Case: Reproductive System

Mr. J, 65yo, male, admitted for a transurethral resection of the prostate

(TURP) after being diagnosed with benign prostatic hypertrophy.
Subjective Data
2 days came to ED because of an inability to void for the past 12H
Complaints of severe bladder pain and pressure
Is very restless and agitated
Relates history of three cans of beer the previous evening; and has not
voided since then
Objective Data
Has prostate enlargement on digital rectal examination
Has hematuria and WBCs in urine
Has palpable bladder above umbilicus
Diagnostic Studies
PSA test: 6ng/ml
Cardex
VS q4H
IO qshift
Antiembolic hose
Sequential teds x 24H
Up in chair this PM
Diet: clear fluids this PM
IV LR @ 100mL/H
IV site R forearm #20
3-way urinary catheter to gravity with continuous irrigation of NS to
keep system free of clots
PRN meds: B&O (Belladonna/Opium) suppository q4H PRN bladder
spasms
1st post-op day
VS: T 37.8C, PR 98, RR 24, BP 154/90
Urinary catheter taped to thigh, urine pinkish, no clots
Grimaces and says, I didnt think it would be this tough
States level of pain is 8 out 10
Further states, I do not think sex will ever be the same.

1.
a) Identify 5 relevant priorities of care
b) with rationale for each priority identified.

Acute Pain may be related to bladder irritability and irrigations;

presence of a 3-way urinary catheter; and surgical trauma as
evidenced by reports of pain stated as 8 out of 10; nonverbal signs of
pain such as grimacing and; stating that I didnt think it would be this
tough; RR = 24 breaths/min; BP = 154/90 mmHg

Ineffective Self-Health Management may be related to a lack of

knowledge regarding the need for follow-up care and activity
restriction postoperatively as evidenced by verbalization of I didnt
think it would be this tough.

Urge Urinary Incontinence may be related to poor sphincter control

secondary to TURP procedure

Risk for Infection may be related to undergoing TURP procedure;

presence of a 3-way urinary catheter

Risk for Sexual Dysfunction

Collaborative problems: urinary retention, impotence, infection

2.
a) Generate management plan to address and manage the 5
identified priorities of care;
b) incorporates relevant nursing interventions;
c) strong rationale is provided in support of the management
plan
Acute Pain
Expected Outcome: Reports Satisfactory Pain Control
Nursing Intervention
Rationale
Independent
Assess pain, noting location,
Changes in pain reports may
characteristics, onset and duration,
indicate developing complications
frequency, quality, intensity (0 to 10 requiring further evaluation and to
scale), or severity of pain, and
plan appropriate interventions.
precipitating factors.
Note: Sharp, intermittent pain with
urge to void and passage of urine
around catheter suggests bladder
spasms, which tend to be more
severe with suprapubic or TUR

Monitor intake and output carefully.

approaches and usually decrease

within 48 hours.
To evaluate fluid balance and
prevent bladder distention.

Percuss bladder or use bladder

scanner

To check for distension to validate

adequate emptying of the bladder

Maintain patency of catheter and

drainage system. Keep tubing free
of kinks and clots.

Maintaining a properly functioning

catheter and drainage system
decreases risk of bladder distention
and spasm. Ensuring a continuous
flow of urine from the bladder and
no clots because these may cause
obstruction of urine flow, resulting in
bladder spasms.
To prevent clots and possible
occlusion of catheter.

Increase the continuous bladder

irrigation rate if there is increased
hematuria postoperatively; irrigate
manually if occluded
Promote intake of up to 3L/day, as
tolerated.
Provide comfort measures, such as
position changes, back rub,
Therapeutic Touch, and diversional
activities. Encourage use of
relaxation techniques, including
deep- breathing exercises,
visualization, and guided imagery.
Instruct the patient to try not to
urinate around the catheter
Give client accurate information
about catheter, drainage, and
bladder spasms.
Assess the patients comfort status
Collaborative
Provide sitz baths or heat lamp, if
indicated.
Administer antispasmodics, such as
the following:Oxybutynin (Ditropan),
flavoxate (Urispas), Belladona &

Decreases irritation by maintaining

a constant flow of fluid over the
bladder mucosa.
Reduces muscle tension, refocuses
attention, and may enhance coping
abilities. These also relieves pain
and decreases spasms.

