NURSING PROCESS: THE PATIENT UNDERGOING PROSTATECTOMY
The nurse assesses how the underlying disorder (BPH or prostate cancer) has affected the patient’s lifestyle. Has he been reasonably active for his age? What is his presenting urinary problem (de-scribed in his own words)? Has he experienced decreased force of urinary flow, decreased ability to initiate voiding, urgency, fre-quency, nocturia, dysuria, urinary retention, hematuria? Does the patient report associated problems, such as back pain, flank pain, and lower abdominal or suprapubic discomfort? If he reports such discomfort, possible causes include infection, retention, and renal colic. Has he experienced erectile dysfunction or changes in frequency or enjoyment of sexual activity?
The nurse obtains further information about the patient’s family history of cancer and heart or kidney disease, including hypertension.
Has he lost weight? Does he appear pale? Can he raise himself out of bed and return to bed without assistance? Can he perform usual activities of daily living? This information will help in determining how soon he will return to normal activities after prostatectomy.
Based on the assessment data, the patient’s major nursing diag-noses may include the following.
· Anxiety about surgery and its outcome
· Acute pain related to bladder distention
· Deficient knowledge about factors related to the disorder and the treatment protocol
· Acute pain related to the surgical incision, catheter place-ment, and bladder spasms
· Deficient knowledge about postoperative care and man-agement
Based on the assessment data, the potential complications may include the following:
· Hemorrhage and shock
· Deep vein thrombosis
· Catheter obstruction
· Sexual dysfunction
The major preoperative goals for the patient may include reduced anxiety and learning about his prostate disorder and the peri-operative experience. The major postoperative goals may include maintenance of fluid volume balance, relief of pain and dis-comfort, ability to perform self-care activities, and absence of complications.
The patient is frequently admitted to the hospital on the morn-ing of surgery. Because contact with the patient may be limited before surgery, the nurse must establish communication with the patient to assess his understanding of the diagnosis and of the planned surgical procedure. The nurse clarifies the nature of the surgery and expected postoperative outcomes. In addition, the nurse familiarizes the patient with the pre- and postoperative rou-tines and initiates measures to reduce anxiety. Because the patient may be sensitive and embarrassed discussing problems related to the genitalia and sexuality, the nurse provides privacy and estab-lishes a trusting and professional relationship. Guilt feelings often surface if the patient falsely assumes a cause-and-effect relation-ship between sexual practices and his current problems. He is en-couraged to verbalize his feelings and concerns.
If discomfort is present before the day of surgery, the patient is placed on bed rest, analgesic agents are administered, and mea-sures to relieve anxiety are initiated. If the patient is hospitalized, the nurse monitors the patient’s voiding patterns, watches for bladder distention, and assists with catheterization if indicated. An indwelling catheter is inserted if the patient has continuing urinary retention or if laboratory test results indicate azotemia (accumulation of nitrogenous waste products in the blood). The catheter can help to decompress the bladder gradually over several days, especially if the patient is elderly and hypertensive and has diminished renal function or an excessive amount of urinary re-tention that has existed for many weeks. For a few days after the bladder begins draining, the blood pressure may fluctuate and renal function may decline. If the patient cannot tolerate a urinary catheter, he is prepared for a cystostomy (see Chaps. 44 and 45).
Before surgery, the nurse reviews with the patient the anatomy of the affected parts and their function in relation to the urinary and reproductive system, using diagrams and other teaching aids if in-dicated. This is often done either during the preadmission test-ing visit or in the urologist’s office. The nurse explains what will take place as the patient is prepared for diagnostic tests and then for surgery (depending on the kind of prostatectomy planned). The nurse describes the type of incision, which varies with the type of surgical approach (directly over the bladder, low on the abdomen, or in the perineal area; in the case of a transurethral procedure, no incision will be made). The patient is informed about the type of urinary drainage system that is expected, the type of anesthesia, and the recovery room procedure. The amount of information given is based on the patient’s needs and questions. Procedures expected during the immediate perioperative period are explained, questions are answered, and support is provided. In addition, the patient is instructed about postoperative use of medications for pain management.
