urethral Resection) When prostate immense (grade 3-4) can do trans vesical prostatektomy open.Clinical gradingAt this measurement as a standard is the number of residual urine. This measurement is done in a way, the patient woke up the morning of the urinary asked to complete, and then inserted a catheter into the bladder to measure the residual urine.Residual urine Normal 0 cc .........................Residual urine 0-50 cc ................... Grade 1Residual urine 50-150 cc ................ Grade 2Residual urine> 150 cc ..................... Grade 3Urinary absolutely can not ...... Grade 4Intra urethra gradingTo see how far lateral lobe protrusion into the lumen of the urethra. These measurements should be viewed with penendoskopy and has become a field of urology specific.Effects that may occur due to prostate hypertropi:To the urethraWhen the medial lobes enlarged, usually resulting in an upward direction pars prostatic urethra lengthened, and therefore fixation ductus ejaculatorius then the extension will spin and cause blockages.To the bladderIn the bladder muscle hypertropi be obtained as a result of the compensation process, which is obtained thickened muscle fibro depressed section (curvature) are called diverticula potential.In the longer process of decompensation will occur in the muscles and as a result there are hypertropi atonia (no power) than the muscles.If the enlargement occurs on the medial lobe, it will form a post-prostatic pouch, this is the bag that contained the bladder behind the medial lobe.Prostatic Post is a source of formation of residual urine (urine is left) and the post prostatic pouch also always found the stones in the bladder.To the ureter and kidneyIf circumstances urethra valve vesica well, then strain into extra vesicles are not forwarded to the above, but if the valve is damaged then forwarded to the pressure, as a result the muscles calyces, pelvis, ureter own experience hipertropy and will lead to hydronephrosis and uremia due up.To sex organsInitially increased libido, decreased libido teatapi eventually.Clinical SymptomsDivided into 4 grades as follows:At grade 1 (congestic)1.) Patients at first difficult months or a few years and began straining bladder.2.) If micturition was satisfied.3.) Urine drips out and poor stream.4.) Nocturia5.) Urine out at night more than normal.6.) Longer than normal erections and more libido than normal.7.) In cytoscopy visible hyperemia of the internal urethral orifice. Occurs slowly bleeding varices could eventually happen (blooding)At grade 2 (residual)8.) When micturition is hot.9.) Dysuri nocturi gain weight.10.) Can not urinate (urinary dissatisfied).11.) Can occur because of residual urine infection.12.) There was high heat and may shiver.13.) Pain in the lumbar region (spreading to the kidneys).At grade 3 (urinary retention)14.) Ischuria paradosal.15.) Incontinensia paradosal.At grade 416.) Full bladder.17.) Patients feel pain.18.) Urine dripped periodically called over flow incontinensia.19.) On physical examination, palpation of the lower abdomen to feel there is a tumor, because of a great dam.20.) With an infection the patient may shiver and high heat about 40-410 C.21.) Then the patient can be coma.Diagnostic testClinical diagnosis of prostate enlargement can be established by examination as follows:a. Anamnesis goodb. Physical examinationCan be done with a toucher rectal examination, in which the will of benign prostate enlargement palpable mass in front of the rectum that dining chewy consistency, which is not too big if it can achieve an upper limit to the fingertips, while an upper limit has not palpable prostate tissue is usually more of 60 gr.c. Examination of residual urined. Examination of ultra sonography (ultrasound)Can be done from the supra pubic or transrectal (Trans Rectal Ultra Sonography: TRUS). For clinical purposes supra pubic and large enough to estimate prostate anatomy, whereas TRUS is usually needed to detect malignancy.e. Examination EndoskopyWhen the toucher rectal examination, not too obtrusive but very clear prostatismus symptoms or to know the size of the prostate that protrude into the lumen.f. Radiological examinationWith radiology examinations such as abdominal plain radiography and intravenous pyelografi often called IVP (Intra Venous Pyelografi) and BNO (Buich Nier Oversich). On the other examination of prostate enlargement can be seen as a defect lesion contrast wedge at the base of the bladder and ureter distal end turned up shaped like a hook / fishing (FISA hook appearance).g. A CT-Scan and MRIComputed Tomography Scanning (CT-Scan) can provide a snapshot of the enlarged prostate, whereas magnetic resonance imaging (MRI) can provide a picture of the prostate in the transverse plane and sagittal slices in many areas, but this is rarely done because pameriksaan expensive.h. Examination sistografiPerformed if the history was found on examination of urine or hematuria was found mikrohematuria. This examination can illustrate the possibility of a tumor in the bladder or the source