This increases the occurrence of

spasm.
Allays anxiety and promotes
cooperation with necessary
procedures.
To continue or revise the plan as
necessary.
Promotes tissue perfusion and
resolution of edema and enhances
healing in perineal approach.
Relaxes smooth muscle to provide
relief of spasms and associated
pain.

Opium suppositories
Propantheline bromide (ProBanthine)

Relieves bladder spasms by

anticholinergic action. Usually
discontinued 24 to 48 hours before
anticipated removal of catheter to
promote normal bladder contraction

Ineffective Self-Health Management

Expected Outcome: Describes follow-up care and activity restrictions
Nursing Intervention
Rationale
Independent
Review implications of procedure
Provides knowledge base from which
and future expectations.
client can make informed choices.
Stress necessity of good nutrition;
Promotes healing and prevents
encourage inclusion of fruits and
constipation, reducing risk of
increased fiber in diet.
postoperative bleeding.
Advise client to avoid or limit intake
Acidic substances can lower urine
of caffeine, citrus juices, carbonated pH, thereby aggravating dysuria.
beverages, and spicy foods for first
few weeks after surgery.
Encourage continuation of perineal
Facilitates urinary control and
exercises.
alleviation of incontinence.
Discuss initial activity restrictions,
such as avoidance of heavy lifting
(not >4.5kg), straining during
defecation, driving, prolonged
sitting, long car trips, climbing >2
flights of stairs at a time, and sexual
activity until the surgeon approves.
Instruct in urinary catheter care if
present. Identify source for supplies
and support.

Instruct client to avoid tub baths

after discharge.
Review s/s requiring medical

Increased abdominal pressure and

straining places stress on the
bladder and prostate, potentiating
risk of bleeding.

Promotes independence and

competent self-care. Catheter may
be in place only on day of surgery
when laser procedure is done or for
days to weeks with other
procedures.
Decreases the possibility of
introduction of bacteria or undue
tension on incision.
Prompt intervention may prevent

evaluation: erythema, purulent

drainage from wound sites; inability
to urinate, changes in character or
amount of urine, presence of
urgency or frequency; and heavy
clots or bright red bleeding, fever, or
chills.
Provide written information to client
and SO regarding recovery
expectations and home
management, as indicated,
regarding pain, incision care, and
catheter-related problems and care.
Stress importance of follow-up care
evaluation by primary healthcare
provider, urologist or oncologist, and
laboratory studies.
Provide information on available
community resources, such as
home-health services, medical
equipment supply company,
housekeeping, and support persons.

serious complications. Note: Urine

may appear cloudy for several
weeks until postopera- tive healing
occurs and may appear cloudy after
intercourse because of retrograde
ejaculation.
Anxiety related to hospitalization;
procedure performed; and
associated diagnosis, fatigue, and
postoperative pain often makes it
difficult for client to absorb
necessary self-care information.
Monitoring and follow-up can reduce
incidence of unaddressed
complications. Persistent
incontinence and other
postoperative issues will require
additional evaluation and treatment.
Can be helpful in assisting client and
SO in coping with challenges they
are faced with following
prostatectomy, whatever the reason
for procedureBPH, cancer,
incontinence, and so forth.

Urge Urinary Incontinence

Expected Outcome: Reports decrease in urine leakage between voidings
Identify factors that contribute to
incontinence episodes.
Instruct the patient to respond
immediately to the urge to void.
Explain the etiology of the problem
and the rationale for actions.
Limit the ingestion of bladder
irritants (e.g., colas, coffee, tea,
chocolate)
Limit fluids for 23 hr before
bedtime.
Advise the patient about devices for
short-term management of dribbling
(e.g., incontinence garments or
pads, a condom catheter, or penile
clamp).

To plan appropriate interventions.

To prevent involuntary leakage.
To help the patient plan appropriate
interventions.
To decrease urinary urgency.
To avoid nighttime urgency.
So the patient is aware of various
devices and can make an informed
decision among alternatives.

Teach the patient Kegel exercises

To strengthen sphincter tone.

