• Subject Name : Nursing

Parkinson’s Disease

Benign prostatic hyperplasia (BPH) is a condition in males which worsen with time and cause the problem in passing urine. This condition increases with the age of the individual and therefore occurs in people who are generally older. It is a very common problem and it causes a significant amount of harm to the patient. In the prostrate, a pathophysiological change occurs that is BPH, which leads to its enlargement. That enlargement can cause an obstruction which can be known as benign prostate obstruction (BPO), which in turn could guide to urinary signs and symptoms (van Rij&Gilling, 2015). Parkinson's disease is a very destructive disorder which is related to the nervous system of humans. It usually affects the person movement and often results in tremors (Oertel et al., 2017). In the case study that has been provided, there is a man named Peter Stacy who is 76 years old. He was experiencing abdominal pain. The doctor diagnosed that he is having BPH and urinary tract infection (UTI). With that, Peter also has to face troubles in his daily life activities as his condition is worsening. In the past, he was also diagnosed with Parkinson's disease. Therefore, in this paper, the pathophysiology of BPH will be discussed and how it contributed towards urinary retention and UTI will also be seen. Discussion about Peter’s medicines will also be considered. Moreover, Nursing care would also be talked about which is related to urinary retention, UTI and Parkinson’s disease.

Pathophysiology of BPH includes multiple classes of cells which are immunocompetent such as macrophages, granulocytes and lymphocytes. They are normally the resident of the prostate and are known as human prostate-associated lymphoid tissue (PALT). The normal response to infectious agents is the activation of the PALT intraglandular immune system (Corona et al., 2014). However, the small amount of inflammation that occurred due to infectious agents could be getting worse if there is a chronic inflammation which can be happened due to metabolic and hormonal derangements or by the exposure to dietary and other environmental factors. The PLAT which gets activated recruits and starts the proliferation of various other immunocompetent cells which will guide to upregulation of proinflammatory cytokines and chemokines (Corona et al., 2014). Prostatic stromal cells which behave like the target of viral or bacterial toll-like receptor antagonists and antigen-presenting cells, later on, plays a very important part in the initiation of inflammatory responses. They also signal to activate CD4+ lymphocytes so that differentiation could happen into Th1 and Th17 subset. With that, toll-like receptor could also lead to proinflammatory cytokines production and formation of chemokines which are capable of employing CXCR-2 and CXCR-1 positive leukocytes and neutrophils which further enhance hyperplasia of the prostate cell by the action of IL-8 and other growth factors (Corona et al., 2014).

In the normal individuals, the neck of the bladder is inverted with having prostrate weight less than 20g and flow rate higher than 20mL/s but in people suffering from BPH, the neck of the bladder is distorted because of prostate adenoma (Foo, 2017). A prostate adenoma gives a slightly different shape to the prostate. This could be seen by intravesical prostatic protrusion measuring on transabdominal ultrasound. Therefore, the BPH condition could be known by ultrasound and uroflowmetry (Foo, 2017).

Peter’s urinary retention could be acute and chronic. Retention which is acute could be spontaneous and retention which is chronic could be high or low pressure. It happens because of anatomical obstruction because of BPH, prostate carcinoma and structure of urethral (Ugare et al., 2014). UTI could also occur in patients because of repetitive infection within the bladder of the person. The infection could happen because of several bacterial factors and also due to host defence deficiencies. Gram-positive and Gram-negative bacteria can cause UTI. One of the most common bacteria is Escherichia coli(Jhang&Kuo, 2017). Another mechanism for recurrent UTI can be because of bacterial survival in the bladder by the progression of communities of intracellular bacteria. Also, people who are immunodeficient, UTI occur in the most often. Diseased individuals with toll-like receptor polymorphisms have a deficiency of recognition of pathogen inside the bladder and thus it leads to recurrent UTIs (Jhang&Kuo, 2017).

Causes other than BPH of urinary retention in Peter could be Urethral stricture and age. The tube which carries the urine to the bodies outside could be narrowed and this is known as urethral stricture. This further causes increment in the time of urination and a feeling which is associated that the bladder has not been emptied (Tritschler et al., 2013). In addition to that, there is increased urgency and micturition frequency. When the formation of stricture occurs than urinary bladder compensate for the resistance in the intravesical region during urination which could be noticed in ultrasonography as the walls of the bladder thickened. After that, decomposition of the function of the voiding happens and there is complete retention of urine (Tritschler et al., 2013). Age is another factor in the case of Peter for developing urinary retention as in the study which is conducted by the scientists have highlighted that the ageing population have more risk of developing urinary retention. This is associated with having carcinoma in the prostate (Yenli et al., 2015).

