Case 7 situation:

This is a case of a 68 year old male, married admitted due to complaints of blood in the
urine, painful urination and sudden weight loss of about a month (from 80 kgs to 68 kgs in a
month). The doctor runs a few diagnostic tests. Her admission vital signs are as follows: BP
120/90 Heart rate 72 Resp rate 19.

After confirmation and surgery of the prostate cancer which is at Stage III, the doctor
prescribed the following medications: Goserelin 3.6mg SC q28 days; Nilutamide 300 mg PO
OD, Docetaxel 75 mg/m2 IV over 1 hr q 3 weeks with daily Prednisone 5 mg PO q12 hr.
The presentation of case analysis includes:

1. Explain the structure and function of the male reproductive system and the
mechanism of urine production.

Structure of the male reproductive system

Two epididymides, two ductus deferentia, two ejaculatory ducts, the urethra, two seminal
vesicles, the prostate gland, and two bulbourethral glands make up the male reproductive system.
The male reproductive organs, which also transport these cells outside of the body and secrete
male sex hormones, are responsible for the production and maintenance of sperm cells. The two
tes-tes, in which sperm cells and male sex hormones are produced, are the principal sex organs,
also known as the male gonads. The internal and external reproductive organs are the accessory
sex organs.

Prostate Gland: The prostate gland, which is somewhat smaller than the urinary bladder, covers
the proximal part of the urethra. It is a muscular structure that has a chestnut- or doughnut-
shaped shape and is around 4 cm in width and 3 cm in thickness. It consists of 20 to 30 branched
tubular glands with ducts that flow into the urethra, and it is coated in a thick connective tissue
capsule. The stroma, a collection of dense connective tissue and smooth muscle, contains these
glands.

Functions of Male Reproductive system:

They produce, preserve, and transport sperm and semen, which are the male reproductive cells
(the protective fluid around sperm). Sperm is released into the female reproductive system by
them. Male sex hormones are created and secreted by them.

Hormones are essential to the male reproductive system in general. These are substances that
control or boost the function of a male’s cells and organs. Follicle-stimulating hormone (FSH),
luteinizing hormone (LH), and testosterone are the main hormones that affect how the male
reproductive system functions.

The pituitary gland produces FSH and LH. It is situated at the base of the brain and controls a
variety of bodily processes. For the generation of sperm, FSH is required (spermatogenesis). To
continue the process of spermatogenesis, testosterone must be produced, which LH stimulates.
The growth of masculine features including muscular size and strength, fat distribution, bone
mass, and sex desire all depend on testosterone.

MECHANISM OF URINE PRODUCTION

Three Steps:

1. Glomerular Filtration

Explanation: Blood is filtered in the glomerulus, which is where glomerular filtration

takes place. This process takes place across three layers: a membrane in between these
two layers, the endothelium of glomerular blood vessels, and the three layers-epithelium
of Bowman's capsule. All plasma components, excluding proteins, make it to the
Bowman's capsule after blood has been filtered. Consequently, this procedure is referred
to as ultrafiltration.

2. Reabsorption
 Explanation: Nearly all of the filtrate collected is reabsorbed by the renal tubules, for
around 99%. Active and passive transport are used to accomplish this.

3. Secretion

Explanation: Tubular secretion is the following phase of urine production. In this phase,
the filtrate is filled with materials secreted by tubular cells, such as hydrogen ions and
potassium ions. The ionic, acid-base, and balance of other bodily fluids are all preserved
by this mechanism. Urine is created when the filtrate and released ions combine. The
nephron tubule releases the urine into a collecting duct.

2. What are the deviations to the normal anatomy and physiology when an individual
has prostate cancer?

Compared to a normal prostate gland, prostate cancer findings includes localized or

