A Comprehensive Case Study and Nursing Care Approach

The patient is a 63-year-old African-American retired firefighter whose brother was recently diagnosed with prostate cancer. As a former firefighter, he has managed to maintain a healthy lifestyle, taking vitamins regularly and having no past medical history. Recently, he visited his primary care physician with complaints of blood in his urine, trouble urinating, and occasional lower back pain. During a general physical exam, including a digital rectal exam, the doctor found that the patient had an enlarged prostate with palpable nodules. Following this abnormal finding, the doctor ordered lab tests and a prostate biopsy, which confirmed the diagnosis of prostate cancer (Case Reports on Prostate Cancer, 2004). After informing the patient about his diagnosis, the nurse educated him about prostate cancer and available treatment options. The nurse's job was to help the patient understand his diagnosis and guide him through the treatment process, ensuring he felt comfortable with what was coming next. The patient has no past medical history and isn't taking any current medications or receiving treatment for other conditions.

Lab Reports (Case Reports on Prostate Cancer, 2004)

The patient's prostate-specific antigen (PSA) level was 95 ng/mL (normal range: 0.0–4.0 ng/mL), whereas six years earlier, it was 1.5 ng/mL. His hemoglobin was 15 g/dL (normal range: 13.2–17.1 g/dL), hematocrit 43% (normal range: 38.5–50%), white blood cells 7,500/mm3, normal differential, platelets 250,000/mm3, blood urea nitrogen 15 mg/dL (normal range: 7–30 mg/dL), and creatinine level 1.0 mg/dL (normal range: 0.5–1.4 mg/dL). Alkaline phosphatase and liver function tests were all normal. Chest X-ray, bone scan, and abdominal CT scan were negative.

Pathophysiology (Alyssa V.)

The exact cause of prostate cancer is unknown. However, factors like age, ethnicity, family history, and exposure to environmental toxins increase the risk (Anatomical Chart Company, 2002). The prostate gland is a walnut-sized organ in the male reproductive system that produces about a third of the seminal fluid. It is located just below the urinary bladder and surrounds the urethra (Leslie et al., 2019). Prostate cancers usually start in the back part of the prostate gland and sometimes near the urethra (Anatomical Chart Company, 2002). Cancer begins with a mutation in healthy prostate gland cells, typically in the peripheral basal cells (Leslie et al., 2019). In its early stages, there might be little to no symptoms; it's in the advanced stage where symptoms appear. Because the prostate is near urinary tract organs like the bladder and urethra, issues within the prostate can cause trouble urinating and blood in the urine. Due to its position, occasional pelvic and lower back pain may also occur. Complications can arise if prostate cancer spreads to the bones, causing severe pain and increasing the risk of fractures, spinal cord compression, or high blood calcium levels, all of which are life-threatening (Treating Prostate Cancer, 2019).

History (Alyssa V.)

The patient has no past medical history because he maintained a healthy lifestyle through his long career as a firefighter. He also takes vitamins regularly but has several risk factors that might explain his diagnosis. The patient is 63 years old, and men over 50 are more likely to develop prostate cancer (Anatomical Chart Company, 2002). African-American men are at higher risk. Additionally, prostate cancer can run in families, and his brother’s diagnosis doubled his risk. His years as a firefighter might also be a factor due to exposure to chemicals or environmental toxins (Prostate Cancer Risk Factors, 2019). The patient complained of blood in his urine, trouble urinating, and occasional lower back pain during his doctor's visit.

Nursing Physical Assessment (Jasmine R.)

The patient's blood pressure was 130/90, which is elevated since normal blood pressure is 120/80. This might be due to the back pain he’s experiencing (Tennant, n.d.). There were no bowel sounds, usually indicating constipation. The patient has been experiencing bouts of constipation, so the lack of bowel sounds confirms this (Abdominal sounds, n.d.). His movement has slightly decreased due to his recurring back pain, causing him to move and walk less. Normal movement would be a person who can walk and move independently. The patient's PSA was 95 ng/mL, extremely high compared to the normal range of 0.0-4.0 ng/mL. This was a severe increase from his PSA of 1.5 ng/mL six years ago (Case reports on prostate, 2004). His hemoglobin was 15 g/dL, within the normal range of 13.2-17.1 g/dL, and his hematocrit was 43%, also within the normal range of 38.5-50%. His white blood cell count was 7,500 mm3, which is normal, as is between 5,000 to 10,000/mm3. His platelets were normal at 250,000/mm3, within the normal range of 150,000 - 400,000 mm3. Blood urea nitrogen (BUN) was normal at 15 mg/dL (normal range: 7-30mg/dL), and his creatinine level was also normal at 1.0 mg/dL (normal range: 0.5-1.4 mg/dL) (Case reports on prostate, 2004). His alkaline phosphatase (ALP) was 40 U/L, within the normal range of 37 to 116 U/L (Alkaline, n.d.). The patient’s liver function tests were all normal. His Alanine transaminase (ALT) was 40 U/L, Aspartate transaminase (AST) was 35 U/L, Albumin was 4.0 g/dL, total protein was 6.4 g/dL, Bilirubin was 1.1mg/dL, Gamma-glutamyltransferase (GGT) was 48 U/L, L-lactate dehydrogenase (LD) was 180 U/L, and Prothrombin time (PT) was 10.5 seconds. Normal ranges for ALT are 7 to 55 U/L, AST is 8 to 48 U/L, Albumin 3.5 to 5.0 g/dL, Total protein 6.3 to 7.9 g/dL, Bilirubin 0.1 to 1.2 mg/dL, GGT 8 to 61 U/L, LD 122 to 222 U/L, and PT 9.4 to 12.5 seconds (Liver Function, 2019). Chest X-ray, bone scan, and abdominal CT scan were negative (Case reports on prostate, 2004). His Gleason score was 8, considered a high-grade cancer. A Gleason score of 6 is low-grade cancer, and a score of 7 is medium-grade cancer. The higher the score, the faster the cancer will spread (NCI, n.d.).