Peter has been provided with Prazosin which is given by the oral route to the patient. Prazosin has the capability to start the arterial vasodilation which leads to relaxation of the smooth muscles, veins and reducing of blood pressure. Prazosin put forth the antihypertensive effect by relaxing peripheral arterioles because of post-synaptic α-AR blockade consequences. It is administered two times daily in the quantity of 0.5mg for the condition of BPH (Zhao &Xu, 2015). The time duration for taking this medicine is two weeks and then prescribed dose could be doubled for the patient benefit for another two weeks. It is generally given to the male patients who have moderate to mild BPH. The results of taking this medicine involve the management of the condition that is BPH (Generali&Cada, 2013). Prazosin is also given for Parkinson's disease in the quantity of 9.5mg. It helps in the sleeping of the patients as this was observed in controlled trials (Loddo et al., 2017). The side effects that can be observed in the patient for prazosin can be orthostatic hypotension, itchy skin and excessive sleepiness (Zhao &Xu, 2015).

Selegiline is a medicine which is taken by the Parkinson's disease patients. The mechanism of this medicine includes irreversible and selective inhibition of dopamine which is catalyzed by MAO-B oxidation within the brain that leads to the increment of dopamine availability in central synapses. Selegiline is given to patient one or two times daily in the quantity of 5mg each time. The adverse events that could happen to the patient could be abdominal pain, dyspepsia, stomatitis, nausea, anorexia and buccal mucosal irritation (DeMaagd, G., & Philip, 2015).

Sinemetlevodopa is known to be the precursor of dopamine. Clinicians prescribe this for the treatment of Parkinson's disease because it can be used as a replacement agent of dopamine. This medication could go through the blood-brain barrier and then be converted into dopamine in the periphery and central nervous system. Dopamine is unable to cross this barrier and hence levodopa is used in its place. Once the transformation of levodopa occurs it initiates the working of the postsynaptic dopaminergic receptor (Gandhi & Saadabadi, 2020). With that, it compensates for the decrement in endogenous dopamine. The quantity of dosage which is provided to the patient is around 25-100mg three times daily. The adverse effect that could cause trouble to the patient could include nausea, headache, dizziness and somnolence. Other than this, patients could also face confusion, delusions, agitation, hallucination and psychosis (Gandhi & Saadabadi, 2020).

Polypharmacy could be reduced in patients by implementing strategies and interventions that are specifically designed to change the healthcare institutes and organizations and the attitude of the healthcare professionals such as nurses with the use of educational programme so that they do not provide patients with duplicate drugs. The arrangement of the delivery could also be changed with involving risk or danger screening tools by the nurses (Rankin et al., 2018). In addition to that, improvements in appropriate medications could also be brought. Deduction of prescribing omission could be checked with the help of evidence-based therapy. Drug-drug interaction could also be noted by the nurses so as to ensure the safety of the patients. This will in turn lower the number of hospitalization and therefore reduce the cost associated with healthcare (Rankin et al., 2018).

Nursing assessment that could be made by the nurse to confirm Peter's urinary retention would be seeing the amount of urine in the patient bladder with the use of the bladder scanner. By doing this, many symptoms could also be highlighted and could be documented in a volume chart. The data and time are noted in addition to intake of fluid and the urine voided. Thus, by doing this nurses could assess the urinary retention (Pearson & Williams, 2014). Nursing assessment that could be made by the nurse to confirm Peter's UTI would involve taking urine and blood sample. Urine and blood sample which is taken helps in finding out the type of microorganism which is causing the infection. Blood culture is best when Peter's condition is febrile and unstable, thus it can be known if he is immunocompromised or not (Beahm et al., 2017).

One of the major problems that could occur after Peter's Transurethral prostatectomy (TURP) is that Sinemet can cause hypotension in him that is his blood pressure could be reduced suddenly. Peter could suffer from orthostatic hypotension. The symptoms which are associated with levodopa include feeling blurry vision and light-headedness on walking or standing (Simonet, Tolosa, Camara & Valldeoriola, 2020). He could also suffer from difficulties in concentration, neck and head discomfit. In addition to that, Peter could also experience frozen posture and he may even lose his consciousness because of the abrupt dropping of his blood pressure after taking the medicine. Levodopa in Sinemet can also cause vomiting and nausea in Peter and thus can cause the situation of dehydration in him. For that, fluid management is a necessary step that needs to be taken (Simonet et al., 2020). The other problem that can be faced by Peter after his surgery is that he might be dehydrated because of the use of levodopa in Sinemet. Dehydration could further bring changes in renal function and could also cause toxicity due to the drug (Puga et al., 2019). Because of dehydration, Peter could thus experience confusion and weakness which will be enhanced due to his Parkinson's disease. Dehydration can thus cause the lowering of the blood pressure. Therefore, this condition could also be managed by taking in fluids so that dehydration does not occur (Puga et al., 2019).

In conclusion, it can be said that BPH and Parkinson's disease are conditions which gets worse with time. BPH occurs in male and causes them significant problems. Parkinson's disease also affects the movements of the patients. In the case study that has been provided, Peter is suffering from BPH and also has a history of Parkinson's disease. He also has the problem of urinary retention and UTI. Thus, the pathophysiology of BPH includes inflammatory response and enlargement of the prostate. Its diagnosis could be done by transabdominal ultrasound. Urinary retention could happen due to obstruction caused by BPH and UTI can occur because of bladder infection due to bacteria. The other causes of urinary retention in Peter could be the age factor and urethral stricture. Prazosin is given to Peter for both of his condition whereas Selegiline and Sinemet are given for his Parkinson’s disease. Nursing assessment for urinary retention could be done by the nurse by seeing Peter's bladder using a bladder scanner. And UTI could be recognized by taking his urine and blood sample and checking for alterations. Two problems that could occur after Peter's Transurethral prostatectomy (TURP) are dropping of his blood pressure and dehydration due to intake of Sinemet which is levodopa.

