Nurses are responsible for the delivery of safe, effective, efficient, timely and patient centered health care services. The first step in delivering health care services is identifying the actual health problems a patient has and potential health care complication the patient will likely have based on the patients health history and the current conditions. In this report, nursing problems are stated for the case of a geriatric patient recovering from a TURP operation. Possible interventions to arrest the identified problems and evaluation of their effectiveness in keeping with the clinical reasoning model are evaluated.
TURP is commonly used to benign prostatic hyperplasia (BPH). BPH is a benign enlargement of the prostrate glad due to swellings in the stromal and epithelial wall cells in the prostrate glad (Schauer & Rowley, 2011). The enlargement of the prostate gland is large enough; it compresses the urethra leading to partial or full obstruction of urine flow. The main symptoms of BPH are frequent need to urinate, painful urination, higher risk of urinary tract infections and a high rate of urinary retention (Suter, Saller,Riedi & Heinrich, 2012). To address BPH complications, a TURP operation is performed during which the prostate gland is visualized through the urethra and some tissues in the BPH are removed. The most common types of TURP operation are monopolar (in which one incision is made), bipolar (in which two incisions are made) and laser prostrate surgery in which laser rays are used to remove part of the prostate tissues (Johnson, 2011). TURP are conducted under general and spinal anesthesia.
Although a TURP operation is generally considered safe, it comes with some complications most of which are observed within a few hours of the operation when the patient is in the PARU section before the patient is discharged or admitted to the general ward. Bleeding is the most common complication experienced post-TURP operation and can is commonly controlled by anti androgen drugs. Other rare complications which occur post a TURP surgery are clot retention, clot colic, hyponatremia, and water intoxication, urinary bladder stenosis at the sphincter, retrograde ejaculation and urinary incontinence (Woo, 2011). Close supervision in the PARU section is important after a TURP operation to discover and address any complications that that may arise.
Quality health care should be aimed at prevention of ill health by addressing risk factors rather than treatment efforts after ill health has occurred. Therefore, it is important to predict and to prevent conditions which may complicate Mr. Rodgers health further. According to Salvador-Carulla and Gasca, focusing health care services on the consequences of illnesses and contextual factors such as adaptive functioning and quality of life should be integrated in health care planning (2010). Practice nurses use stems approach or nursing functional assessment models and clinical reasoning cycle to identify potential nursing problems. This frame works allow the nurse to have a holistic view. For instance, Mr. Rodgers ha s dentures and arthritis, he has never been a smoker but drinks up to three beers a day. All this seemingly unrelated observations are factored into his health care plan through application of the clinical reasoning cycle rigorously.
Clinical Reasoning Cycle
The nursing problems statement covers the problems that Mr. Rodgers is likely to experience after his TURP operation. They are generated from the clinical reasoning cycle. The clinical reasoning cycle is tool used by nurses to enhance decision making and care through identification and interpretation of facts. The clinical reasoning cycle used by nurses has eight steps although they may not be readily separated in some cases. These steps are; patient situation, information review, process information, problem identification, synthesis of facts, establishing goals, taking actions, evaluating outcomes and reflecting on the process (Marcum, 2012). This will be the cycle used to identify nursing problems related to Mr. Rodgers care at the PARU.
The patient situation is a description of the patient while information review relates to the medical history of the patient. Mr. Rodgers is 65 years old and married. He does not smoke but drinks up to three beers a day. He has a history of arthritis but has no other major chronic conditions such as cardiovascular disease or diabetes. He was admitted on an initial diagnosis of urinary retention and the recommended treatment is a bipolar TURP operation. Because of the medical problem of arthritis, Mr. Rodgers was given 1000mg of Pnadol Oesteo and voltaren as recorded in the record of anesthesia form. In addition, he was administered with morphine, gentamyclin (160 mg), diprivan (200mg), midazolam (5ml) and fentanyl (100mg). during the operation, vital signs taken include temperature, blood pressure, conscious state, pain, respiration rate, and heart rate. The vital signs taken were all within the normal range. At 65 years old, Mr. Rodgers is a geriatric patient and is this is an important factor in the nursing care plan.