When the patient is scheduled for a prostatectomy. Elastic compression stockings are applied before surgery and are partic-ularly important for prevention of deep vein thrombosis if the pa-tient is placed in a lithotomy position during surgery. An enema is usually administered at home the evening before surgery or the morning of surgery to prevent postoperative straining, which can induce bleeding.
During the postoperative period, the patient is at risk for imbal-anced fluid volume because of the irrigation of the surgical site during and after surgery. With irrigation of the urinary catheter to prevent its obstruction by blood clots, fluid may be absorbed through the open surgical site and retained, increasing the risk for excessive fluid retention, fluid imbalance, and water intoxication. The urine output and the amount of fluid used for irrigation must be closely monitored to determine if irrigation fluid is being retained and to ensure an adequate urine output. The patient also is monitored for electrolyte imbalances (ie, hyponatremia), rising blood pressure, confusion, and respiratory distress. The risk for fluid and electrolyte imbalance is increased in elderly patients with preexisting cardiovascular or respiratory disease. These signs and symptoms are documented and reported to the surgeon.
After a prostatectomy, the patient is assisted to sit and dangle his legs over the side of the bed on the day of surgery. The next morn-ing, he is assisted to ambulate. If pain occurs, the cause and loca-tion are determined. It may be related to the incision or may be the result of excoriation of the skin at the catheter site. It may be in the flank area, indicating a kidney problem, or it may be due to bladder spasms. Bladder irritability can initiate bleeding and result in clot formation, leading to urinary retention.
Patients experiencing bladder spasms may note an urgency to void, a feeling of pressure or fullness in the bladder, and bleeding from the urethra around the catheter. Medications that relax the smooth muscles can help to ease the spasms, which can be inter-mittent and severe; these medications include flavoxate (Urispas) and oxybutynin (Ditropan). Warm compresses to the pubis or sitz baths may also relieve the spasms.
The nurse monitors the drainage tubing and irrigates the sys-tem as prescribed to relieve any obstruction that may cause dis-comfort. Usually, the catheter is irrigated with 50 mL of irrigating fluid at a time. It is important to make sure that the same amount is recovered in the drainage receptacle. Securing the catheter drainage tubing to the leg or abdomen can help to decrease ten-sion on the catheter and prevent bladder irritation. Discomfort may be caused by dressings that are too snug, saturated with drainage, or improperly placed. Analgesic agents are administered as prescribed.
When ambulatory, the patient is encouraged to walk but not to sit for prolonged periods because this increases intra-abdominal pressure and the possibility of discomfort and bleeding. Prune juice and stool softeners are provided to ease bowel movements and to prevent excessive straining. An enema, if prescribed, is ad-ministered with caution to avoid rectal perforation.
After prostatectomy, the patient is monitored for major compli-cations such as hemorrhage, infection, deep vein thrombosis, catheter obstruction, and sexual dysfunction.
The immediate dangers after a prostatectomy are bleeding and hemorrhagic shock. This risk is increased with BPH because a hy-perplastic prostate gland is very vascular. Bleeding may occur from the prostatic bed. Bleeding may also result in the formation of clots, which then obstruct urine flow. The drainage normally begins as reddish-pink and then clears to a light pink within 24 hours after surgery. Bright-red bleeding with increased viscos-ity and numerous clots usually indicates arterial bleeding. Venous blood appears darker and less viscous. Arterial hemorrhage usu-ally requires surgical intervention (eg, suturing of bleeders or transurethral coagulation of bleeding vessels), whereas venous bleeding may be controlled by applying prescribed traction to the catheter so that the balloon holding the catheter in place applies pressure to the prostatic fossa. The surgeon applies traction by se-curely taping the catheter to the patient’s thigh.
Nursing management includes strategies to stop the bleeding and to prevent or reverse hemorrhagic shock. If blood loss is ex-tensive, fluids and blood component therapy may be adminis-tered.
