Sei sulla pagina 1di 126

BENIGN PROSTATE

HYPERPLASIA (BPH)
10 DIN 0131
KPJIUC

LEARNING OBJECTIVE

LEARNING OBJECTIVES

Definitions of Benign Prostate Hyperplasia (BPH)


State the etiologies of Benign Prostate Hyperplasia (BPH)
Explain pathophysiology of Benign Prostate Hyperplasia (BPH)
Explain the statistic patient having Benign Prostate Hyperplasia
(BPH)
State the clinical manifestations of Benign Prostate Hyperplasia
(BPH)
State the complications of Benign Prostate Hyperplasia (BPH)
List the investigations of Benign Prostate Hyperplasia (BPH)
List the treatments and medications given to patient Benign
Prostate Hyperplasia (BPH)
Carry out nursing responsibilities Pre-op & Post-op
Care of patient with Continuous Bladder Irrigation (CBI)
Carry out nursing care plans to patient Benign Prostate
Hyperplasia (BPH)
Provide health educations for patient Benign Prostate Hyperplasia
(BPH)

PATIENT DATA

NURSING ASSESSMENT
PATIENT DATA

NAME: Mr.Z
I/C NO: XXX
R/N: 48XXX
AGE: 53 Years
SEX: Male
RACE: Malay
RELIGION: Islam
LANGUAGE SPOKEN: Malay
OCCUPATION: Retired from MARA
CONSULTANT: Dr.A
DATE:/TIME OF ADMISSION: 1/11/2011
@
1800 hours
REASON FOR ADMISSION: C/O back pain for 4/12,sense of unable to
empty the bladder
fully,frequent urination and
bladder
distanded for 1/12
MEDICAL HISTORY: Nil
SURGICAL HISTORY: Nil
FAMILY MEDICAL HISTORY: Nil
CURRENT MEDICATIONS: Nil
ALLERGIES: Nil

CONDITION ON ADMISSION

CONDITION ON ADMISSION
VITAL SIGN
TEMPERATURE
: 36.0 C
PULSE
: 80 bpm
RESPIRATION
: 20 bpm
BLOOD PRESSURE: 127/80 mmHg
WEIGHT
: 65 kg
HEIGHT
: 156 cm
MODE OF ADMISSION
WALK IN
LEVEL OF CONSCIOUSNESS
CONSCIOUS
MENTAL STATUS
ORIENTATED
EMOTIONAL STATUS
CALM

PHYSICAL EXAMINATION

PHYSICAL EXAMINATION

HAIR
Short hair
White colour
No dandruf
EYES
No jaundice
No redness
Both eyes are symmetry
NOSE
No bleeding
No discharge
No displacement of nasal bone
EARS
No bleeding

No discharge
Both ears are symmetry

MOUTH
No dryness
No discharge
No ulcer
NECK
No scar
No enlargement of lymph nodes
CHEST
Respiratory movement normal
Chest is symmetry
No scar
UPPER LIMBS
No scar
Joint is normal movement
Capillary refill is normal

ABDOMEN
Distended bladder
GENITILIA PART
No abnormalities detected
LOWER LIMBS
No edema
Joint is normal movement
Capillary refill is normal
BACK
No displacement of spinal
No scar
The alignment is normal (straight)

CBD

IV LINE

ANTERIOR

POSTERIOR

ACTIVITY DAILY LIVING

ACTIVITIES OF DAILY LIVING

BREATHING
NO HAVE DIFFICULTIES IN BREATHING
NO HAVE ANY COUGH
NO SMOKE
EATING/DRINKING
NO ANY FOOD/DRINK THAT HE DO NOT TAKE
NO HAVE ANY PROBLEM WITH EATING/DRINKING
ELIMINATIONS-BOWEL
TWICE PER DAY OFTEN HE MOVE HIS BOWEL
NO CHANGES IN BOWEL HABITS LATELY
NO TAKE ANY MEDICATION FOR BOWEL MOVEMENT
BLADDER
BLADDER DISTANDED

SLEEPING
HAVE PROBLEM IN SLEEPING CAUSE 4 TIMES GET UP AT
NIGHT TO PASS URINE
NO REQUIRE MEDICATION TO SLEEP
MOBILITY
AMBULANT
PERSONAL HYGIENE
SELF
SAFE ENVIRONMENT
SIDERAIL
SPIRITUAL
NO REQUIRE ANY SPIRITUAL SUPPORT
HOBBIES
READING NEWS PAPER
COMMUNICATION
MALAY
SPEECH
NORMAL

VISION
VISUAL AIDS (SPECTACLES)
HEARING
NORMAL
SKIN CONDITION
NIL
OTHERS
NIL

ANATOMY & PHYSIOLOGY

ANATOMY AND PHYSIOLOGY


MALE REPRODUCTIVE SYSTEM
The male genitals include:A) Testicles
B) Duct system - Epididymis & Vas Deferens
C) Accessory glands - seminal vesicles and
prostate
gland
D) Penis
E) Others Scrotum

TESTICLE -

Production of testosterone (sex hormone).


- Produce sperm.
DUCT SYSTEM- EPIDIDYMIS
Storage and maturation of sperm.
-VAS DEFERENS
Transports the sperm containing semen out of the
scrotal sac.
ACCESSORY GLANDS- SEMINAL VESICLES
Release a fluid that forms part of
semen.
- PROSTATE GLAND
Add nourish fluid to semen before
ejaculation.
PENIS - Male reproductive organ.
-Male organ of urination.
SCROTUM- Regulate the temperature of testicles, which need
to be kept cooler than body temperature to produce sperm.

URINARY SYSTEM

KIDNEY- Filter the blood,remove the

wastes,and excrete the wastes in the urine.


URETERS- Tubes that carries urine from the
kidneys to the urinary bladder.
URINARY BLADDER- It is a reservoir for
urine (300-400ml urine capacity)
URETHRA- Carries the semen and urine
passes and exits from body.

PROSTATE GLAND

Surrounds the urethra and is traversed by

the ejaculatory duct,a continuation of the


vas deferens.
Produces a secretion that is chemically and
physiologically suitable to the needs of the
spermatozoa in their passage from the
testes.
Empties its secretions into the urethra
during ejaculation,providing lubrication.

