Prostate Cancer Case Study
Order ID 53563633773 Type Essay Writer Level Masters Style APA Sources/References 4 Perfect Number of Pages to Order 5-10 Pages Description/Paper Instructions
A.B. is a 55-year-old man who was referred to the urology clinic by his primary care provider (PCP) for an elevated prostate-specific antigen (PSA). He reports that he has been feeling well and has no specific complaints. He had a CBC, basic metabolic panel (BMP), urinalysis (UA), lipid profile, and screening PSA completed the week before when he was seen by his PCP. His CBC, lipid profile, UA, and blood chemistries are all within normal limits. His PSA is elevated at 11.9 ng/mL, and the prostate is slightly tender on exam.
- A.B. wonders whether he has prostate cancer. What can you tell A.B. about his PSA?
PSA is a glycoprotein produced by prostate cells. It is unique to the prostate and is not produced anywhere else in the body. Normally, prostate cells leak a small amount of PSA into the bloodstream; this small amount is what is measured when a PSA is drawn. An enlarged prostate naturally leaks more PSA and causes an elevated PSA level in the blood. When a prostate cell is damaged, it leaks more PSA; damage might be caused by infection, inflammation, or cancer. A.B.’s result of 11.9 ng/mL reflects a moderate elevation. Further testing needs to be done.
- A.B. is scheduled for a transrectal ultrasound (TRUS) of the prostate. What is the purpose of this test?
This test is a good tool in the early diagnosis of prostate cancer when combined with the PSA and DRE. The sound waves emitted by the ultrasound provide an image of the prostate gland. The transrectal ultrasound can also be helpful in guiding a prostate biopsy.
- Based on the PSA and TRUS results, A.B. is scheduled for a prostate biopsy. He wonders what he needs to do to prepare for this test. Explain a prostate biopsy procedure and how to prepare for the procedure.
- Patients preparing for a prostate biopsy should stop all medications that increase bleeding time: warfarin (Coumadin), clopidogrel (Plavix), aspirin, or NSAIDs such as ibuprofen (Motrin, Advil) or naproxen (Naprosyn, Aleve). Warfarin should be stopped 5 to 7 days before this procedure, so patients should talk to their provider before stopping this medication. Other anticoagulants/ antiplatelet medications should be stopped 1 week before this procedure. Patients can expect to find some blood in their bowel movement for up to 2 weeks following a biopsy.
- The patient will probably be sedated for this procedure and need a driver to take him home. If sedation is used, he will need to fast before this procedure but can take his other medications as usual. If not allergic, he will be medicated with an antibiotic the day before, the day of, and the day after the procedure. In addition, he can have a Fleet enema the morning of the procedure. The pre-procedure treatment might vary from practice to practice; check the practice in your area before instructing the patients about medications.
- A prostate biopsy is performed by inserting a large US probe into the rectum. Because the prostate is located next to the rectum, the probe can be angled to visualize the prostate on the US screen.
A biopsy needle is inserted through the wall of the rectum into the prostate to obtain a prostate tissue sample. The urologist will usually get six tissue samples from each side of the prostate for a total of 12 samples.
CASE STUDY PROGRESS
A.B.’s prostate biopsy is positive for cancer, with a Gleason grade of 7. He has discussed his diagnosis with the urologist. He is now thinking about his treatment options and asks you to answer some questions. He was told about his Gleason grade but is not sure what this is.
- What is a Gleason grade?
Cancer cells are graded according to how abnormal the cells look. Grading is from 1 to 5, with 1 being nearly normal and 5 being very abnormal. The grades from two different areas are added together for a Gleason score. A score of 2 to 4 is a low-grade cancer, which is less aggressive, whereas a score of 8 to 10 is an aggressive cancer and needs to be treated more aggressively. The more aggressive the cancer, the faster it grows and spreads.
- The urologist discusses possible treatment options with A.B. Identify three treatment options for prostate cancer.
- Watchful waiting, which involves simply monitoring A.B.’s condition and intervention if symptoms become troublesome.
- Brachytherapy: Radioactive seeds are implanted in the prostate (these people have irritative voiding symptoms [frequency] for months after the procedure), or external beam radiation can be used.
