Nursing diagnosis for TURP – Transurethral resection of the prostate

Transurethral resection of the prostate( TURP) is a surgical procedure to treat an enlarged prostate gland (benign prostatic hyperplasia). The prostate is located near the urinary bladder of an adult male. The urine flows through the prostate gland from the bladder to the urethra when urinating. When the prostate gland enlarges, the bladder is blocked from eliminating urine, and the process is interrupted. The symptoms include urgency to urinate, waking up at night to urinate, an abnormally small amount of urine, and retained urine. The high intensity of the symptoms will lead to alleviation through a minimally invasive procedure (TURP).  

Nursing care plans for TURP

Diagnosis

  1. Impaired Urinary Elimination related to loss of bladder tone due to continued decompression and preoperative overdistension as evidenced by fullness of the bladder and frequent urination.
  2. Risk for Deficient Fluid Volume secondary to the vascular nature of the surgical area; difficulty controlling bleeding, restricted intake preoperatively and post obstructive diuresis.
  3. Risk for infection secondary to invasive procedures (surgical instruments, catheter, traumatized tissue, frequent bladder irrigation, and surgical incision).
  4. Acute pain related to irritation of the bladder mucosal lining as evidenced by the patient reporting painful bladder spasms, restlessness, and autonomic responses.
  5. Risk for Sexual Dysfunction  secondary to the situation at hand (urine incontinence, leakage after catheter removal, and involvement of the genitals)
  6. Deficient Knowledge related to misinterpretation of information and lack of exposure as evidenced by the patient asking many questions and inability to follow through with instructions.

 

Impaired Urinary Elimination related to loss of bladder tone due to continued decompression and preoperative overdistension as evidenced by fullness of the bladder and frequent urination.

Desired Outcomes

  • The patient will achieve a regular urinary elimination pattern.
  • The patients will be able to void residuals without retaining urine.

Nursing Interventions

  • Assess urine output and drainage system during bladder irrigation. Rationale – Urine retention can be caused by swelling of the surgical area, bladder spasms, and blood clots.
  • When the patient is voiding, help him assume a normal position. After the catheter is removed, encourage the patient to stand and go to the bathroom at frequent intervals. Rationale – To encourage urine to pass freely and help the patient feel normal.
  • Check the incision site regularly for drainage or any bleeding. Also, check for any signs of infection. Rationale – To ensure the sutures are intact and manage any infection.
  • After removing the catheter, note down the time and amount of voiding. Note down reports of inability to void,  bladder fullness, or urgency. Rationale – Urethral swelling and loss of bladder tone can cause voiding, even after catheter removal.
  • Encourage the patient to void when pressed every 2–4 hours. Rationale – Urinary retention does not occur when the patient voids with urgency; urinary retention does not occur. This will increase bladder tone and aid in bladder retraining.
  • Use a suprapubic catheter to measure any present residual volumes. Rationale –  To monitor how the bladder is effective in emptying urine. High residual amounts will need catheterization until bladder tone improves.
  • Encourage high fluid intake with tolerance. In the evening or when the catheter has been removed, limit intake of fluids. Rationale – To maintain hydration and renal perfusion for the flow of urine. Reducing the amount of fluids in the evening decreases voiding and sleep interruption.
  • Encourage the patient to perform perineal exercises: Stopping and starting a urine stream, tightening buttocks. Rationale -To minimize incontinence and regain urinary control or bladder control.
  • Educate the patient about “dribbling,” what is expected after the catheter is removed and how it will resolve. Rationale – Informing the patient enables having an idea of the problem and how to deal with it.
  • Irrigate the bladder continuously, as indicated in the early postoperative period. Rationale – To maintain catheter patency and urinary flow. Irrigation flushes blood clots and debris in the bladder. 

 

Risk for Deficient Fluid Volume secondary to the vascular nature of the surgical area; difficulty controlling bleeding, restricted intake preoperatively and post obstructive diuresis.

Desired Outcomes

  • The patient will show no active bleeding.
  • The patient will have adequate hydration evidenced by: Stable vital signs, palpable peripheral pulses, good capillary refill, moist mucous membranes, and appropriate urinary output.

Nursing Interventions

  • Monitor fluid input and output. Rationale – To indicate fluid balance in the body and the need for replacement through estimating blood loss and urine output.
  • Monitor vital signs (note down increased pulse and respiration, pallor, delayed capillary refill, decreased BP, and dry mucous membranes). Rationale – Changes in vital signs; hypertension, bradycardia, nausea, and vomiting indicate the need for immediate intervention. Dehydration or hypovolemia requires immediate intervention to prevent impending shock.
  • Investigate any changes in behavior, restlessness, and confusion by the patient. Rationale – These may indicate decreased cerebral perfusion or cerebral edema due to excessive solution absorbed into the venous sinusoids during the TURP procedure.
  • Encourage high fluid intake unless the patient has contraindications. Rationale – To flush bacteria and blood clots from the kidneys and the bladder. Note: Lack of close monitoring can cause water intoxication or fluid overload.
  • Avoid manipulating the catheter. Rationale – Moving the catheter may cause bleeding or formation of clots, a distended bladder, and catheter plugging.
  • Observe drainage of the catheter and note down any bleeding. Rationale –  Continued active bleeding requires medical evaluation and interventions.
  • Check the color and consistency of urine. Rationale – Bright red indicates arterial bleeding. Dark burgundy with dark clots and highly viscous indicates venous bleeding that will subside on its own. Bleeding without clots indicates systemic clotting problems.
  • Administer IV fluids or blood products as indicated. Rationale – To indicate if the patient may need additional fluids, check for adequate oral intake, and check if losses are excessive.
  • Maintain catheter traction by taping it to the inner thigh. Rationale – To control bleeding by creating pressure on the arterial supply of the prostatic capsule.
  • Administer laxatives and stool softeners as indicated. Rationale – To prevent straining or constipation and reduce the risk of rectal-perineal bleeding.