DEFINITION

DEFINITIONS
In many patients older than 50 years,the

prostate gland enlarges,extending upward


into the bladder and obstructing the
outflow of urine by encroaching on the
vesicle orifice. This condition is known as
benign prostatic hyperplasia (BPH),the
enlargement,or hypertrophy of the
prostate. BPH is one of the most common
pathologic conditions in older men.
Suzanne C.Smeltzer & Brenda G Bare,
page (1486-1513)

Enlargement of BPH),is the most common

disorder in the aging male client.The


prostate, very small at birth,grows of
puberty,reaches adult size around age
20.and grows again inmost men in the fifth
decade.The incidence of BPH increases with
age.Approximately 50% of men over the age
of 60 have symptoms of BPH,and more than
90% of men over 80 years old have evidence
of the disease.Symptomatic BPH tends to
develop earlier in African,Americans thai in
European Americans,at a mean age of 60
versus 65 years.
Lemone Burke, page (1972-1999)

ETIOLOGY

ETIOLOGY
1) Unknown
2) Male Hormone Mechanism
A) Androgen Testosterone
- stimulate cell growth in the tissue line the prostate gland
B) Estrogen
- sometime in older, level of testosterone will drop and level of
estrogen increase with in the gland and promote cell growth possibly
triggering
prostate growth.
3) Aging
- Begin at age around 40-45 years of age and continuous slowly,
25% by 50 years but 90% by 80 years
- About 10% are symptomatic.
-At age 70 years and 80 years,80% will experience urinary symptoms.
4) Prostatitis
- is an inflammation of the prostate gland that is caused by
infectious agents (bacteria,fungi,mycoplasma) or other condition
(prostatic hyperplasia)

5) Family History
- particularly involving first degree relatives.
6) Environment and diet.
- Although men from both Western and Eastern cultures
develop
BPH disease at about the same rates, men from western
cultures
are much more likely develop BPH. For diet, high in zinc,
butter
and margarine, where by the in individual who eat lot of
fruits are
though to have lower risk for BPH.
7) Race
- Highest in African Americans lowest in native Japanese.

PATOPHYSIOLOGY

PATOPHYSIOLOGY

Aging process and hormone imbalance (dihydrotestosteron)

Older men continue to produce and accumulate high level of DHT in


prostate,the accumulating of DHT may encourage the growth of cell.
Nodule hyperplasia and glandular hypertrophy develop in the inner part
of the prostate.
The enlargement prostate gland gradually compress the urethra.
Leading to partial or complete obstruction.

Disturb the urinary flow from bladder towards urethra and cause
urinary retention.
Prostatic tissue enlarged by BPH,the bladder neck and urethra
obstructed and cause urinary flow slowed

STATISTIC

STATISTIC ON PATIENT WITH BPH IN SPECIALIST HOSPITAL FROM JAN UNTILL JUNE 2011
20-40 41-60
5

JANUARY
0

FEB
0

MARCH

APRIL
0

MAY
0

JUN
0

JULY
0

AUG
0

SEPT
0

OCT
0

INTERPRITATION OF STATISTIC
The above graph was show the STATISTIC ON PATIENT WITH
BPH IN SPECIALIST HOSPITAL FROM JAN TILL JUNE based on
the statistic from Jan have 1 patient at age of41-60.On Feb
have 2
patient at age of 41-60.On March have 5 patient but their
only 1
patient at age of 20-40 and the rest at age of 41-60. On April
have 2
patient at age of 41-60 and on May also have 2 patient at
age of 4160.Lastly, on June have 4 patient at age of 41-60.Majority
total of
case is 16 patient with BPH and it is above at age of 41-60
cause of
aging process and hormone imbalance (dihydrotestosterone).

STATISTIC PATIENT WITH BPH


UNDERGONE SURGICAL OR MEDICAL
MANAGEMENT FROM JAN UNTILL JUNE
2011

20%

Patient going done the cystoscopy


procedure
Patient treat with medical treatment

80%

INTERPRITATION OF STATISTIC
The pie chart above show that the statistic for the patient
with
Benign Prostate Hyperplasia which undergone medical and
surgical
management fro Jan untill June 2011. Based on the statistic
total of
patient who have BPH is 20 patient which are 16 of the
patient
undergone the cystoscopy procedure surgically.Whereas,the
balance of 4 patient was treat medically. Based on the pie
chart the
majority of the patient had undergone the surgical treatment
is
because the aging process and hormone imbalance
(dihydrotestosterone)

CLINICAL MANIFESTATION

CLINICAL MANIFESTATIONS
VOIDING SYMPTOMPS
Frequent and urgent need to urinate,especially at night
(Nocturia)
Dribbling or leaking after urination (Postvoid)
Diminished force of urinary stream
Straining to urinate
Pain or burning during urination
Sensation of incomplete bladder emptying
IRRITATIVE SYMPTOMS
Urinary retention
Frequency
Urgency
Urge incontinence
Dysuria (difficult or painful micturition)
Problems in ejaculation
Back pain

COMPLICATION

COMPLICATIONS
Increasing bladder distention- diverticula
(outpouchings) on the bladder wall.
Ureters obstruction.
Infection- retained urine or ascend from
bladder to kidneys due to diverticula.
Hydroureter- an accumulation of urine in a
ureter.
Hydronephrosis- an accumulation of urine in
the pelvis of the kidney.
Renal insufficiency.

INVESTIGATION

INVESTIGATIONS

Patient
Lab.No.
Sex
Age
Reported
00048
1411xx
M
53Y
Ward/Clinic: SURGICAL WARD
Examination
Result
Reference range
FULL BLOOD COUNT
Haemoglobin
13.1
Red cell count
5.1
***Haematocrit (PCV)
38
***MCV
75
***MCH
26
MCHC
34
RDW
13.0
Platelet Count
228
MPV
10.6
White blood cell count
7.1

Date Received
01/11/2011

Date
01/11/2011

unit

g/Dl
10^12/L
%
f/L
pg
g/Dl
%
10^3/Ul
f/L
10^3/Ul

13.0-18.0
4.5-5.9
41-53
76-103
26-34
31-36
8.0-14.6
150-450
5.8-12.0
4.3-10.5

--White blood cell differential count


Neutrophil
48.8
75
Lymphocyte
36.7
45
Eosinophil
3.8
Monocyte
10.4
Basophil
0.3
UREA ELECTROLYTES/BUSE
Urea
4.6
6.8
Sodium
139
155
Potassium
4.0
5.5
Chloride
102
111