Nursing Problems Statement
Bleeding is the first and the most significant problem facing patients in post TURP operation care. Bleeding is a consequence of the damage on blood vessels in the kidney. Blood loss is a serious nursing problem because when severe, it can lead to low blood pressure, and failure of organs such as the kidney (Goodman, Burke & Livingston, 2012). These are complications which can be fatal and together with the commonality of bleeding problems in post TURP operation patients are the reasons which make bleeding to be classified as a high priority risk. Although post-TURP operation bleeding is a common problem, there are factors which increase the risk of bleeding. Rodgenhofer et al., assert that bleeding in post urological surgeries is a significant problem for patients with multiple comobidity and especially hemorrhagic bleeding disorders such as hemophilia A, hemophilia B and von Willebrd disease (2012). These conditions do not increase the risk of bleeding for patients recovering from TURP operation per se but if bleeding occurs, it is more significant hence a serious risk factor. Mr. Rodgers does not suffer from any hemorrhagic bleeding disorder but the risk of bleeding remains. Another factor that affects bleeding in post TURP patients is the type of surgery they underwent. Laser TURP surgery carries a low inherent risk of bleeding during recovery. Fagerstrom, Nyman & Hahn conducted a single centre randomized trial with 202 participants to evaluate the bleeding problems associated with monopolar and bipolar TURP techniques (2010). They found that the bipolar TURP technique carries a lower risk of bleeding than monopolar TURP technique.
The second significant nursing problem facing Mr. Rodgers is urinary incontinence. Urinary incontinence is the inability to control the passage of urine. It is common in geriatric patients. For Mr. Rodgers, certain factors increase his risk of suffering from urinary incontinence. The first one is his history of BPH. Severe BPH can restrict urine flow by blocking the urethra either wholly or partially leading to urine retention. Urine retention increases the risk of developing urinary tract infection. In addition to the urine retention, Mr. Rodgers has been inserted with a triple lumen catheter for irrigation and draining of the urinary bladder. Catheters can cause urinary tract infections (Gould, Umscheid, Agarwal, Kubtz & Pegues, 2010). A weak pelvic muscle and surgical errors can also cause urinary incontinence. The problem of incontinence is serious because it has physical and psychological implications which must be incorporated in the nursing care (Glazer et al., 2010). The physical challenge posed by incontinence is increasing the risk of bedsores, making personal hygiene more challenging why the psychological challenges relate to the inability of an adult to control the passage of urine and the requirement to use adult urinary pads analogous to the diapers children use.
The third nursing problem is development of hyponetremia and water intoxication. Hyponatremia refers to imbalance in electrolyte levels in the body commonly caused by excess water which causes dilution of the blood leading to low salt levels in blood. According to Boukatta et al., salt levels of around 125mmol/L are classified as severe hyponatremia (2013). The symptoms of hyponatremia include nausea, vomiting, headache, loss of mental acuity, lethargy, fatigue and loss of appetite. Severe hyponatremia affects brain functioning due to imbalance in electrolyte levels. This is the basis of a water poisoning diagnosis. Some patients experience seizures and decreased consciousness and may even develop coma due to sustained severe hyponatrepia. The risk of water poisoning and hyponatremia occurs as a result of inhibited kidney functioning leading to accumulation of excess water in the body. For Mr. Rodgers, the risk of hyponatremia is minimal because fluid balance report indicates that electrolyte levels in the body are within the normal range.