generalized firmness (hard nodule), and bogginess of the prostate gland due to
uncontrolled growth of cells (White & O'Brien, n.d.). When cancer cells start to have the
capacity to spread to other organs, like the lymph nodes, urinary tract, and bones
(Mustafa et al., 2016). With the mutation of cancer cells in the prostate gland overtime, it
spreads to the stroma (prostate tissue) that forms a tumor; this can harm the nerves and
muscles that control your urination as it grows, which can cause urinary retention, urine
leakage, and bladder irritation that results in blood in the urine ("Advanced prostate
cancer: Managing symptoms," 2021). When it begins to metastisize to the lymphatic
system, the cancer cells can inhibit the drainage of lymph fluid that causes build up and
lead to swelling in the area where the cancer has spread ("Advanced prostate cancer:
Managing symptoms," 2021). Bones can also be affected as the cancer cells may develop
bone metastases that leads to bone pain, fracture and death (Wong, et al., 2019). To
combat the activated cancer cells, the body releases cytokines as part of the immune
system. These cytokines can affect an individual's appetite because they have an impact
on the hypothalamus, which causes loss of appetite. More calories are burned as a result
of the activation and mutation of cancer cells because these demand more energy than
healthy cells ("Is weight loss a cancer symptom?," 2021). One can gradually lose weight
by experiencing a decrease in appetite and a high demand for energy.

3. What are the risk factors for prostate cancer?

● Age: Men under the age of 40 are less likely to develop prostate cancer
than older men, although the risk increases significantly after age 50. Men
older than 65 are affected by prostate cancer in about 6 out of 10
instances.
● Family History: Prostate cancer appears to run in some families,
suggesting that there may be an inherited or genetic element in some
cases. A man's risk of having prostate cancer is more than doubled if he
has a father or sibling who has the condition. Men who have several
affected relatives are at significantly higher risk, especially if their
relatives were young when the cancer was discovered (the risk is larger for
men who have a sibling with the disease than for those who have a father
with it).
● Gene Changes: The risk of prostate cancer may be higher if the client
carries the BRCA1 or BRCA2 gene or has a strong family history of
breast cancer. As Harvard Medical School conducted a prostate cancer
screening with the prostate-specific antigen (PSA) test in 2020, the results
demonstrate that the BRCA2 mutation carriers had the greatest cancer
risk. Prostate cancer risk is higher in men who have Lynch syndrome, also
known as hereditary non-polyposis colorectal cancer (HNPCC), a disorder
carried on by inherited gene changes.
4. Define the laboratory and diagnostic tests ordered by the physician. Why are they
being requested to this patient?
1. Digital Rectal Exam: The lower rectum, pelvis, and lower belly are all examined
during a digital rectal exam (DRE). The doctor can use this test to screen for
cancer and other health issues, such as male prostate cancer. an unusual lump in
the rectum or anus.
 2. The prostate-specific antigen (PSA) level in the blood is assessed by the test. The
prostate is a tiny gland that resides underneath the bladder in males. Both
malignant and noncancerous tissue in the prostate produces the protein known as
PSA. High PSA levels could be a sign of prostate cancer and can be found by the
PSA test.
3. An ultrasound examination of the prostate gland is known as a transrectal
ultrasound scan (TRUS). During this examination, The doctor may collect
prostate tissue samples. A TRUS-guided biopsy was performed. It can assist in
the diagnosis of prostate cancer.
4. Assessing inflammation in the urinary tract that might be an indication of cancer
can be done with the use of a urinalysis. Hematuria (microscopic blood fragments
in the urine) and infection-related symptoms, such as an elevated white blood cell
count, are checked for in the urine sample. These findings can point to the spread
of malignancy or signify an infection.
5. Postoperative Histopathology- The assessment of clinical disease through
microscopic inspection of a biopsy or surgical specimen that has been prepared
and put onto glass slides.
-
- The prostate gland is situated directly underneath the bladder, and it surrounds the upper
part of the tube that drains the bladder of pee (urethra). The major job of the prostate is to
make the fluid that sustains and transmits sperm (seminal fluid).
-
5. Why are these drugs given to this patient? Do a drug study on ALL of the drugs
prescribed by the doctor.