of the bleeding if the blood coming from the mouth of the ureter or radiolucent stones in the vesica. Additionally sistoscopi can also provide information about prostate by measuring the length of the urethra pars prostatic protrusion prostatica and look into the urethra.i. Another inspectionSpecifically for the inspection of benign prostate enlargement have not been there, there is the examination of a tumor marker for prostate carcinoma is the examination Prostatic Specific Antigen (PSA), PSA cut-off rate is 4 nanograms / ml.Differential diagnosisBy due process of micturition depends on detrusor contraction strength, elasticity bladder neck resistance to tone muscles and urethra which is a factor in the difficulty of micturition. Detrusor weakness caused by neurological disorders (neurologic bladder) such as: spinal cord lesions, the use of sedatives. Vesica neck stiffness caused by the process of fibrosis, whereas urethral resistance caused by an enlarged prostate benign or malignant, tumors in the bladder neck, stones in the urethra or urethral stricture.TreatmentEach micturition difficulties arising from any of the factors such as reduced detrusor contraction strength or elasticity decrease vesica neck, the treatment measures aimed at reducing the volume of the prostate, reducing tone vesica neck or urethra opening pars prostatica and detrusor contraction strength in order to increase the micturition process becomes easy.Treatment for prostate hipertropy there are 2 kinds:a.Konsevatifb.OperatifIn this treatment was based on prostate size distribution, ie the degree of 1-4.I a.DerajatDo conservative treatment, for example with fazosin, prazoin and terazoin (for smooth muscle relaxation).b.Derajat IIIndications for surgery. Usually recommended endoscopic resekesi through the urethra.c.Derajat IIIEstimated prostate big enough and the action taken to open surgery through the transvesical, retropubic or perianal.d.Derajat IVFreeing people from total urinary retention by placing a catheter, for further examination in the implementation of the plan surgery.Conservative.Conservative treatment aims to slow the growth of prostate enlargement. Action performed when surgical treatment can not be done, for example: refuse surgery or any contra-indications for surgery.Conservative therapeutic measures, namely:a.Mengusahakan so suddenly enlarged prostate not due to secondary infection with antibiotics.b.Bila done Catheterisasi urinary retention.OperativeSurgery is the primary treatment in benign prostatic hypertrophy (BPH), prostate gland during surgery and removed intact soft tissues that have an enlarged tissue removed through four ways: (a) transurethral (b) suprapubic (c) retropubic and (d) perineal.Transurethral.Implemented when enlargement occurs in the medial lobes immediately surrounds the urethra. Resected tissue only slightly so there is no bleeding and surgical time is not too long. Rectoscope connected with an electrical current then entered into the urinary urethra.Kandung rinse continuously during the procedure berjalan.Pasien got the tools for the future of the electric shock was given a metal plate placed in lube under paha.Kepingan soft tissue in the waste sliced and bleeding spots on the lid with a cauterized.After TURP in pairs of three-channel Foley catheter equipped balloon catheter balloon 30 ml.Setelah developed, catheter in the pull down so the balloon is in the works as the prostate fossa hemostat.Ukuran large catheter in pairs to facilitate the expenditure of blood clots from bladder urine.Bladder irrigated continue with a three-point drop with salt fisiologisatau another solution in use by expert bedah.Tujuan of constant irrigation is to free the bladder from that block the flow of blood ekuan kemih.Irigasi constant bladder was stopped after 24 hours if not kemih.Kemudian clot out of the bladder catheter can be rinsed usual every 4 hours until the catheter once the lift is usually 3 to 5 days after catheter operasi.Setelah in lifting patients should measure the amount of urine and micturition time every time.Suprapubic Prostatectomy.Method of open surgery, resection of the prostate gland supra pubic removed from the bladder through the urethra.Retropubic ProstatectomyAt retropubic prostatectomy, an incision is made in the lower abdominal but not the bladder is opened.Perianal prostatectomy.Performed on suspicion of prostate cancer, an incision made between the scrotum and rectum.Complicationa.Perdarahanb.Inkotinensiac.Batu bladderd.Retensi urinee.Impotensif.Epididimitisg.Haemorhoid, hernia, rectal prolapse from strainingh.Infeksi urinary tract caused by Catheterisasii.HydronefrosisThings that should be performed in patients after discharge from the hospital is;weight training, weight lifting and sexual intercourse be avoided for 3 weeks after the home.Should not take the vehicle.Straining during defecation should be avoided, faeces should be mushy if necessary medication to soften faeces.Recommends plenty of water to prevent infection and to make static and soft faeces.Basic