40-

20-

%
%
%

0-6.0
1-11
0-2

mmol/L

2.0-

mmol/L

135-

mmol/L

3.5-

mmol/L

95-

Patient
Lab.No.
Sex
Reported
00048
1411xx
M
01/11/2011
Examination
Reference range
Urine FEME/Urinalysis (UFEME 1)
Urine FEME/Urinalysis (UFEME 2)
Appearance/urine
Yellow
Specific gravity,urine
1.025
Ph,urine
Protein,urine
Glucose,urine
Ketone,urine
Bilirubin screen,urine
Urobilinogen screen,urine
Nitrite,urine
Leukocytes esterase,urine
Blood,urine

Age
53Y
Result

Date Received

Date

01/11/2011

unit

Pale yellow

Yellow/Pale

1.025

1.005-

6.0
Negative
Negative
Negative
Negative
Normal
Negative
Negative
Negative

4.8-7.5
Negative
Negative
Negative
Negative
Normal
Negative
Negative
Negative

--Microscopic examination,urine
WBC,urine
5
RBC,urine
3
Epithelial cell,
Occasional
Cast,urine
Crystal,urine
*Bacteria,urine
Nil
Yeast cell,urine
*Others,urine

1/hpf

0-

1/hpf

0-

Not seen
Nil
Nil
Occasional
Nil
See below
Mucous strand occ

Nil
Nil

Nil

THE REPORT
CHEST X RAY

Radiological Report
Name : Mr.Z Sex
:M
MRN : 48XXX Room No
: 432
IC No : 58XX
DEPT
:
Age : 53 Y
DATE
: 02/11/2011
CHEST
(CXR)
Heart size normal. Both lung fields appear normal.
No hilar abnormality seen.
IMPRESSION
Normal examination.

MEDICATION

IV CEFTREX
Generic name
: Ceftriaxone Na
Group
: Anti-Infectives
Indication
: Intra-abdominal infections.
Route
: IV
Dosage
:2g
Contraindication : Hypersensitivity to cephalosporins.
Side efect
: GI disturbances,haematological changes,skin
reactions,anaphylactoid
reactions,phlebitis.
Date on
: 01/11/2011
Date of
: 04/11/2011
Nsg.Responsibilities:
Wash hands before and after.
Follow 7 R
Check medication for 3 times before administer to patient.
Observe IV line to prevent phlebitis.
Ensure no bubble inside the tubing.

T.LASIX
Generic name
: Furosemide
Group
: Diuretics
Indication
: Oedema (cardiac, hepatic,renal;oedema due to burns) HTN
Route
: Oral
Dosage
: 40 mg
Contraindication : Acute renal failure with anuria,hepatic coma and
precoma,hypokalemia,
hyponatremia,hypovolemia with or without hypotension or
dehydration.
Side efect
: Symptomatic
hypotension,dehydration,haemoconcentration,hypokalaemia
hyponatraemia,metabolic alkalosis;increase in blood lipid
levels,urea,uric
acid,reduced glucose tolerance.
Date on
: 03/11/2011
Date of
: 04/11/2011
Nsg.Responsibilities:
Wash hands before and after
Follow 7 R
Check medication for 3 times before administer to patient.
Monitor urine output of patient.

SLOW-K
Generic name
: KCI
Group
: Electrolytes
Indication
: K deficiency
Route
: Oral
Dosage
: 600 mg
Contraindication : Hyperkalaemia.Marked renal failure.Con-comitant
treatment with K-sparing
diuretics and patient in whom there is cause for
arrest or delay in tab passage
through the GI.
Side efect
: GI upsets.
Date on
: 03/11/2011
Date of
: 04/11/2011
Nsg.Responsibilities:
Wash hand before and after.
Follow 7 R
Check medication for 3 times before administer to patient.
Advice patient to take with food
Advice patient do not chew or crush

VESICARE
Generic name
Group
Indication
urinary

: Solifenacin succinate
: Drug for Bladder & Prostate Disorders
: Symptomatic treatment of urge incontinence &/or increased

frequency
& urgency in patients with overactive bladder syndrome.
Route
: Oral
Dosage
: 5 mg
Contraindication : Urinary retention,severe GI condition (including toxic
megacolon)
myasthenia gravis,narrow-angle glaucoma.
Haemodialysis.Severe renal
impairment or moderate hepatic impairment.
Side efect
: Dry mouth.
Date on
: 01/11/2011
Date of
: 02/11/2011
Nsg.Responsibilities:
Wash hands before and after
Follow 7 R
Check medication for 3 times before administer to patient.
Advice patient take with or without food.

T.DORMICUM
Generic name
: Midazolam
Group
: Hypnotics & Sedative

Indication
: Tab Short-term treatment of insomnia, premed prior to
surgery or diagnostic procedures. Amp Conscious sedation before
diagnostic or therapeutic procedures, premed before induction of anaesth,
ataralgesia in combination w/ ketamine in childn, long-term sedation in ICU.
Route
: Oral
Dosage
: 7.5 mg
Contraindication : Hypersensitivity to benzodiazepines.
Side efect
:Drowsiness, numbed emotions, reduced alertness,
confusion, fatigue, headache, dizziness, muscle weakness, ataxia, double
vision; GI disturbances, changes in libido, skin reactions; amnesia;
depression; paradoxical reactions; local efect on inj site.
Date on
: 01/11/2011
Date of
: 03/11/2011
Nsg.Responsibilities:
Wash hands before and after
Follow 7 R
Check medication for 3 times before administer to patient and administer
on night.

MANAGEMENT
CYSTOSCOPY

SURGICAL MANAGEMENT
CYSTOSCOPY
Cystoscopy is a test that allows the doctor to look at
the inside of bladder and the urethra using a thin,
lighted instrument called a cystoscope .
The cystoscope is inserted into the urethra and
slowly advanced into the bladder. Cystoscopy allows
the doctor to look at areas of the bladder and
urethra that usually do not show up well on X-rays.
Tiny surgical instruments can be inserted through
the cystoscope that allow the doctor to remove
samples of tissue (biopsy)or samples of urine.
Small bladder stones and some small growths can
be removed during cystoscopy. This may eliminate
the need for more extensive surgery.