Drug Indication Contraindicat Mechanism Side Effect/ Nursing

ion of Action Adverse Responsibility
Effect
Generic Name: Stage B2-C ➔ Goserelin is LHRH agonists According to ➔ During the first
prostate not (LHRHa) Cancer month of

Goserelin cancer in recommended promote the Research UK, therapy,

combination for secretion of the common individuals with
with individuals luteinizing side effects of prostate cancer
Brand Name:
radiotherapy who are hormone (LH, Goserelin in should be
and flutamide allergic to gonadotropin) men with closely
Zoladex
● Start 8 goserelin, initially, prostate cancer monitored for
weeks GnRH, or leading to a are the S&S showing
Therapeutic
before Gonadotropin transient following: spinal cord
Classification:
initiatin -Releasing increase in compression or
g Hormone serum ● Hot flushes ureteral
Antineoplast radiothe (GnRH) testosterone in blockage.
ics rapy and Analogs; males and ● Less Inform your
continue anaphylactic serum estradiol interest in doctor right

Pharmacologic during responses to in women sex (Low away

Classification: radiatio synthetic (PDR, n.d). Libido) (GOSERELIN

n GnRH or ACETATE,

Gonadotropin- therapy. GnRH agonist ● Inflammatio n.d.).

releasing Give 3.6 analogs have n in around ➔ In patients with

hormone mg been the prostate cancer,

analogues subcut documented. Injection expect a

into site temporary
anterior ➔ History of exacerbation of
Dosage: abdomi hypersensitivi ● Erection symptoms (e.g.,
nal wall ty reaction to Problems bone pain)
3.6mg every below goserelin or during the initial
28 days navel 8 any of its Occasional weeks of
weeks components,9 Side effects: treatment
before other LHRHa, ● high (GOSERELIN
Route:
blood
radiothe ACETATE,
 rapy, or LHRH1. sugar n.d.).
Subcutaneousl followe levels
● changes
y every 28 days d in 28
in your
into the anterior days by
mood
abdominal wall 10.8 mg
(includin
below the navel subcut. g
line. Or, give depressio
four n)

injectio ● tingling
in your
ns of 3.6
fingers or
mg at
toes
28-day
● pain in
intervals your
, two lower
injectio back or

ns problems
passing
precedin
urine.
g and
Contact
two
your
during advice
radiothe line if
rapy. this
happens
● heart
problems
which
can be
serious
● changes
in blood
pressure
● skin rash
 ● pain in
your
bones
and
thinning
of your
bones
● swelling
and
tendernes
s of your
breasts
● weight
gain

Drug Indication Contraindicat Mechanism Side Effect/ Nursing

ion of Action Adverse Responsibility
Effect
Generic Name: ➔ Nilutamide is ➔ Severe At the cellular ➔ Dizziness Acquire patients’
medicated to hepatic level, it inhibits ➔ Impaired chest x ray and

Nilutamide treat patients impairment the actions of adaptation to the following x

after surgery ➔ Severe androgen darkness; rays.
for prostate respiratory (testosterone). Abnormal Monitor the patient
Brand Name:
cancer. insufficiency Prostate cancer Vision for S&S of
➔ Medicated to ➔ Hypersensitiv spread is ➔ Interstitial pneumonitis
Nilandron
the patient on ity to reduced as a Pneumonitis Monitor the patient
the day of the nilutamide. result of the ➔ Hypertension for liver
Therapeutic
surgery or therapeutic ➔ Hot Flashes functions at 3
Classification:
day after the effects. ➔ Hair Loss months interval
surgery ➔ Sweating Monitor the patient
ANTINEOPLA taking
STIC
phenytoin,
theophylline, or
Pharmacologic warfarin for
Classification: toxic levels of
these drugs.
ANTIANDROG
EN

Dosage:

300 mg OD PO

Route:

Oral route or
PO
 Drug Indication Contraindicat Mechanism Side Effect/ Nursing
ion of Action Adverse Responsibility
Effect
Generic Metastatic ➔ Docetaxel or ➔ Compounds ➔ CNS: According to the
Name: castration- other that induce, asthenia, drug guide written
resistant polysorbate inhibit, or are paresthesia, by RobHolland:

Docetaxel prostate 80-containing metabolised dysesthesia,

➔ Lab tests:
cancer, with medicines, by CYP3A4 peripheral
Monitor
prednisone paclitaxel, (cyclosporine, neuropathy,
Brand Name: bilirubin,
➔ 75 neutrophil erythromycin, weakness.
AST or
mg/m2 count 1500 ketoconazole, ➔ CV: fluid
Taxotere ALT, and
IV, as a cells/mm3, troleandomyc retention,
alkaline
1-hour biliary tract in): May peripheral
Therapeutic phosphatas
infusion illness, modify edema,
Classification: e prior to
every 3 hepatic metabolism of arrhythmias,
each drug
weeks, disease, docetaxel. chest
ANTINEOPLA cycle.
given jaundice, Use together tightness,
STIC Generally,
with 5 neutropenia, cautiously. flushing,
do not give
mg intramuscular hypotension.
Pharmacologi to patients
prednison injections, ➔ EENT:
c with
e PO thrombocytop tearing,
Classification: elevations
b.i.d. enia, altered
of
continuou breastfeeding, hearing
Taxoids bilirubin
sly. pregnancy ➔ GI: anorexia,
or with
Premedic (category D), diarrhea,
significant
ate with acute dysphagia,
Dosage: elevations
dexameth infection esophagitis,
of
asone 8 nausea,
75 mg/m2 IV 1 transamina
mg PO at stomatitis,
hour infusion ses
12 hours, vomiting,
concurrent
every 3 weeks 3 hours, dysgeusia.
with
and 1 ➔ Hematologic:
elevations
hour febrile
of alkaline
Route: before neutropenia,
phosphatas
IV / docetaxel leukopenia,
e. Monitor
Intravenous infusion. myelosuppres
frequently
sion,
CBCs with
neutropenia,
differential
thrombocytop
. Withhold
enia, anemia.
drug if
➔ Hepatic:
platelets
hepatotoxicity
<100,000
➔ Musculoskele
or
tal: myalgia,
neutrophils
arthralgia,
<1500
back pain
cells/mm3.
➔ Respiratory:
➔ Monitor
dyspnea,
for S&S of
pulmonary
hypersensi
edema
tivity (see
➔ Skin:
Appendix
alopecia,
F), which
desquamation
may
, skin
develop
eruptions, nail
within a
pigmentation
few
alterations,
minutes of
nail pain,
initiation
rash, reaction
of
at injection
infusion. It
site.
➔ Other: is usually
infection, not
chills, drug necessary
fever, to
hypersensitivi discontinu
ty reactions. e infusion
for minor
reactions
(i.e.,
flushing or
local skin
reaction).
➔ Assess
throughout
therapy
and report
cardiovasc
ular
dysfunctio
n,
respiratory
distress;
fluid
retention;
developme
nt of
neurosenso
ry
symptoms;
severe,
cutaneous
 eruptions
on feet,
hands,
arms, face,
or thorax;
and S&S
of
infection.

Drug Indication Contraindicat Mechanism Side Effect/ Nursing

ion of Action Adverse Responsibility
Effect
Generic Name: Hormone- ➔ Systemic Decreases ➔ Musculoskele ➔ Determine if
refractory fungal inflammation, tal: growth patient is

Prednisone metastatic infections and mainly by suppression in sensitive to

prostate known stabilizing children, other
cancer (with hypersensitivi leukocyte muscle corticosteroids.
Brand Name:
docetaxel) ty lysosomal weakness, ➔ Immediate-
➔ 5 mg ➔ Use membranes; osteoporosis. release drugs
Rayos /
b.i.d. (in cautiously in suppresses ➔ Metabolic: may be used for
Prednisone combina patients with immune hypokalemia, alternate-day

Intensol tion recent MI, GI response; hyperglycemi therapy.

with ulcer, renal stimulates bone a, ➔ Always adjust
docetax disease, HTN, marrow; and carbohydrate to the lowest
Therapeutic
el) for osteoporosis, influences intolerance, effective dose.
Classification:
up to 10 diabetes protein, fat, and hypercholeste ➔ For better
cycles. mellitus, carbohydrate rolemia, results and less
Corticosteroids
seizures, metabolism hypocalcemia toxicity, give a
hypothyroidis , weight gain. once-daily dose
Pharmacologic
m, cirrhosis, ➔ CNS: in the morning.
Classification:
active euphoria, ➔ Elderly patients
hepatitis, insomnia, may be more
Adrenocorticoi
diverticulitis, psychotic susceptible to
ds
nonspecific behavior, osteoporosis
ulcerative pseudotumor with long-term
Dosage:
colitis, recent cerebri, use.
intestinal vertigo, ➔ Monitor patient
5 mg two
anastomoses, headache, for signs and
times a day
thromboembo paresthesia, symptoms of
lic disorders, seizures. infection. Drug
Route:
myasthenia may mask or
Oral
gravis, HF, worsen
TB, ocular infections,
 herpes including latent
simplex, and amebiasis.
psychiatric ➔ Unless
disturbances contraindicated,
give a low-
sodium diet
that's high in
potassium and
protein. Give
potassium
supplements as
needed