Related Treatments (Jasmine R.)

The patient is getting systemic therapy and local palliative care. Radiation therapy is used to control local obstructive problems. The patient is also receiving hormone therapy to lower the levels of androgens, like testosterone and dihydrotestosterone (DHT), because androgens can stimulate prostate cancer cells to grow (The American Cancer Society medical and editorial content team, 2019). The hormone given was Abarelix, a gonadotropin-releasing hormone (GnRH) antagonist. After three months of Abarelix with external beam radiation therapy, there was a rapid decline in the patient's PSA to less than 0.1 ng/mL, which helped with his pain. There was also a significant improvement in his urological symptoms. He received 40 radiation treatments over eight weeks, consisting of 3-dimensional conformal radiation therapy, delivering a total dose of 6570 Gy to the prostate (Case reports on prostate, 2004). The palliative care focused on the patient's quality of life, successfully reducing his pain, lowering his PSA, and significantly improving his urological symptoms.

Nursing Diagnosis and Patient Goals (Ellie Le. - also formatting, editing, flow, APA)

The patient's major nursing diagnoses are impaired urinary elimination, risk for infections, acute pain, and self-care deficit (Vera, 2013). He experiences urinary dysfunction due to an enlarged prostate and bladder distension. Radiation therapy causes inflammation in normal cells, leading to symptoms like diarrhea, rectal leakage, burning urination, and urinary incontinence (American Cancer Society, 2019). Depending on the severity of the therapy, the patient may experience sexual dysfunction, fatigue, and decreased libido. There's also a high risk for lower urinary tract infections. Acute pain is a constant companion during cancer progression, treatment, and aftercare. Lastly, the patient and his family may lack knowledge about cancer, urinary difficulties, complications, and treatments. The goals for the patient include improving urinary elimination patterns, enjoying modified sexual functioning, avoiding complications, relieving pain, and understanding the diagnosis and self-care.

Nursing Interventions (Alyssa Y.)

The following information about treatment was given to the patient:

Hormone therapy might cause hot flashes, impaired sexual function or desire, weakened bones, itching, nausea, and diarrhea (PDQ, 2019).

External beam radiation therapy (EBRT) involves treatment five days a week for several weeks. The process is usually painless. The side effects of EBRT may include (ACS, 2019):

• Bowel problems: Radiation may irritate the bowel, causing diarrhea, blood in the stool, and rectal leakage. A diet plan may be assigned to reduce these problems. Most of these issues resolve on their own over time.
• Urinary problems: Radiation may irritate the bladder, causing frequent urination, a burning sensation during urination, or blood in the urine. These issues may or may not improve over time.
• Erection problems: Problems with erections may develop slowly over time.
• Fatigue: Fatigue may last weeks to months after treatment.
• Lymphedema: Radiation may damage the lymph nodes around the prostate, causing swelling or pain. Lymphedema can be treated with physical therapy, although it may not resolve completely.
• Urine management: Encourage fluid intake to 3000 mL per day (Vera, 2019). Monitor urine output and specific gravity.
• Infection: Keep the patient’s room clean and make sure every visitor washes their hands before interacting with the patient. Emphasize personal hygiene (Vera, 2019).
• Pain: Assess the patient’s pain level on a numeric rating scale of 0-10 (Vera, 2019).
• Sexual function: Explain to the patient and his partner that sexual function or desire may decrease. Reassure the patient that this is common and recommend help, such as medicine or a sex therapist (Vera, 2019).

Evaluation (Sam S.)

The nurse helped with hormonal therapy for the patient, educating him about the therapy and administering it. The patient also received external radiation therapy to improve his obstructive problems (Case Reports on Prostate Cancer, 2014). The nurse educated the patient about the radiation therapy treatment and potential side effects (Wood & Lockhar, 2000). The side effects emphasized included weakness, bowel and urinary dysfunction, and sexual dysfunction (ACS, 2019). The patient received 40 treatments over 8 weeks and noted improved urination and a decrease in blood in his urine (Case Reports on Prostate Cancer, 2004). Six months after hormonal and radiation therapy, the patient appeared healthy, and his labs reported good values, with PSA levels less than 0.1 ng/ml (Case Reports on Prostate Cancer, 2004).

Recommendations (Alyssa Y.) (ACS, 2019)

• Follow-up appointments may consist of exams or lab tests to monitor cancer or side effects of treatment
• PSA tests every 6 months for the first 5 years after treatment, and once a year after that
• Maintain a healthy weight and diet
• Participate in regular physical activity
• Establish a support group (friends, family, counselors, etc.)
• Long-term gonadal suppression drugs

References:

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3. Anatomical Chart Company. (2002). Atlas of Pathophysiology. Springhouse, PA: Springhouse
4. Banasik J.L. & Copstead L.E. (2019). Pathophysiology. St. Louis, MO: Elsevier.
5. Case reports on prostate cancer. (2004). Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1472886/.
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13. The American Cancer Society medical and editorial content team (ACS). (2019, August 1). Radiation therapy for prostate cancer. Retrieved from https://www.cancer.org/cancer/prostate-cancer/treating/radiation-therapy.html
14. The American Cancer Society medical and editorial content team (ACS). (2019, December 18). Hormone therapy for prostate cancer. Retrieved from https://www.cancer.org/cancer/prostate-cancer/treating/hormone-therapy.html
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17. Vera, M. (2019, June 1). 13 cancer nursing care plans. Retrieved from https://nurseslabs.com/cancer-nursing-care-plans/#Risk-for-Altered-Sexuality-Patterns