 

Risk for Infection secondary to invasive procedures (surgical instruments, catheter, traumatized tissue, frequent bladder irrigation, and surgical incision).

Desired outcomes

  • The patient will experience no signs of infection.
  • The patient will achieve timely healing.

 Nursing Interventions

  • Maintain a sterile environment around the catheter, provide a regular catheter and apply antibiotic ointment around the site. Rationale – To prevent the introduction of bacteria on the catheter site that may cause Infectioninfection or sepsis.
  • Ambulate with a drainage bag. Rationale – To avoid the introduction of bacteria to the bladder caused by backward reflux of urine.
  • Monitor vital signs and note rapid pulse and respiration, low-grade fever, irritability,  restlessness, chills, and disorientation. Rationale – To be alert to increased risk for surgical or septic due to manipulation and use of surgical instruments. 
  • Observe drainage from the incision site and around the catheter. Rationale – To prevent the risk of Infectioninfection shown by erythema and purulent drainage.
  • Frequently change the dressing and clean and dry skin on the incision site. Rationale – To decrease the risk for wound infection caused by skin irritation and channels for bacterial growth on the use of wet dressings.
  • Use ostomy-type skin barriers. Rationale – To protect the surrounding skin from excoriation and reduce the risk of infection.

 

Acute pain related to irritation of the bladder mucosal lining as evidenced by the patient reporting painful bladder spasms, restlessness, and autonomic responses.

Desired outcomes

  • The patient will report relief from pain.
  • The patient will be relaxed and have adequate sleep and rest.
  • The patient will demonstrate the use of relaxation skills for diverting pain.

Nursing Interventions

  • Assess the scale of pain, presenting characteristics, and location. Rationale – Sharp pain with urgency to urinate or void around the catheter indicates bladder spasms.
  • Maintain the drainage system and patency of the catheter by keeping tubes from kinking. Rationale – To relieve pain through maintaining a proper catheter and drainage system, which will decrease the risk of bladder distension and bladder spasms.
  • Encourage high fluid intake with tolerance. Rationale – This will maintain constant fluid flow over the bladder mucosa to decrease irritation.
  • Inform the patient about bladder spasms, catheter, and drainage. Rationale – To relieve anxiety and promote patient cooperation.
  • Make the patient comfortable by regularly changing position, rubbing the back, and doing activities to divert pain. Rationale – To reduce muscle tension, enhance coping abilities and regain attention.
  • Provide hip baths if indicated. Rationale – To relieve swelling, promote tissue perfusion, and enhances perineal healing.
  • Administer antispasmodics. Rationale – To relax the smooth muscle and provide relief from bladder spasms and associated pain.

 

Risk for Sexual Dysfunction  secondary to the situation at hand (urine incontinence, leakage after catheter removal, and involvement of the genitals)

Desired outcomes

  • The patient will report understanding of sexual function and changes that can occur with surgery.
  • The patient will discuss sexual functioning concerns and body image changes with the partner.
  • The patient will demonstrate problem-solving skills for solutions to arising problems.

Nursing interventions

  • Encourage the patient to talk about concerns about incontinence and sexual functioning. Rationale – To relieve the patient from anxiety about the effects of surgery.
  • Discuss basic human anatomy, and be honest and open to answering patients’ questions. Rationale – To educate the patient on the nerve plexus that controls erection and runs through the capsule posteriorly to the prostate. Inform the patient that surgical procedures may not provide a permanent cure and hypertrophy may recur.
  • Talk to the patient about what to expect from regaining sexual function. Rationale – To create awareness of physiological impotence during radical procedures when the perineal nerves are cut. Sexual activity can usually be regained in 6–8 weeks.
  • Discuss with the patient retrograde ejaculation. Rationale – With the condition, seminal fluid goes into the bladder, causing urine to be cloudy. It is excreted with the urine, and the result is decreased fertility.

Deficient Knowledge related to misinterpretation of information and lack of exposure as evidenced by the patient asking many questions and inability to follow through with instructions.

Desired outcomes

  • The patient will verbalize understanding of the surgical procedure and any potential complications.
  • The patient will verbalize understanding of therapeutic needs.
  • The patient will correctly perform necessary procedures.
  • The patient will initiate necessary lifestyle changes.
  • The patient will actively participate in the therapeutic regimen.

Nursing interventions

  • Review conclusions of procedure and what to expect in future. Rationale – To provide the patient with Knowledge to help make informed choices.
  • Encourage the patient to focus on good nutrition, including fruit and fiber. Rationale – To reduce the risk for postoperative bleeding by promoting healing and preventing constipation. 
  • Discuss activity restrictions like avoiding heavy lifting, strenuous exercise, prolonged sitting, and long trips. Rationale – To reduce the risk of bleeding as activities stress the bladder and prostate, increasing abdominal pressure. 
  • Encourage the patient to continue with perineal exercises. Rationale – To help in controlling urine flow and alleviate incontinence.
  • Instruct the patient to avoid tub baths after discharge. Rationale – To decrease the introduction of bacteria and the possibility of infection.
  • Educate the patient on the importance of follow-up care. Rationale – To monitor PSA levels and assess for residual tumors.

Conclusion

Hemorrhage is the most common complication of TURP. The nurse should teach the patient the importance of notifying the doctor when bleeding occurs. The patient is encouraged to take a high fiber diet to help prevent constipation. Hygiene in the perennial area is emphasized as it reduces the risk of infection. Patients are advised to take antibiotics as prescribed by the physician. Kegel exercises are essential in strengthening the pelvic floor muscles. The nurse then evaluates the patient to follow up on what has been achieved.