6. Show the total dosage of Docetaxel needed by the patient.

75 mg/m2 IV over 1 hr q3 Weeks with daily prednisone 5 mg PO q12hr

(Medscape, 2021)

7. What will be your health teaching with regards to all the drugs prescribed?

Goserelin

● Encourage the patient to call a doctor right away if they are having problems
urinating or if their arms and legs are feeling weak and numb.
● Tell the patient to always let their doctor know if they notice any unusual
symptoms.
● Tell the patient to stay out of the sun and to apply sunscreen with an SPF of 15 or
higher, along with sun protection clothes.
● Tell patient to completely avoid drinking alcoholic beverages.
● Advise patient to get plenty of rest and maintain a proper nutrition.
● Remind the patient that while taking goseralin, it is important to have regular
checkups to evaluate side effects and determine how well they are responding to
therapy.
 Nilutamide

● Inform the patient to speak with their healthcare practitioner if they have chest
pain, jaw pain, or other discomfort along with difficulty urinating.
● Ensure that the patient knows to tell the doctor about all of their current drugs
before beginning the nilutamide treatment such as prescription, over-the-counter,
vitamins, herbal remedies and others
● Encourage the patient to keep moving their bowels. To help prevent constipation
that could be brought on by this medication, their doctor may advise them to take
a stool softener.
● Tell the patient to consume 2 to 3 quarts of liquid every 24 hours, unless
instructed to do otherwise, and to maintain a healthy diet. This will lessen the
likelihood of constipation and stop dehydration.
● Tell the patient to stay out of the sun and to apply sunscreen with an SPF of 15 or
higher, along with sun protection clothes.
● Tell the patient to completely avoid alcoholic beverages.
● Remind the patient to get regular checkups. The physician could also prescribe
regular blood tests to check your complete blood count (CBC) and the condition
of other organs (such your kidneys and liver).

Docetaxel

● Tell the patient to call their physician immediately if they develop chills or a fever
of at least 100.4 ℉ (38 degrees Celsius) this could be a possible sign of infection.
● Before beginning the docetaxel treatment, tell the patient to inform the doctor of
any additional medications you are currently taking. Unless your doctor expressly
approves, avoid taking aspirin or aspirin-containing products.
● Inform the patient that while taking docetaxel, they should not get any kind of
vaccination or immunization without their doctor's permission.
● Tell the patient to wash their hands often.
● Tell the patient to use an electric razor and soft toothbrush to minimize bleeding.
● Inform the patient to stay away from any potentially dangerous contact sports or
activities.
● Tell the patient to stay out of the sun and to apply sunscreen with an SPF of 15 or
higher, along with sun protection clothes.
● Tell the patient to avoid alcoholic beverages completely.
● Remind the patient to get regular checkups. The physician could also prescribe
regular blood tests to check your complete blood count (CBC) and the condition
of other organs (such your kidneys and liver).

Prednisone

● Ensure that the patient knows to tell the doctor about all of their current drugs
before beginning the nilutamide treatment such as prescription, over-the-counter,
vitamins, herbal remedies and others
● Encourage the patient to consult their doctor before getting any vaccines (shots to
prevent infections).
● Tell the patient that taking prednisone may reduce their ability to fight illness and
may stop them from experiencing symptoms if they contract an infection. When
using this medication, stay away from ill people and wash your hands frequently.
Avoid those who have the measles or chicken pox. If you believe you may have
come into contact with someone who had the chicken pox or measles, call your
doctor right once.
● Tell the patient that the doctor might recommend adhering to a low-salt, high-
potassium, or high-calcium diet. Additionally, your doctor might advise or
prescribe a calcium or potassium supplement. Be sure to adhere to these
recommendations.
● Educate the patient on the possibility that taking Prednisone could make them
more likely to develop osteoporosis. Consult your doctor about the dangers of
taking prednisone as well as preventative measures you can take to lessen your
risk of developing osteoporosis.
● Remind the patient to keep all scheduled appointments with their doctor and the
lab. To monitor your body's response to prednisone, your doctor will request
specific lab tests.
 8. Write your references/bibliography.

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