Risk for Infection

Expected Outcome: Experience no signs of infection and achieve timely
healing.
Nursing Intervention
Rationale
Independent
Maintain sterile catheter system;
Prevents introduction of bacteria
provide regular catheter and urinary and resultant infection.
meatus care with soap and water,
applying antibiotic ointment around
catheter site per protocol.
Ambulate with drainage bag
Avoids backward reflux of urine,
dependent.
which may introduce bacteria into
the bladder.
Monitor vital signs, noting low-grade Client who has had cystoscopy or
fever, chills, rapid pulse and
TURP is at increased risk for surgical
respiration, restlessness, irritability,
and septic shock related to
and disorientation.
instrumentation.
Observe drainage from wounds
Presence of drains and suprapubic
around suprapubic catheter.
incision increases risk of infection,
as indicated by erythema or
purulent drainage.
Change suprapubic/retropubic and
perineal incision dressings
frequently, cleaning and drying skin
thoroughly each time.
Use ostomy-type skin barriers.
Collaborative
Administer antibiotics, as indicated.

Wet dressings cause skin irritation

and provide medium for bacterial
growth, increasing risk of wound
infection.
Provides protection for surrounding
skin, preventing excoriation and
reducing risk of infection.
May be given prophylactically
because of increased risk of
infection with prostatectomy.

Risk for Sexual Dysfunction

Expected Outcome: Report understanding of sexual function and alterations
that may occur with surgery in individual situation. Discuss concerns about
possible changes in body image and sexual functioning with partner/SO and
caregiver.Demonstrate problem-solving skills regarding solutions to problems
that occur.
Nursing Intervention
Rationale

Independent
Provide openings for client and SO
to talk about concerns of
incontinence and sexual functioning.
Discuss basic anatomy. Be honest in
answers to clients questions.

May have anxieties about the effects

of surgery and may be hesitant
about asking necessary questions.
Anxiety may have affected ability to
access information given previously.
The nerve plexus that controls
erection runs posteriorly to the
prostate through the capsule. In
procedures that do not involve the
prostatic capsule, impotence and
sterility are usually not
consequences. Surgical procedure
may not provide a permanent cure,
and hypertrophy may recur.

Give accurate information about

expectation of return of sexual
function.

Physiological impotence occurs

when the perineal nerves are cut
during radical procedures; with
other approaches, sexual activity
can usually be resumed within
weeks. If erectile dysfunction
persists after healing is complete,
client may want to pursue options to
restore functionuse of medications
such as sildenafil citrate (Viagra).

Discuss retrograde ejaculation if

transurethral or suprapubic
approach is used.

Seminal fluid goes into the bladder

and is excreted with the urine. This
does not interfere with sexual
functioning, but will decrease
fertility and cause urine to be
cloudy.
Tightening pelvic floor muscles prior
to standing, coughing, and sneezing
promotes regaining bladder and,
perhaps, erectile function.
Persistent or unresolved problems
may require professional
intervention.

Instruct in perineal and pelvic floor

exercises and interruption of urinary
stream exercises
Collaborative
Refer to sexual counselor as
indicated.
3.

a) Identify and develop 3 detailed health promotion strategies to

meet patient needs in case scenario;
b) provide clear rationale for selected strategies.

Health Promotion Strategies

Regular Prostate specific antigen (PSA)
monitoring
Lifestyle changes - decrease alcohol
consumption and scheduling bathroom visits.

Monitor fluid intake and output.

Rationale
Early prostate cancer screening may reduce the
mortality rate by as much as 35%.
Ingestion of alcohol increases prostatic
symptoms because of its diuretic effect. The
buildup of urine increases bladder distention.
Scheduling regular bathroom visits - once
every 2 to 3 hours or upon feeling the urge encourages return of normal patterns of urine
elimination ("retraining"). Prolonging might
overstretch the bladder muscle and cause
damage.
To check for adequate hydration. Increasing
fluid intake at this moment will aid in flushing
out any remaining blood or clots from the
bladder. Having less fluid intake will not help
the client but may worsen the situation by
making him dehydrated or prone to infections.