Nursing interventions include close monitoring of vital signs; administering medications, intravenous fluids, and blood com-ponent therapy as prescribed; maintaining an accurate record of intake and output; and careful monitoring of drainage to ensure adequate urine flow and patency of the drainage system. The pa-tient who experiences hemorrhage and his family are often anx-ious and benefit from explanations and reassurance about the event and the procedures that are performed.
After perineal prostatectomy, the surgeon usually changes the dressing on the first postoperative day. Further dressing changes may become the nurse’s responsibility. Careful aseptic technique is used because the possibility for infection is great. Dressings can be held in place by a double-tailed, T-binder bandage or a padded athletic supporter. The tails cross over the incision to give double thickness, and then each tail is drawn up on either side of the scrotum to the waistline and fastened.
Rectal thermometers, rectal tubes, and enemas are avoided be-cause of the risk for injury to and bleeding in the prostatic fossa. After the perineal sutures are removed, the perineum is cleansed as indicated. A heat lamp may be directed to the perineal area to promote healing. The scrotum is protected with a towel while the heat lamp is in use. Sitz baths are also used to promote healing.
Urinary tract infections and epididymitis are possible com-plications after prostatectomy. The patient is assessed for their occurrence; if they occur, the nurse administers antibiotics as prescribed.
Because the risk for infection continues after discharge from the hospital, the patient and family need to be instructed to monitor for signs and symptoms of infection (fever, chills, sweats, myalgias, dysuria, urinary frequency, and urgency). The patient and family are instructed to contact the urologist if these symptoms occur.
Because patients undergoing prostatectomy have a high incidence of deep vein thrombosis (DVT) and pulmonary embolism, the physician may prescribe prophylactic (preventive) low-dose hep-arin therapy. The nurse assesses the patient frequently after surgery for manifestations of DVT and applies elastic compression stockings to reduce the risk for DVT and pulmonary embolism. The pa-tient who is receiving heparin must be closely monitored for excessive bleeding.
After a TUR, the catheter must drain well; an obstructed catheter produces distention of the prostatic capsule and resultant hem-orrhage. Furosemide (Lasix) may be prescribed to promote uri-nation and initiate postoperative diuresis, thereby helping to keep the catheter patent.
The nurse observes the lower abdomen to ensure that the catheter has not become blocked. An overdistended bladder pre-sents a distinct, rounded swelling above the pubis.
The drainage bag, dressings, and incisional site are examined for bleeding. The color of the urine is noted and documented; a change in color from pink to amber indicates reduced bleeding. Blood pressure, pulse, and respirations are monitored and com-pared with baseline preoperative vital signs to detect hypotension. The nurse also observes the patient for restlessness, cold sweats, pallor, any drop in blood pressure, and an increasing pulse rate.
Drainage of the bladder may be accomplished by gravity through a closed sterile drainage system. A three-way drainage system is useful in irrigating the bladder and preventing clot for-mation (Fig. 49-5). Continuous irrigation may be used with TUR. Some urologists leave an indwelling catheter attached to a dependent drainage system. Gentle irrigation of the catheter may be prescribed to remove any obstructing clots.
If the patient complains of pain, the tubing is examined. The drainage system is irrigated, if indicated and prescribed, to clear any obstruction. Usually, the catheter is irrigated with 50 mL of irrigating fluid at a time. The amount of fluid recovered in the drainage bag must equal the amount of fluid injected. Over-distention of the bladder is avoided because it can induce secondary hemorrhage by stretching the coagulated blood vessels in the prostatic capsule.
The nurse maintains an intake and output record, including the amount of fluid used for irrigation.
The drainage tube (not the catheter) is taped to the shaved inner thigh to prevent traction on the bladder. If a cystostomy catheter is in place, it is taped to the abdomen. The nurse explains the purpose of the catheter to the patient and assures him that the urge to void results from the presence of the catheter and from bladder spasms. He is cautioned not to pull on the catheter be-cause this causes bleeding and subsequent catheter blockage, which leads to urinary retention.