Concepts of NursingNursing care of patients with prostatic hypertrophy through the nursing process approach consisting of nursing assessment, nursing planning, implementation and evaluation of nursing.Nursing AssessmentThe data collectionBasic data related to postoperative prostate hypertrophy. Classifying data is a step taken after holding data collection obtained as follows:Pain in the surgery area.Dizziness.Changes in urinary frequency.Urgency.DysuriaNegative flatus.Wound surgery on the prostate region.Retention, the bladder is full.IncontinenceDry lips.Fasting.Bowel sounds negative.Grimacing facial expressions.Installation of permanent catheter.Restless.Less information.Reddish-colored urine.Nursing diagnosesNursing diagnoses in order of priority problems in patients post surgery prostate hypertrophy, is as follows:Changes in urinary elimination related to mechanical obstruction: blood clots, edema, trauma, surgical procedures, pressure and irritation of the catheter / balloon.Risk of lack of fluid volume related to the area of vascular surgery: difficulty controlling bleeding.The risk of infection related to invasive procedures: a tool for surgery, catheter, bladder irrigation often, tissue trauma, surgical incisions.Impaired sense of comfort: pain related to irritation of the bladder mucosa: a reflex spasm of muscles in connection with surgical procedures and / bladder pressure of the balloon.Risk of sexual dysfunction associated with crisis situations (incontinence, urine leakage after removal of the catheter, the involvement of the genital area).Anxiety associated with lack of knowledge, incorrect interpretation of information, do not know the source of information.Planning NursingChanges in urinary elimination related to mechanical obstruction: blood clots, edema, trauma, surgical procedures, and pressure irrigation catheter / balloon, characterized by:Pain in the surgery area.Changes in urinary frequency.Urgency.Dysuria.Installation of permanent catheter.The existence of wound surgery on the prostate region.Reddish-colored urine.Objective: The client said no complaints, with the following criteria:Catheter remained patent at tempatntya.There is no blockage of blood flow through the catheter.Without excessive urination flow.Retention does not occur during irrigation.Intervention:Assess urine output and system catheter / drainage, especially during bladder irrigation.Rational:Retention may occur due to the surgical area edema, blood clots and spasms of the bladder.Note the time, the number and size of urinary stream after the catheter is removed.Rational:Catheter is usually removed 2-5 days after surgery, but voiding can continue to be a problem for some time due to edema and loss of urethral tone.Encourage clients when it feels the urge to urinate but not more than 2-4 hours.Rational:Urge to urinate with to prevent retention, urine. Limitations to urinate every 4 hours (if tolerated) increased bladder tone and helps the bladder retraining.Measure residual volume when there is a supra pubic catheter.Rational:Monitor the effectiveness of the bladder to empty. More than 50 ml residue indicates the need for continuity catheter until the bladder muscle tone improves.Push 3000 ml fluid intake as tolerated.Rational:Maintain adequate hydration and renal perfusion to the flow of urine.Medical collaboration for bladder irrigation as indicated in the early postoperative period.Rational:Bladder wash of blood clots and to maintain catheter patency / flow of urine.Risk of lack of fluid volume related to the area of vascular surgery: difficulty controlling bleeding, characterized by:Dizziness.Negative flatus.Dry lips.Fasting.Bowel sounds negative.Reddish-colored urine.Objective: There is a shortage of fluid volume, with the following criteria:Normal vital signs.Palpable peripheral pulse.Good capillary refill.Mucous membranes well.Appropriate urine output.Intervention:Immerse catheter, avoiding manipulation berlenihan.Rational:Withdrawal / catheter movement can cause bleeding or blood clot formation.Keep an eye on fluid intake and expenditure.Rational:Indicator fluid balance and replacement needs. On bladder irrigation, estimated blood loss and the watch accurately assess urine output.Evaluation of color, komsistensi urine.Rational:To indicate the presence of bleeding.Keep an eye on vital signsRational:Dehydration / hypovolemia requires rapid intervention to prevent continued to shock. Hypertension, bradycardia, nausea / vomiting showed TURP syndrome, requiring immediate medical intervention.Collaboration for laboratory tests as indicated (hemoglobin / hematocrit, red blood cell count)Rational:Useful in the evaluation of blood loss / replacement needs.The risk of infection associated with surgical procedures, catheter, bladder irrigation often, tissue trauma, surgical incisions, characterized by:Regional pain surgery.Dysuria.Wound surgery on the prostate region.Installation of permanent catheter.Purpose: Shows no signs of infection, with the following criteria:No visible signs of infection.Incontinence