Why It Is Done
Cystoscopy may be done to:
Find the cause of symptoms such as blood in
the urine (hematuria), painful urination
(dysuria), urinary incontinence urinary
frequency or hesitancy, an inability to pass
urine (retention), or a sudden and
overwhelming need to urinate (urgency).
Find the cause of problems of the urinary
tract, such as frequent, repeated urinary tract
infections or urinary tract infections that do
not respond to treatment

Look for problems in the urinary tract, such as blockage in

the urethra caused by an enlarged prostate, kidney stones,


or tumors.
Evaluate problems that cannot be seen on X-ray or to further
investigate problems detected by ultrasound or during
intravenous pyelography, such as kidney stones or tumors.
Remove tissue samples for biopsy.
Remove foreign objects.
Place ureteral catheters (stents) to help urine flow from the
kidneys to the bladder.
Treat urinary tract problems. For example, cystoscopy can
be done to remove urinary tract stones or growths, treat
bleeding in the bladder, relieve blockages in the urethra, or
treat or remove tumors.
Place a catheter in the ureter for an X-ray test called
retrograde pyelography. A dye that shows up on an X-ray
picture is injected through the catheter to fill and outline the
ureter and the inside of the kidney

What is a cystoscopy?
A cystoscopy is an examination of the inside of the
bladder and urethra, the tube that carries urine
from the bladder to the outside of the body. In
men, the urethra is the tube that runs through the
penis. The doctor performing the examination uses
a cystoscope -- a long, thin instrument with an
eyepiece on the external end and a tiny lens and a
light on the end that is inserted into the bladder.
The doctor inserts the cystoscope into the patient's
urethra, and the small lens magnifies the inner
lining of the urethra and bladder, allowing the
doctor to see inside the hollow bladder. Many
cystoscopes have extra channels within the sheath
to insert other small instruments that can be used
to treat or diagnose urinary problems.

Male and female urinary tracts.

A doctor may perform a cystoscopy to find the

cause of many urinary conditions, including


frequent urinary tract infections
blood in the urine, which is called hematuria
a frequent and urgent need to urinate
unusual cells found in a urine sample
painful urination, chronic pelvic pain,
interstitialcystitis/painful bladder syndrome
urinary blockage caused by prostate enlargement
or some other abnormal narrowing of the urinary
tract
a stone in the urinary tract, such as a kidney
stone
an unusual growth, polyp, tumor, or cancer in the
urinary tract

What are the preparations for a cystoscopy?


People scheduled for a cystoscopy should ask their
doctor about any special instructions. In most cases,
for cystoscopy, people will be NBM (Nil By Mouth)
before the surgery.
Because any medical procedure has a small risk of
injury, patients must sign a consent form before the
surgery. They should not hesitate to ask their doctor
about any concerns they might have.
Patients may be asked to give a urine sample before
the test to check for infection. They should avoid
urinating for an hour before this part of the surgery.
Usually, patients lie on their back with knees raised
and apart. A nurse or technician cleans the area
around the urethral opening and applies a general
anesthetic so the patient will not experience any
discomfort during the surgery.

How is a cystoscopy performed?


After a general anesthetic is used to take away
sensation in the ureter, the doctor gently inserts the tip
of the cystoscope into the urethra and slowly glides it up
into the bladder. A sterile liquid -- water or salt water,
called saline -- flows through the scope to slowly fill the
bladder and stretch it so the doctor has a better view of
the bladder wall.
As the bladder is filled with liquid, patients feel some
discomfort and the urge to urinate. The doctor may then
release some of the fluid, or the patient may empty the
bladder as soon as the surgery is over.
The time from insertion of the scope to removal may be
only a few minutes, or it may be longer if the doctor
finds a stone and decides to treat it,will also make the
procedure last longer. In most cases, the entire
examination, including preparation, takes 15 to 30
minutes.

What happens after a cystoscopy ?


Patients may have a mild burning feeling when they
urinate, and they may see small amounts of blood in
their urine. These problems should not last more than
24 hours. Patients should tell their doctor if bleeding
or pain is severe or if problems last more than a day.
To relieve discomfort, patients should drink two 8ounce glasses of water each hour for 2 hours after the
procedure. They may ask their doctor if they can take
a warm bath to relieve the burning feeling. If not, they
may be able to hold a warm, damp washcloth over the
urethral opening.
The doctor may prescribe an antibiotic to take for 1 or
2 days to prevent an infection. Any signs of infection
including severe pain, chills, or fever should be
reported to a doctor.

TRANSURETHRAL RESECTION
OF PROSTATE (TURP)

SURGICAL MANAGEMENT

TURP (TRANSURETHRAL RESECTION OF PROSTATE)


DEFINITION
Surgical procedure by which portions of the prostategland are removed
through the urethra.
1)It perfor med under spinal anesthesia
2)It takes around 40 minutes
3)Insertion of an instrument called resectoscope into the penis through
the
urethra.
4)Contain light, valves (control irrigation fluid) , electrical loop
(remove obstructing tissue, blood vessel)
5)Remove the obstructing tissue - irrigating fluid carry the tissue to the
bladder.
6)The debris is removed by irrigation and any remaining debris is
eliminated
in the urine over time.

TURP COMPLICATION
1) Bleeding
2) Clot retention
3) Urinary tract infection
4) Inability to void
5) Incontinence
6) Retrograde ejaculation (semen entering
bladder)
7) TURP syndrome
8) Impotence

TURP SYNDROME
Sometimes during CBI in progress, TURP
syndrome may appear due to absorption of
large amount of isotonic irrigation fluids
Early sign detection of TURP syndrome :1) Restlessness
2) Headache
3) Tachypnea
4) Respiratory distress
5) Hypoxia
6) Vomiting
7) Confusion and coma

NURSING RESPONSIBILITIES PRE-OP


1) Evaluate patient regarding understanding
towards surgery.
2) Recheck consent
3) Make sure patient Nil By Mouth at least 8
hours before surgery
4) Inform patient regarding outcome of the
surgery, there will be a CBI and patient
have to maintain CRIB for at least 48 hours.
5) Do routine OT checklist

NURSING RESPONSIBILITIES POST-OP


1) Check spinal dressing as soon as patient return to ward.
2) Put patient Nil by mouth until first nausea due to side efect
of anesthesia.
3) Position patient in supine for first 24 hours.
4) Assess patient lower limb sensation hourly x4hours, when
patient is full sensation is return advised patient to remain in
bed for at least 6 hours- for promote adequate rest , safety
measures.
5) Monitor patient vital sign hourly x4hours.
6) Administered medication analgesic as prescribe by doctor.
7) Monitor accurate intake output chat as well as CBI flow.
- by doing strictly I/O chart and regulate the irrigation according
to output colour.

CONTINUOUS BLADDER
IRRIGATION (CBI)

MANAGEMENT
CONTINUOUS BLADDER IRRIGATION (CBI)
Is a procedure to cleanse the urinary bladder
from blood clots following bladder operation
or injuries, prostate operation or after
Transurethral Resection of Prostate (TURP)
A three-way Foleys catheter with a 30-45 ml
retention balloon is inserted.
The catheter is pulled down into the prostatic
fossa to help provide hemostasis.
Usually discontinued 24-48 hours after TURP.