References for Benign Prostatic Hyperplasia

Beahm, N. P., Nicolle, L. E., Bursey, A., Smyth, D. J., &Tsuyuki, R. T. (2017). The assessment and management of urinary tract infections in adults: Guidelines for pharmacists. Canadian Pharmacists Journal: CPJ = Revue Des Pharmaciens du Canada: RPC150(5), 298–305. https://doi.org/10.1177/1715163517723036

Corona, G., Vignozzi, L., Rastrelli, G., Lotti, F., Cipriani, S., & Maggi, M. (2014). Benign prostatic hyperplasia: A new metabolic disease of the aging male and its correlation with sexual dysfunctions. International Journal of Endocrinology,2014.https://doi.org/10.1155/2014/329456

DeMaagd, G., & Philip, A. (2015). Parkinson's disease and its management: Part 3: nondopaminergic and nonpharmacological treatment options. P & T: A Peer-Reviewed Journal for Formulary Management40(10), 668–679.

Foo K. T. (2017). Pathophysiology of clinical benign prostatic hyperplasia. Asian Journal of Urology4(3), 152–157. https://doi.org/10.1016/j.ajur.2017.06.003

Gandhi, K. R &Saadabadi A. (2020).Levodopa (L-Dopa).StatPearls.StatPearls Publishing: Treasure Island (FL): United States of America

Generali, J. A., &Cada, D. J. (2013).Prazosin: Benign prostatic hyperplasia. Hospital Pharmacy48(3), 196–197. https://doi.org/10.1310/hpj4803-196

Jhang, J. F., &Kuo, H. C. (2017). Recent advances in recurrent urinary tract infection from pathogenesis and biomarkers to prevention. Tzu-Chi Medical Journal29(3), 131–137. https://doi.org/10.4103/tcmj.tcmj_53_17

Loddo, G., Calandra-Buonaura, G., Sambati, L., Giannini, G., Cecere, A., Cortelli, P., &Provini, F. (2017).The treatment of sleep disorders in Parkinson's disease: From research to clinical practice. Frontiers in Neurology8, 42.https://doi.org/10.3389/fneur.2017.00042

Oertel W. H. (2017). Recent advances in treating Parkinson's disease. F1000 Research6, 260.https://doi.org/10.12688/f1000research.10100.1

Pearson, R., & Williams, P. M. (2014).Common questions about the diagnosis and management of benign prostatic hyperplasia. American Family Physician, 90(11), 769-774.

Puga, A. M., Lopez-Oliva, S., Trives, C., Partearroyo, T., & Varela-Moreiras, G. (2019). Effects of Drugs and Excipients on Hydration Status. Nutrients11(3), 669. https://doi.org/10.3390/nu11030669

Rankin, A., Cadogan, C. A., Patterson, S. M., Kerse, N., Cardwell, C. R., Bradley, M. C., Ryan, C., & Hughes, C. (2018). Interventions to improve the appropriate use of polypharmacy for older people. The Cochrane Database of Systematic Reviews9(9), CD008165. https://doi.org/10.1002/14651858.CD008165.pub4

Simonet, C., Tolosa, E., Camara, A., &Valldeoriola, F. (2020).Emergencies and critical issues in Parkinson’s disease. Practical Neurology20(1), 15-25.

Tritschler, S., Roosen, A., Füllhase, C., Stief, C. G., &Rübben, H. (2013). Urethral stricture: Etiology, investigation and treatments. DeutschesArzteblatt International110(13), 220–226. https://doi.org/10.3238/arztebl.2013.0220

Ugare, U. G., Bassey, I. A., Udosen, E. J., Essiet, A., &Bassey, O. O. (2014).Management of lower urinary retention in a limited resource setting. Ethiopian Journal of Health Sciences24(4), 329–336. https://doi.org/10.4314/ejhs.v24i4.8

vanRij, S., &Gilling, P. (2015). Recent advances in treatment for benign prostatic hyperplasia. F1000 Research4, F1000 Faculty Rev-1482.https://doi.org/10.12688/f1000research.7063.1

Yenli, E. M. T., Aboaha, K., Gyasi-Sarponga, C. K., Azorliade, R., &Arhina, A. A. (2015).Acute and chronic urine retention among adults at the urology section of the accident and emergency unit of KomfoAnokye teaching hospital, Kumasi, Ghana. African Journal of Urology21(2), 129-136. https://doi.org/10.1016/j.afju.2014.08.009

Zhao, L. S., &Xu, C. Y. (2015).Effect of prazosin on diabetic nephropathy patients with positive α1‑adrenergic receptor autoantibodies and refractory hypertension. Experimental and Therapeutic Medicine9(1), 177-182. https://doi.org/10.3892/etm.2014.2036

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