Question

Mr. Jackson, 68 years old, had a TURP this morning after having been diagnosed with benign prostatic hypertrophy. Latest VS: T. 98.2, P. 88, R. 20, BP. 150/88, pulse ox 98%. The following post op orders have been noted:
VS q4h I&O-qs

Antiembolic hose
Sequential Teds x 24hr

Up in chair this PM   IV: lactated Ringer’s @ 100mL/hr
IV site: RFA #20g

3-way urinary catheter to gravity with continuous irrigation o NS to keep UA free of clots   Diet: Clear liquids this PM

PRN Medication: B&O (Belladonna & Opium) supp.q4h prn bladder spasms
As you enter the room, Mr. Jackson is alert, you notice that his urinary bag is almost full with dark red urine and some blood clots; the normal saline solution irrigation bag is empty.

Prioritize the five nursing interventions as you would do them to take care of Mr. Jackson. Write in the number in the box to identify the order of your interventions (#1=first intervention, #2=second intervention, etc.) and state an evidence-based rational for each intervention (cite your source)
INTERVENTIONS PRIORITY # RATIONALE______

Take VS, assess pain level       

Assess continuous urinary irrigation system      

Empty urine bag      
Perform a body system physical assessment      

Hang a new normal saline solution irrigation bag      
On the first postop day you assess the following on Mr. Jackson:
1.   VS: T 99.6, P 98, R 24, BP 154/90
2.   Urinary catheter taped to thigh, urine pinkish, no clots
3.   Grimaces and says, “I didn’t think it would be this tough.” States pain level 8 out of 10.
4.   Further states, “I do not think sex will ever be the same.”
All of the following nursing diagnosis may apply to Mr. Jackson
Risk for infection, Impaired tissue integrity, Excess fluid volume, Deficient knowledge, Anxiety, risk for injury, Impaired urinary elimination, Acute pain, Ineffective sexuality pattern, Situational low self-esteem, Urinary retention, Risk for bleeding
1.   Select the ONE nursing diagnosis above that is of priority at this time
2.   Provide a rationale for your selection
3.   List three nursing interventions that meet the needs of Mr. Jackson

Nursing Diagnosis   Rationale   Nursing Interventions
       1.

2.

3.

The normal saline solution irrigation is discontinued at 12:00 noon the first postop day. Toward the end of the shift (3:00 pm), you assess the following on Mr. Jackson: complaints of pain. States pain level 10, no output since3 12:00pm, abdominal distention, and Mr. Jackson somewhat restless.
On the basis of the 3:00 assessment, identify and write the priority problem in the box below. Then, starting with the small box labeled #1, prioritize the nursing intervention for this situation and identify your follow-up action plan for Mr. Jackson.   
Priority Problem #1 #2 #3 #4 #5 #6
  

Nursing Interventions New Action Plan
A.   Take the vital signs
B.   Inform MD
C.   Prepare to do a urinary irrigation
D.   Give an antispasmodic
E.   Place patient in low Fowler to semi-Fowler
position
F.   Encourage fluids

Answer 1

Five nursing intervention

1. Start new normal saline solution irrigation to clear any blood clots and making urinary flow clear of any hemorrhage
2. Administer medication as per order to prevent spasm ,pain
3. Monitor vital signs every 4 hours to know the patient status
4. Strictly maintain intake output chart to know the prognosis after surgery
5. Mobilize the patient to prevent deep vein thrombosis post operatively and for early recovery

Post op day 1

Nursing diagnosis

Acute pain related to surgical procedure as evidenced by verbalisation

Nursing intervention and rationale

• Assess the pain level to know the baseline status of patient and plan for care
• Administer analgesics, anti spasmodic as per order to relieve pain
• Ensure continuous bladder irrigation to prevent pain because any kink ,blockage, obstruction in the flow can discomfort the bladder and cause severe pain

The priority problems and nursing intervention are

1. Monitor the vital signs of the patient to get baseline status of the patient
2. Place patient in low Fowler's to high Fowler's position to enhance gravity and induce urination
3. Inform MD for further orders
4. Administer antispasmodics to relieve pain
5. Urinary irrigation preparation has to be done o empty the bladder (this can be done as a priority care but it can be a problem if done in a post TURP patient)
6. Encourage to take fluid intake to maintain easy flow of urine