PURPOSE
To prevent blood clot formation.
To keep the catheter free of obstruction.
To facilitate detection of obstruction or
other complications.
Allow free flow of urine.
Maintain indwelling catheter (IDC)
patency,by continously irrigating the
bladder with Normal Saline.

EXPECTED OUTCOME

The

urinary catheter remains patent and


urine is able to drain freely via the IDC.

The patients comfort is maintained.

Clot formation within the bladder or IDC


prevented or minimised.

The patients risk of Urinary Track Infection


(UTI) is minimised,through the use of aseptic
technique when connecting bladder irrigation
to IDC.

PRE CARE OF PATIENT WITH CBI


1. Prior to performing the procedure,introduce self and verify
the clients identity using agency protocol. Explain to the
client what are going to do,why it necessary,and how he
can cooperate. The irrigation should not be painful or
uncomfortable. Discuss how the results will be used in
planning further care of treatments.
2. Perform hand hygiene and observe appropriate infection
control procedures.
3. Provide for client privacy.
4. Put on clean gloves.
5. Empty,measure,and record the amount and appearance
of urine present in the drainage bag. Discard urine and
gloves.
R-Emptying the drainage bag allows more accurate
measurement of urinary output after the irrigation is in
place or completed. Assessing the character of the urine
provides baseline data for later comparison.

6. Prepare the equipment.


Perform hand hygiene.
Connect the irrigation infusion tubing to the
irrigation solution and flush the tubing with
solution,keeping the tip sterile.
R-Flushing the tubing removes air and prevents it
from being instilled into the bladder.
Apply clean gloves and cleanse the port with
antiseptic swabs.
Connect the irrigation tubing to the input port of
the three way catheter.
Connect the drainage bag and tubing to the
urinary drainage port if not already in place.
Remove the gloves and perform hand hygiene.

7. Irrigate the bladder.


a) For closed continuous irrigation,open the
flow clamp on the urinary drainage tubing
(if present). See. R- This allows the
irrigating solution to flow out of the bladder
continuously.
Open the regulating clamp on the irrigating
tubing and adjust the flow rate as
prescribed by the primary care provider or
to 40 to 60 drops per minute if not
specified.
Assess the drainage for amount,color,and
clarity. The amount of drainage should

b) For closed intermittent irrigation, determine


whether the solution is to remain in the bladder for
a specified time.
If the solution is to remain in the bladder (a bladder
irrigation or instillation), apply the flow clamp to the
urinary drainage tubing. R- Irrigating solution will
flow through the urinary drainage port and
tubing,removing mucous shreds or clots.
Open the flow clamp on the irrigating tubing,
allowing the specified amount of solution to
infuse.Clamp the tubing.
After the specified period the solution is to be
retained,open the drainage tubing flow clamp and
allow the bladder to empty.

Assess the drainage for amount,color,and

clarity.The amount of drainage should equal the


amount of irrigant entering the bladder plus
expected urine output.
8. Assess the client and the urinary output.
Assess the clients comfort.
Empty the drainage bag and measure the
contents. Subtract the amount of irrigant instilled
from the total volume of drainage to obtain the
volume of urine output.
9. Document the procedure and results in the client
record using form or checklists supplemented by
narrative notes when appropriate.
Note any abnormal constituents such as blood
clots,pus,or mucous shreds.

DURING CARE OF PATIENT WITH CBI


1. Must use only normal saline for irrigation of the
bladder.
R) The irrigation fluid must be isotonic to the blood to
prevent complication such as hemolysis and
possible for some irrigation fluid to be absorbed
through bleeding blood vessels.
2.As soon as CBI is set, run solution at a rate as
prescribed, usually very fast. (for the first period)
R) To flush out the debris and drain through urine.
3. Monitor the color of the output by doing strictly I/O
chart and adjust the rate accordingly, chart when
change the irrigation bag as well as empty urine
bag.
R) If the output is bloody, the rate should be increase
as the dilution of blood aids in the prevention of clot
formation.

4. Instruct patient to remain on bed rest.


R) Bed rest promotes hemostasis.
5. Monitor patient output frequently for any
evidence of obstruction external
obstruction(kinks patient lying on the tubing),
internal obstruction (clot or tissue fragments,
bladder spasm)
R) If the bladder become distended with fluid, it
can cause severe discomfort and damage the
surgical incision or surgical site.
6. If the catheter is obstruct turn of the CBI, hand
irrigate the catheter with 60ml irrigating syringe.

R) To accurately measure the amount of fluid


to instill with hand irrigation, the CBI should
be stopped to prevent overdistention of the
bladder. Hand irrigation provides the
negative pressure needed to aspirate clots
or tissue fragments obstructing the patient
catheter.
7. Notify the physician if the obstruction is
not resolved after hand irrigation perform.
R) Medical intervention may be needed to
resolve the obstruct.

POST CARE OF PATIENT WITH CBI


The client may have some burning,dribbling
and leakage- symptoms normal and will
subside.
Instruct the client to really increase his fluid
intake to a minimum of 3000ml/day which
will helps to decrease the dysuria and to
keep the urine clear.
2 to 5 days postoperatively,the client should
be voiding 150-200ml of clear yellow urine
every 3-4 hours.
Bladder washout is necessary, to remove
blood clott and patency of CBI.

NURSING CARE PLAN

NURSING CARE PLAN


PRE OPERATIVE
1.Alteration in emotional status: anxiety related to surgical
procedure (cystoscopy)
POST OPERATIVE
2. Alteration in comfort: pain related to surgical
intervention (cystoscopy)
3. Potential bleeding related to surgical interventio
(cystoscopy)
4. Potential of infection related to insertion of indwelling
Foleys catheter.
5. Knowledge deficit related to home care management.

NCP 1
Date/Time:
02.11.2011/1000 am
Nursing Diagnosis: Alteration in emotional status: anxiety
related
to surgical procedure (cystoscopy)
Supporting Data:
Verbal: Patients asking a lot of questions regarding the
surgery
(cystoscopy)
Non- Verbal: Patients expression look anxious before the
surgery
(cystoscopy)
Goal: Patients anxiety will be reduced within 1 hours before
surgery after interventions given during
hospitalization.