- Hormone therapy: A PSA is drawn and medications are given, based on PSA levels. In some cases, medications are given to shrink the tumor before surgery.
- Chemotherapy: Systemic cytotoxic chemotherapy might be done for patients whose cancer has metastasized.
- Surgery: There are two surgical procedures:
- Laparoscopic radical prostatectomy (LRP) is a minimally invasive procedure that uses a robot-assisted procedure. Benefits include a decreased hospital stay (1 to 2 days), smaller incisions, less postop discomfort, decreased time for the indwelling urinary catheter, and faster recovery. In addition, there are nerve-sparing advantages.
- Radical open prostatectomy: The patient might have blood loss during surgery and suffer incontinence and erectile dysfunction postoperatively.
CASE STUDY PROGRESS
After consulting with his urologist, A.B. has decided to have his prostate removed with the laparoscopic procedure. He is planning on having surgery in 2 weeks but is concerned about the possible conse-quences of surgery.
- Identify the major immediate postoperative concerns for A.B.
Bleeding and pain
- What are the two main long-term consequences of prostatectomy?
- Erectile dysfunction: If a patient has a low-grade tumor that is small, the urologist will try to spare the nerves that help provide erections.
- Urinary incontinence (UI): The risk of incontinence is greatest just after catheter removal, and it will gradually subside over the first 2 years postoperatively, to a rate of 35% to 50%. Most will
experience only mild UI, but approximately 8% will have significant, long-term UI that requires continuous use of adult briefs or containment devices.
Patients who have the laparoscopic radical prostatectomy have a lower incidence of these problems.
- The urologist you work for has asked you to give A.B. preoperative instructions. What should you tell him?
- Follow a clear liquid diet the day before surgery.
- Use a bowel prep to evacuate stool and clear the rectum. He might be given a laxative to take the afternoon before surgery and a few doses of oral antibiotics preoperatively. This protocol might be practice-specific, so check the protocol in your area.
- Remain NPO after midnight.
CASE STUDY PROGRESS
A.B. returns status post-laparoscopic radical prostatectomy (LRP). Initial postoperative orders are written.
- Which orders are appropriate for A.B.? (Select all that apply, and correct the inappropriate answers.)
- Vital signs per hospital protocol
- Notify physician if urinary output is less than 30 mL/hr.
- Up ad lib.
- Change Foley catheter if clotting occurs.
- Oxybutynin (Ditropan XL) 10 mg PO every morning
- Docusate (Colace) 100 mg PO qd
- Morphine 4 mg IV push q4h prn pain
Answers: A, B, E, F, G
C is incorrect. He can get up as tolerated but only with assistance to ensure that there is no tension on the urinary catheter. In addition, he might be receiving an opioid (morphine) for pain, and he could be at risk for falling. D is incorrect. Do not remove the Foley catheter under any circum-stances. The surgical area could be disrupted, and bleeding might occur.
- What would be ordered if clotting of the Foley catheter occurs?
Careful irrigation of the catheter system with an isotonic solution might be ordered if clotting occurs.
Practices will vary.
- After giving A.B. a complains of bladder spasms and is given a dose of oxybutynin (Ditropan XL), the nurse will monitor for which adverse effects? (Select all that apply.)
- Dry mouth
- Watery eyes
- Dizziness
- Diarrhea
- Palpitations
Answers: A, C, E
Oxybutynin adverse effects include dry mouth and eyes, dizziness, drowsiness, anxiety, restless-ness, constipation, and palpitations.
CASE STUDY PROGRESS
A.B. does not require any additional therapy after surgery. At his 6-month follow-up visit, he reports he can get an erection but has difficulty maintaining an erection for sexual relations.
- You discuss erectile aids with A.B. What options should you address?
- Oral erectile medications (sildenafil [Viagra], vardenafil [Levitra], tadalafil [Cialis])
- Injecting the penis with vasodilating drugs
- Transurethral suppository (alprostadil [Muse])
- Vacuum constriction device
- Surgically implanted penile prosthesis
RUBRIC
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