4.
a) Identify 3 relevant teaching priorities to meet patients care
needs;
b) develop a detailed teaching plan for patient and family to
manage patients condition.
Teaching Priorities
Strategies To Implement
Temporarily avoid activities
These activities include sitting upright and standing for
that increase intraprolonged periods, straining due to constipation, long
abdominal pressure
travel times, driving, stair climbing, sexual activity, and
heavy lifting.
Inform client that his surgeon will approve these
activities when bleeding from TURP is no longer a
possibility.
Explain the relationship between increased abdominal
pressure and postoperative hemorrhage.
Remind client of the date and time of his follow-up
appointment as scheduled by his physician or surgeon.
Stress the importance of coming back to see his
physician or surgeon even after he feels better.
Urinary sphincter toning or
Provide videos to watch about how the male urinary
retraining
system functions.
Explain the reason for urinary incontinence and
dribbling.
Give step by step instructions on how to do Kegel
exercises and encourage him to practice 10-20 times in a
day.

Sexual activity expectations

after undergoing TURP

Provide a urinal for the client to use after instructing

him to practice starting and stopping the stream several
times during urination.
Inform client that it usually takes several weeks to
achieve urinary continence.
Acknowledge client's concern about sexual activity
changes. Client verbalized "I don't think sex will ever be
the same".
Allow client to express his concerns and ask questions.
Provide client with researched information about the
unlikely development of erectile dysfunction from
TURP procedure.
Educate the client about retrograde ejaculation.
Inform the patient that ejaculate may be decreased in
amount or totally absent. but is not harmful.
Refer client and his partner to a sexual counselor.

5.
a) Identify 2 relevant medications based on patients situation/
health condition;
b) complete a thorough case study for the 2 medications,
a. the trade and generic name of the medication;
b. mechanism of action;
c. uses;
d. route;
e. dosage;
f. common side effects;
g. adverse reactions;
h. contraindications;
i. precautions and interactions;
j. development (lifespan) considerations;
k. important health teaching for the patient and the family.
Trade Name:
Generic Name:
Classification:
Mechanism:

B & O Suppositories
Belladonna alkaloids and opium
Narcotic analgesic and anti-spasmodic combination
medication
Belladonna relaxes smooth muscles and stops muscle
spasms. Opium is converted to morphine which is an
opioid pain reliever. Opioids can reduce gastrointestinal
motility, propulsion, secretions, and increase
gastrointestinal muscle tone. Opioids also stimulate
receptors on nerves in the brain to increase the threshold
to pain (increasing the amount of stimulation it takes to

feel pain) and reduce the perception of pain (the

perceived importance of the pain). These effects help in
controlling pain and relieving spasms, especially bladder
spasms. Belladonna/opium is a controlled substance.
Uses:
Treat moderate to severe pain from spasm of the urinary
tract.
Route:
Rectal
Dosage:
Insert 1 suppository rectally once or twice daily. Not to
exceed >4 suppositories/day or as directed by physician.
Side effects
Drowsiness, dizziness, blurred vision, dry mouth, urine
retention, nausea, vomiting, constipation, itching, and
hives.
Adverse
Slow shallow breathing; severe drowsiness or dizziness.
Effects:
Can be habit forming and has abuse potential because of
its opium content.
Contraindicatio Not recommended for children 12 years or younger
ns:
Precautions
Alvimopan (Entereg) increases belladonna and
and
opium levels in the body; opioid must be stopped 7
interactions
days prior to starting Alvimopan.
MAO inhibitors like phenelzine (Nardil), selegiline
(Zelapar, Emsam, Eldepryl), and isocarboxazid
(Marplan) as well as linezolid (Zyvox) antibiotic
may lead to serious changes in blood pressure,
fever, sleepiness, agitation, confusion and in severe
cases, death. Must be stopped or separated by 14
days before administering B&O.
Naltrexone (Revia) decreases levels and
therapeutic effects of B&O, leading to treatment
failure.
Narcotic analgesics increased risks of dizziness,
sedation, and respiratory depression.
Cimetidine, Butorphanol, Nalbuphine, Potassium
tablets, Pramlimtide, Rifampin

Health
Teaching

Development
(lifespan)
Consideration:

Do not stop abruptly as it may cause withdrawal

symptoms.
Do not increase dose.
May cause addiction.
Store at room temperature away from light and
moisture.
Do not refrigerate.
Do not store in the bathroom.
Keep away medications from children and pets.
Do not flush medication in the toilet or pour them
into the drain unless instructed to do so.
Properly discard product when it is expired or no
longer needed.
Consult your pharmacist or local waste disposal for
safe disposal of product.
PREGNANCY: There are no adequate studies done on
belladonna/opium suppositories to determine safe and
effective use in pregnant women. They should be used
only if clearly needed.
NURSING MOTHERS: Opium is converted to morphine.
Morphine is excreted in breast milk, however, the
American Academy of Pediatrics committee states that it
is safe to use while nursing.

Trade Name:
Generic Name:
Classification:
Mechanism:

Uses:

Detrol, Detrol LA
tolterodine tartate
cholinergic (acetylcholine) receptor blockers
The urinary bladder is a muscular "bag." Urine coming
from the kidneys fills the bladder and causes it to stretch
like a balloon. As bladder stretches, pressure in the
bladder increases and, when the bladder reaches a
certain level of stretch, a desire to urinate is felt. Nerves
in the muscular wall of the bladder release acetylcholine,
a chemical that attaches to receptors on the muscle cells
and causes the cells to contract (tighten). This contributes
further to the increase in pressure within the bladder and
the desire to urinate.
By blocking the effect of acetylcholine on the muscle
cells, tolterodine slows the build-up of pressure in the
bladder, reduces the sensation to urinate, and prevents
uncontrolled urination.
treat uncontrollable urination overactive bladder or urge

incontinence. Symptoms include the need to urinate

frequently, an urge to urinate immediately, and an
inability to control the release of (urinary incontinence).
Route:
By mouth
Dosage:
Taken 2x daily. The starting dose is 1 or 2 mg 2x daily. The
starting dose when using long-acting tolterodine is 2 or 4
mg daily. The dose may need to be reduced for patients
who have impaired liver or kidney function.
Side effects
Dry mouth, dry eyes, headache, upset stomach, dizziness,
drowziness, constipation, and may cause blurred vision.
Adverse
vision changes, severe stomach pain, trouble urinating,
Effects:
signs of kidney infection, irregular heartbeat, severe
dizziness, fainting
Contraindicatio Contraindicated with people who/have heart problems.
ns:
Caution is recommended for patients with narrow-angle
glaucoma, obstruction to the flow of urine, or poor
emptying of the stomach since tolterodine may worsen
these medical conditions.
Precautions
Tolterodine is broken down by liver enzymes before
and
elimination from the body. Drugs that block these
interactions
liver enzymes may slow the elimination of
tolterodine, raise tolterodine blood levels, and lead
to side effects.
interfere with the elimination of tolterodine includes
erythromycin, clarithromycin (Biaxin), ketoconazole
(Nizoral), itraconazole (Sporanox), cyclosporine,
vinblastine, and miconazole (Monistat, Micatin). The
dose of tolterodine should be reduced to 1 mg twice
daily if taken with any of these drugs.
Health
Suck hard candies or ice chips to relieve dry mouth
Teaching
Eat adequae fiber, drink plenty of water and
exercise to prevent constipation.
Do not drive or/ use machinery when taking this
drug.
Limit alcoholic beverages.
Drink lots of fluids.

Developmental PREGNANCY: At doses much greater than those used in

(lifespan)
humans, tolterodine causes fetal abnormalities in animals,
Considerations but there are no studies with tolterodine in pregnant
women. Therefore, tolterodine should only be given to
pregnant women if the benefits are felt to outweigh the
potential risks.
NURSING MOTHERS: Tolterodine is secreted into breast
milk in animals; however, it is not known if tolterodine is
secreted into the breast milk of women. Therefore,
nursing mothers should either not breast feed or
discontinue tolterodine.
Group Members:
Asuncion, Grace
Bautista, Julius
Bernardo, Bryan Floyd
Cheong, Caitlin Marie
Manimtim, Kristine
Ong, Mary Stephenie
Soluta, Rochelle Marie