Nursing Interventions:
1.Assess patients general condition such as facial
expression look anxious and level of anxiety such as
asking a lot of questions regarding the surgery.
R-As a base line data for further interventions.
I:Before giving any information and explanation
regarding surgery to patients,I observe patients
facial expression and he looks anxious and I let be
patients express his feeling to reduce his anxious.
2.Reinforce doctor explanations regarding nature of
the surgery such as purpose doing surgery.
R-Ensure patients understand and reduce his anxiety.
I:I explain to patients about surgery base on what
doctor had inform before such as purpose of the
surgery,how the surgery will be performed and how
long the surgery will performed.

3.Explain to patients about pre-opertion care before


surgery.
R-To allay anxiety and gain cooperation from the
patients.
I:I inform to patients purpose of him to nil by mouth
(NBM) before surgery.
4.Inform patients regarding post operation
management such as he will be back to the ward
with CBI and need to complete rest in bed (RIB)
R-Reduce anxiety related post-operative care.
I-I informed patients that he will be back to the
ward with the CBI in order to provide free drainage
of bloood and he need to CRIB till the CBI been of.

5.Encourage patients family members to be with patients


for patients express his feeling especially his wife.
R-To feel more relief by sharing the feelings with family
members.
I:I encouraged patients family members to be with patients
and I told them that it will help in reducing patients
anxiety.
6.Use simple language and words to explain each procedure
to patients and avoid using difficult medical term.
R-For better understanding.
I:I explained regarding the surgery to patients using simple
words and he was able to understand it easily.
7.Provide conducive and quiet environment switch on air
cond and silent around the ward.
R-To reduce patients anxiety according the surgical
procedure.
I:Patients bed in single room in his room I switched on the air
cond and ensure surrounding the ward is quiet.

8.Introduce patients with other patient had gone same surgery.


R-Ensure patients shared his feeling and shared experience
with other patient.
I:I introduce patients with another patient that had gone same
surgery and patients can shared experience and feeling
with the patient regarding the surgery.
Date/Time:
02.11.2011/1100 am
Evaluation:
Patients anxiety has reduced after 1hours before surgery after
interventions given during hospitalization.
Supporting Data:
Verbal: Patients do not asking a lot of question regarding the
surgery.
Non-Verbal: Patients look calm and not anxious
Sign:
STN NOOR AZIMAH BINTI MISWAN

NCP 2
Date/Time:
03.11.2011/1100 am
Nursing Diagnosis: Alteration in comfort: pain related to
surgical
intervention (cystoscopy)
Supporting Data:
Verbal: Patients verbalized that he having pain at the
surgery site.
Non- Verbal: Patient facial expression look pale,anxious and
restless.
Goal: Patients pain will be reduced within 2 hours after
nursing
interventions given during hospitalization.

Nursing Intervention:
1.Assess patients general condition such as patients
facial expression look pale,anxious and also
restless.
R-As a base line data for further interventions.
I:After patient return to ward,I observed ptients
facial expression look pale,anxious and restless.
2.Assess patients level of pain by using pain score
and asking patients whether the pain is mild (13),moderate (4-6),severe (7-10) and observe site of
pain.
R-As a references for detect any abnormalities.
I:After patients return to ward I observed site of
surgery and asking patients level of pain using
pain score and patients verbalized he having
moderate pain (4-6)

3.Monitor patients vital signs especiallly blood pressure and


pulse rate for the first 4 hours and continues with 4 hourly
observation.
R-Elevate blood pressure and pulse rate may indicate
patients in pain.
I:I had monitor patients vital signs especially blood pressure
and pulse rate hourly and document in observation chart.
Time
B/P
Pulse
Resp
Temp
1230
110/76 76
20
36.4C
1330
108/74 74
20
36.3C
1430
118/79 74
20
36.9C
1530
121/90 72
20
36.5C
1630
115/84 62
20
36.6C
1730
119/72 74
20
37.0C
1830
136/84 75
20
37.0C
2030
128/73 83
20
37.3C

4.Position patients in supine position and prop up 15


degree
R-To make patients more comfortable.
I:I help my patients to lying in supine position and prop up
her bed 15 degree.I make sure my patients is
comfortable by asking her before I leave her room.
5.Advise patients not to move with excessive movement.
R-Excessive movement will cause more painful at surgical
site.
I:I advised patients not to move frequently.
6.Encourage patients to do deep breathing exercise.
R-Deep breathing exercise may relax the muscle by
divertional therapy and reduce pain.
I:I teach patients to take a deep breathing with his hand
support at his abdomen and hold for 5-10 second and
exhale through mouth by pursed lips.I encourage him to
perform when he feel pain.

7.Encourage patients to rest in bed (RIB)


R-Promote comfortable and muscle relaxation.
I:I encourage patients to rest in bed and put up the side
rail.
8.Provide conducive environment to patients such as
restrict visitor.
R-To encourage patients to rest and reduce pain.
I:There was limited visitor,its only his wife and son
accompanied her.
9.Administer analgesic IM Dynastat 40 mg STAT as
prescribed by doctor.
R-Help to relief pain.
I:I administer IM Dynastat 40 mg STAT at upper outer
quadrant observed by staf nurse and record it in drug
chart and staf nurse document it in nursing report.

Date/Time:
03.11.2011/1300 pm
Evaluation:
Patients pain was reduced after 2 hours nursing
intervention given
during hospitalization.
Supporting Data:
Verbal:Patients verbalized his pain is reduced and he felt
comfortable.
Non-Verbal:He looks more relax and comfort than before.
Sign:
STN NOOR AZIMAH BINTI MISWAN

NCP 3
Date/Time:
03.11.2011/1230 pm
Nursing Diagnosis: Potential bleeding related to
surgical intervention (Cystoscopy)
Supporting Data:
Verbal: Patients verbalized he felt not comfortable.
Non-Verbal: Patients urine color is bright blood
stain.
Goal:Patients bleeding will be minimal and no sign
and symptom of excessive bleeding will be
detected within 24 hours after nursing
intervention given during hospitalization

Nursing Interventions:
1. Assess sign and symptom of bleeding such as bloody
urine output, presence of large blood clot and decrease
urine output.
R- As a early detection of bleeding to plan for further
interventions.
I: I assess sign and symptoms of bleeding, there is bright
red color appears in urine.
2. Monitor patients vital sign every hourly for 6 hours
and followed by every 4 hours after surgery especially
blood pressure and pulse rate.
R- Dropping blood pressure below the normal range
(100-140 systolic) (60-90 diastolic) and tachycardia
indicate patients having bleeding.
I: I monitor patients vital sign every hourly for 6 hours
and record in observation chart, and his condition
stable.