is not the case.Surgical wound dry quickly.Intervention:Provide care in a sterile catheter remains.Rational:Prevent the introduction of bacteria and infection / cross infection.Ambulation dependent drainage bag.Rational:Avoid turning reflex urine, which can include bacteria to the bladder.Keep an eye on vital signs.Rational:Clients who are at risk for TUR surgical shock / septic connection with instrumentation.Change the bandage with frequent, cleaning and drying of the skin over time.Rational:Wrap wet can cause irritation, and provide a medium for bacterial growth, increased risk of infection.Medical collaboration for the delivery of antibiotic drug classes.Rational:Can kill pathogenic bacteria causing the infection.Impaired sense of comfort; pain associated with irritation of the bladder mucosa: reflex muscle spasm associated with surgical procedures and / pressure of the balloon bladder, characterized by:Pain in the surgery area.Wound surgery.Grimacing facial expressions.Retention of urine, so that the bladder is full.Intervention:Assess the level of pain.Rational:Knowing the level of perceived pain and facilitate our clients in providing the action.Maintain the position of the catheter and drainage system.Rational:Maintain the function of the catheter and drainage system, reduce the risk of distension / bladder spasm.Teach relaxation techniques.Rational:Merileksasikan muscles so the blood supply to the tissues is met / adequate, so the pain is reduced.Give sitz baths when indicated.Rational:Increase tissue perfusion and edema repair and promote healing.Medical collaboration for the provision of anti-spasmodic and analgesic.Rational:Class of anti-spasmodic drugs to relax the smooth muscle, to give / reduce spasm and pain.Classes of analgesic drugs can inhibit pain receptors so not transmitted to the brain and the pain is not felt.Risk of sexual dysfunction associated with crisis situations (incontinence, urine leakage after removal of the catheter, the involvement of the genital area) is characterized by:Prostate gland surgery.Objective: Sexual function can be maintained, the criteria:Patients can discuss their feelings about sexuality with people nearby.Intervention:Provide information about the expectations of the return of sexual function.Rational:Physiological Impotence: occurs when a nerve is cut for perineal radical surgical procedures: in other approaches, sexual activity can be carried out as normal in 6-8 weeks.Discuss basic anatomy.Rational:Nerve plexus controls the flow to the prostate through the posterior capsule. On procedures that do not involve the prostate capsule, impotence and sterility is usually not the case.Instruct perineal exercises.Rational:Improve muscle control increased urinary continence and sexual function.Collaboration advisor to sexuality / sexology as indicated.Rational:For further require professional intervention.Anxiety associated with lack of knowledge, incorrect interpretation of information, do not know the source of information, characterized by:Restless.Less informationObjective: The client expressed anxiety resolved, with the following criteria:Clients are not restless.RelaxedIntervention:Assess the level of anxiety.Rational:Knowing the level of anxiety experienced by the client, making it easier to give further action.Observation of vital signs.Rational:Indicators in knowing the client experienced an increase in anxiety.Provide clear information about the action procedure to be performed.Rational:Understand / understand the disease process and the actions provided.Provide support through a spiritual approach.Rational:That the client has the spirit and not in a desperate run for the healing treatmentImplementation of Nursing.At this step, nurses provide nursing care, the nursing plan based implementation that has been adjusted in the previous step (planning nursing actions).Evaluation of Nursing.Nursing care in the form of changes in patient behavior is the focus of an objective evaluation, the evaluation of nursing with postoperative prostate hypertrophy is as follows:Urinary elimination pattern can be normal.Outcomes:Demonstrate behaviors to control bladder reflexes.Bladder emptying in the absence of suppression / distended bladder / urinary retention.The requirement for fluids.Outcomes:Normal vital signsGood peripheral pulse / palpable.Good capillary refill.Mucous membranes moist.Appropriate urine output.Prevent infection.Outcomes:Achieve healing and showed no signs of infection.Pain reported lost / controlled.Outcomes:Demonstrate the use of relaxation skills and activities appropriate therapeutic indications and individual situations.Looks relaxed.Sexual function can be maintained.Outcomes:Expressed understanding of individual situationsDemonstrate problem solving skills.Clients know / understand about the disease.Outcomes:Participate in the treatment program.Perform the necessary behavior changes.Perform the necessary procedures correctly and explain the reasons for the action.
bibliography
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