Once the nursing problems have been stated in order of priority, the next step in the clinical reasoning cycle is setting the goals. Mr. Rodgers will be in the PARU section for four hours as he recovers from the effects of anesthesia and is under observation. The first goal relates to the problem of bleeding. Staining of urine with blood is normal after a TURP operation but severe bleeding is not. Therefore the first goal will be controlling bleeding. The second goal will be maintaining control over the passage of urine to preempt urinary incontinence while the third goal will be maintaining normal electrolyte levels to prevent hyponetremia and water intoxication
Nursing Interventions to meet the Goals
Close monitoring of blood pressure at the PARU will be the first action taken to control bleeding. A reduction in blood pressure is an indication of internal bleeding. In the event of severe bleeding, blood transfusion will be the intervention taken to reverse the situation. Mr. Rodgers has given informed consent to a blood transfusion in the hospital admission booklet. Getting a patients consent is important to ensure that the nursing interventions taken are agreeable to the patients culture and religion. This is part of offering quality patient-centric care. The intervention that will be taken to control urinary incontinence will be regular checks at the operation of the urine emptying bags and regular irrigation and draining of the urinary bladder. This will prevent urine retention. Fluid balance analysis to check the electrolyte levels will be conducted. If there is hyponetremia, normal saline solution will be administered to maintain electrolyte balance by improving the level of sodium ions in the body.
Evaluation and Reflection
Evaluation tests the effectiveness and efficiency of the nursing interventions taken with an aim of making improvements based on evidence. If the nursing interventions work to meet the goals, they are improved while if the nursing actions fail, they are replaced with alternatives based on the cause of the failure.
Boukatta, B., Sbai, H., Messaoudi, F., Lafrayiji, Z., El Bouazzaoui, A., & Kanjaa, N. (2013).
Transurethral resection of prostate syndrome: report of a case. The Pan African Medical Journal, 14.
Campbell, S. E., Glazener, C. M. A., Hunter, K. F., Cody, J. D., & Moore, K. N. (2011). Conservative management for men with urinary incontinence after prostate surgery.
Fagerström, T., Nyman, C. R., & Hahn, R. G. (2010). Bipolar transurethral resection of the prostate causes less bleeding than the monopolar technique: a single‐centre randomized
trial of 202 patients. BJU international, 105(11), 1560-1564.
Glazener, C. M. A., Boachie, C., Buckley, B., Cochran, C., Dorey, G., Grant, A. M., & Vale, L. D. (2010). Conservative treatment for urinary incontinence in men after prostate surgery (MAPS). NIHR Health Technology Assessment programme, Southampton, United Kingdom.
Goodman, D. M., Burke, A. E., & Livingston, E. H. (2012). Bleeding Disorders. JAMA: the
Gould, C. V., Umscheid, C. A., Agarwal, R. K., Kuntz, G., & Pegues, D. A. (2010). Guideline
for Prevention of Catheter‐Associated Urinary Tract Infections 2009. infection control and hospital epidemiology, 31(4), 319-326.
Johnson, B. E. (2011). Urologic Surgery. In Perioperative Medicine (pp. 145-150). London, UK:
Marcum, J. A. (2012). An integrated model of clinical reasoning: dual‐process theory of cognition and metacognition. Journal of Evaluation in Clinical Practice, 18(5), 954-961.
Rogenhofer, S., Hauser, S., Breuer, A., Fechner, G., Mueller, S. C., Oldenburg, J., & Goldmann, G. (2012). Urological surgery in patients with hemorrhagic bleeding disorders
Hemophilia A, Hemophilia B, von Willebrand disease: a retrospective study with
matched pairs analysis. World journal of urology, 1-5.
Salvador-Carulla, L., & Gasca, V. I. (2010). Defining disability, functioning, autonomy and dependency in person-centered medicine and integrated care. International journal of integrated care, 10(5).
Schauer, I. G., & Rowley, D. R. (2011). The functional role of reactive stroma in benign prostatic hyperplasia. Differentiation, 82(4), 200-210.
Suter, A., Saller, R., Riedi, E., & Heinrich, M. (2012). Improving BPH symptoms and sexual dysfunctions with a saw palmetto preparation? Results from a pilot trial. Phytotherapy
Woo, H. H. (2011). We should cease offering TURP in favour of alternative surgery options for anticoagulated patients. BJU international, 108(s2), 50-50.