Time : 2030 pm
Date : 03/11/2011
Blood pressure : 128/73 mmHg
Pulse : 83 bpm
Temperature : 37.3C
Respiration :20 bpm
3. Observe for the continuous bladder drainage such as color of
urine.
R- Color of urine will changed from bright blood stain to the slight
blood stain and clear urine (light pinkish)
I:I observed the urine color and found that the color had change
from bright red to the slight blood stain during the CBI progress.
4.Position patients to supine position for 24 hours.
R- To prevent pressure on the hypogastric region that can triggers
bleeding by increase intra-abdominal pressure towards surgical
incision.
I: I position patients to supine position and ensure that he
maintain the position by remind his wife as well.

5. Maintain the CBI as per regime; according to the blood stained


from the drainage.
R- To prevent formation of blood clot.
I: I ensure the CBI is dropping as prescribed and change the
irrigation fluid when finished.
6. Put patients on strictly input and output chart.
R-For monitor reducing of blood by observing color and to ensure
the correct amount been administering to patients as well as
output of patients.
I: I chart in the I/O chart every time I change the irrigation and
document the amount and color of output drainage. There is
equal intake and output administering to patients.
7. Encourage fluid intake at least 2L/day.
R- Drinking a lot of water will result in increasing of urine output
that will help to flush out the blood and prevent blood clot.
I: I encourage patients to drink a lot of water by serving him a
cup and mineral water as well as explain the purpose of it.
Patients verbalized that he understand and he will drink a lot
of water.

8. Inform the doctor if there is any sign and symptoms of


bleeding such as appears bloody urine output and
dropping blood pressure below normal.
R- For further management
I: I inform to the staf nurse in charge that patients had
changed the urine color form bright red to slight red in
color and during doctor do ward round, the staf had
informed the doctor, and doctor advice patients to drink
a lot of water.
Date/Time:
03.11.2011/1530 pm
Evaluation:
Patients bleeding appears minimal, no excessive bleeding
detected, patients urine color change from bright blood
stain to
slight blood stain in urine until of irrigation.

Date/Time:
04.11.2011/1200pm
Re-evaluation:
There is no sign of excessive bleeding detected, patients
urine
color from bright blood stain to slight blood stain and
followed by
slight red urine color until CBD remove.
Supporting Data:
Verbal: Patients verbalized that he felt comfortable and no
complain.
Non-Verbal: Patients urine output appears slightly
hematuria.
Sign:
STN NOOR AZIMAH BINTI MISWAN

NCP 4
Date/Time:
03.11.2011/1230 pm
Nursing Diagnosis: Potential of infection related to insertion of
indwelling Foleys catheter.
Supporting Data:
Verbal: Patients verbalized that he feel itchiness at private
part.
Non-Verbal: Patients have indwelling Foleys catheter
inserted
after surgiacal procedure.
Goal: Patients will be free from signs and symptoms of
infection while catheter insitu after interventions given during
hospitalization.

Nursing Interventions:
1.Assess for any signs and symptoms of infection such
as color of urine,fever and itchiness at private part.
R-As a base line data for further inteventions.
I:I assess the site of catheter insertion for any redness
and also observed urine output for any cloudiness or
foul smell when empty the urine bag.
2.Monitor patients vital signs especially body
temperature.
R-Hyperthermia may indicate early sign of infection.
I:I had monitor patients vital sign especially patients
body temperature 4 hourly to detect any abnormalities
during my shift.
1230
36.4C
1630
36.6C
2030
37.3C

3.Advice patients the collection bag must be raised above


the level of the patients bladder and clamp the
drainage tube.
R-Prevent back flow of contaminated urine into the
patients bladder from the urine bag.
I-I adviced patients to hold his urine bag below his hip
level when he is walking or going to toilet.When he lying
down,I assissted him to hang the bag beside the bed.
4.Clamp the tubing of urine bag during empty the urine
bag for urine output measurement.
R-Prevents infection of backflow contaminated urine into
the patient bladder from the urine bag.
I:During empty the urine bag for urine output
measurement I clamp first and after finished empty the
urine bag I released back the tubing and the urine
output measurement I record in intake and output chart
during my shift.

5.Empty the urine bag at least every 8 hours.


R-To reduce the risk of bacterial proliferation.
I:I monitor patient urine output regarding his fluids intake and
empty it during my shift.I also ensure the tubing is not
kinked or twisted.
6.Ensure the closed system is not loose,leak or disconnect of
the tubing and the collection bag must never touch on the
floor.
R-Loose connection or leakage may introduce ascending
infection and to prevent contamination of the closed system.
I:During my shift I ensure the connection of urine bag system
is not loose and no leakage especially when empty the urine
bag.
7.Advise patients to avoid unnecessary handling or
manipulation of the catheter.
R-To minimize risk of contamination.
I:I advised patients and his relatives not to touch the catheter
site unnecessarily and explained the consequence.

8.Maintain hand hygiene before and after handling the catheter,tubing


and urine bag.
R-To minimize risk of infection.
I:I wash my hand before and after and wear glove when empty urine bag.
9.Inform doctor if there is any signs and symptoms of infection such as
color and smell of urine,fever,redness and itchiness at private part.
R-For further interventions.
I:Patients condition did not shown signs and symptoms of infection so is
not necessary to inform doctor.
Date/Time:
03.11.2011/1230 pm
Evaluation:
Patient free from signs and symptoms of infection while catheter insitu
after interventions given during hospitalization.
Supporting Data:
Verbal: Patients verbalized he not feel itchiness at private part.
Non-Verbal: Patients body temperature 36.5C
Sign:
STN NOOR AZIMAH BINTI MISWAN

NCP 5
Date/Time:
04.11.11/1300 pm
Nursing Diagnosis: Knowledge deficit related to home care
management.
Supporting Data:
Verbal: Patients asked a lot of question regarding self care
at home
after discharged.
Non-Verbal: Patients look confused and not understand
regarding
self care at home after discharge.
Goal: Patients will be understand regarding health
education given
to him and able to take care of him self after discharged.

Nursing Interventions:
1.Assess patients level of understanding and knowledge regarding
self care management.
R-As a base line data to plan further health educations to patients.
I:I asked patients whether he knew about self care after discharged
and he verbalized that he is not very clear about it and hope that I
can help in giving informations regarding self care.
2.Advice patients in physical activity that suitable for him after
discharged which is light exercise and avoid heavy exercise such
as lift heavy things.
R-Heavy exercise may cause increase in intra-abdominal pressure
and lead to bleeding.
I:I advice patients not to do heavy work such as lifting and tell him
the purpose.
3.Inform patients that slide blood stained an urine are normal.
R-Reduce anxiety that may feel by patients if urine color are slide
pinkish.
I:I explained to patients that he may has slide bleeding in urine and
tell that it will stop within few days.

4.Advice patients to monitor urine for few days after


discharged especially color of urine.
R-Detect complication of surgery which is bleeding that may
showed by increase in redness of the urine.
I:I advice patients to check his urine every time he pass urine
and ensure that color of urine change from pinkish to clear
urine after few days.
5.Advice patients to take care of his personal hygiene
especially perineal part every time he pass urine.
R-Help in reducing risk of infection that may cause by bleeding.
I:I advice patients to clean his perineal part and dry it with
clean towel.
6.Encourage patients to increase fluid intake such as 1-2 L/day.
R-Help to flush out blood clot that may still persist and prevent
further complication such as infection.
I-I encourage patients to drink a lot of water and he also
verbalized the dr advice him to do the same thing.

7.Explained to patients regarding his medication prescribed


by doctor after discharged.
R-Clear explanation about medications help in correct way of
taking it.
I-I explained to patients regarding his medications. I also
advice him to take the medications on time.
8.Explained to patients the complications of surgery that
may developed such as bleeding.
R-Help patients to detect if any complications occur after
discharged.
I-I explained to patients that the complications of
cystoscopy.
9.Remind patients to came for follow up as schedule or if
any complications occur.
R-To monitor progress of patients as well as treat if
complications occur.
I:I remind patients to come for follow up on 10/11/2011 at 10
am in dr clinic.

Date/Time:
04.11.2011/1300 pm
Evaluation:
Patients understand regarding health education given to
him and able to take care of him self after discharged.
Supporting Data:
Verbal: Patients verbalized that he was more clear about
self care after health educations given.
Non-Verbal: He look more understanding and cheerful.
Sign:
STN NOOR AZIMAH BINTI MISWAN

HEALTH EDUCATION

HEALTH EDUCATION
1) ACTIVITY
- Explain to patients that the process of healing may take: 4 - 8
weeks.
- Advise patients to have good rest.
- No strenuous activity and heavy lifting.
- Cycling are not allowed (bleeding).
- Should avoid long motor trip within 2 weeks.
2) ELIMINATION
- Keep bowel movement regular.
- Possibility sign & symptom of urgency, passing out small blood
clot in
urine, burning sensation.
- Bladder may take up to 2 month to return to its normal capacity.
- Retrain the bladder, because previously patient is on catheter so
the
bladder unable to hold the urine.

3) DIET
- Instruct patients to increase intake of fluid
more than 1-2 L/day to flush out the blood clot
that may persist.
- Encourage patients to take high protein diet
(promote wound healing) and also high fiber
diet (prevent constipation)
4) MEDICATION
- Reinforce patients regarding taking medication,
to make sure there is no skip doses and
complete the medications.
- Emphasize patients to taking medication with
full stomach.

5) FOLLOW UP
- Remain patients to come for the follow up
on 10/11/11 @ 10.00 am at doctor clinic.
- I also inform patients and his wife to bring
him to seek for the doctor if there is any
complication occur within day before for
the follow up date.

DISCHARGE

DISCHARGE
Mr.Z discharged on 04/11/2011 by Dr A. Condition Mr.Z during
discharge is stable and no complain of pain and difficul to pass urine.
His vital
signs on discharged:
Temperature
: 36.8C
Pulse
: 71 bpm
Blood Pressure : 112/72 mmhg
Respiration
: 20 bpm
Medication for discharged as Dr P ordered is :
Ural 11/11 BD
T.Mobic 7.5mg BD
Before discharged, I ensured the branula and ID band had been
removed
and reminded him about the follow up and take the medications as
prescribed.

FOLLOW UP

FOLLOW UP
On 10/11/2011, Mr. Z and his wife came to the
hospital and go to
the Dr A clinic for the follow up. Her condition
looks stable and
more comfortable and cheerful.
He also did not complained any pain or difficulty
to pass urine and
Dr.A decide want to see him another follow up
after 4/12.

SUMMARY

SUMMARY
Mr.Z, 53 years old admitted to Specialist Hospital on 01/11/2011at 1800
pm.He had back pain,difficult to pass urine and bladder distanded for 4/12. On
admission, he was accompanied by his wife and staf reception to admitted in Surgical
ward at 4th floor. His bed no is 432.
During hospitalization, Dr A had ordered some investigations such as FBC, BUSE,Urine
FEME for lab investigations on 01/11/2011. CXR and ECG on 02/11/2011.Dr A also
do special orders such as Cystoscopy at SPD on 02/11/2011 and Cystoscopy + diode
laser vaporisation of prostate surgery at OT on 03/11/2011.Patients NBM at 12 MN
before surgery.
In ward Dr A ordered medication such as IV Cefrex 2g Daily,Dormicum 7.5mg
NOCTE,T.Lasix 40mg TDS and T.Slow K Daily.
Mr.Z discharged on 04/11/2011 by Dr.A. Dr. A has prescribed medications such as Ural
11/11 BD and T.Mobic 7.5mg BD.
His follow up is on 10/11/2011 at 1000 am in Dr A Clinic. During follow up patients
look more comfortable and cheerful.He also did not complained any pain or difficulty to
pass urine and Dr.A decide want to see him another follow up after 4/12.

REFERENCE

REFERENCES
1. Lemone Burke, Medical Surgical Nursing Critical Thinking in Client
Care (2nd Edition) page (1972-1999)
2. Suzanne C.Smeltzer & Brenda G Bare,Brunner & Suddarths Textbook
of Medical Surgical Nursing (10th Edition) page (1486-1513)
3. Berman &Synder &Kozier Erb, Fundamentals of Nursing
(Concepts,Process and Practice) (8th Edition) page (1285-1319)
4. Anne Waugh & Allison Grant,Ross and Wilson Anatomy and
Physiology in Health and Illness (10th Edition) page (441-462)
5. Barbara F. Weller, Baillire Tindall (2009), Baillieres Nurses
Dictionary for Nurse and Health Care Workers (25 th Edition)
6. MIMS MALAYSIA DIMS (2011), (126th Edition) page (50,185,240,290)
Available: www.cancer.gov/dictionary?cdrid=44372
www.medterms.com/script/main/art.asp?articlekey=8946
www.kidney.niddk.nih.gov/statistics/uda/Benign.Prostatic.HyperplasiaChapter 02.pdf