After the catheter is removed (usually when the urine appears clear), urine may leak around the wound for several days in pa-tients who have undergone perineal, suprapubic, and retropubic surgery. The cystostomy tube may be removed before or after the urethral catheter is removed. Some urinary incontinence may occur after catheter removal, and the patient is informed that this is likely to subside in time.
Depending on the type of surgery, the patient may experience sexual dysfunction related to erectile dysfunction, decreased libido, and fatigue. These issues may become a concern of the pa-tient soon after surgery or in the weeks to months during reha-bilitation. Erectile dysfunction may occur following prostate surgery. Several options to restore erectile function are discussed with the patient by the surgeon or urologist. These options may include medications, surgically placed implants, or negative-pressure devices. A decrease in libido may also occur following surgery and is usually related to the impact of the surgery on the man’s body. Reassurance that the usual level of libido will return following recuperation from surgery is often helpful to the patient and his partner. The patient may also experience fatigue during rehabilitation from surgery. This fatigue may also decrease his li-bido and alter his enjoyment of usual activities.
Nursing interventions include assessing for the presence of sexual dysfunction following surgery. Providing a private and confidential environment to discuss issues of sexuality is impor-tant. The emotional challenges of prostate surgery and its conse-quences need to be carefully explored with the patient and his partner. Providing the opportunity to discuss these issues can be very beneficial to the patient. For patients who demonstrate sig-nificant problems adjusting to their sexual dysfunction, a referral to a sex therapist may be indicated.
The patient undergoing prostatectomy may be discharged within several days. The length of the hospital stay depends on the type of prostatectomy performed. Patients undergoing a perineal prostatectomy are hospitalized for 3 to 5 days. If a retropubic or suprapubic prostatectomy is performed, the hospital stay is 5 to 7 days. The patient and family require instructions about how to manage the drainage system, how to assess for complications, and how to promote recovery. Verbal and written instructions are provided about the need to maintain the drainage system and to monitor urinary output, about wound care, and about strategies to prevent complications, such as infection, bleeding, and throm-bosis. They are informed about signs and symptoms that should be reported to the physician (eg, blood in urine, decreased urine output, fever, change in wound drainage, calf tenderness).
As the patient recovers and drainage tubes are removed, he may become discouraged and depressed because he cannot regain bladder control immediately. Moreover, urinary frequency and burning may occur after the catheter is removed. Teaching the following exercises may help the patient regain urinary control:
· Tense the perineal muscles by pressing the buttocks together; hold this position; relax. This exercise can be performed 10 to 20 times each hour while sitting or standing.
· Try to interrupt the urinary stream after starting to void; wait a few seconds and then continue to void.
Perineal exercises should continue until the patient gains full urinary control. The patient is instructed to urinate as soon as he feels the first urge to do so. It is important for the patient to know that regaining urinary control is a gradual process; he may continue to “dribble” after being discharged from the hos-pital, but the dribbling should gradually diminish (within up to 1 year). Lining underwear with absorbent pads can help to min-imize embarrassing stains on clothing. The urine may be cloudy for several weeks after surgery but should clear as the prostate area heals.
While the prostatic fossa heals (6 to 8 weeks), the patient should avoid activities that produce Valsalva effects (straining at stool, heavy lifting) because this increases venous pressure and may produce hematuria. He should avoid long motor trips and strenuous exercise, which increase the tendency to bleed. He should also know that spicy foods, alcohol, and coffee may cause bladder discomfort. The patient is cautioned to drink enough fluids to avoid dehydration, which increases the ten-dency for a blood clot to form and obstruct the flow of urine. Signs of complications, such as bleeding, passage of blood clots, a decrease in the urinary stream, urinary retention, or urinary tract infection symptoms, should be reported to the physician (Chart 49-3).
Referral for home care may be indicated if the patient is elderly or has other health problems, if the patient and family cannot provide care in the home, or if the patient lives alone without available supports. The home care nurse assesses the patient’s physical status (cardiovascular and respiratory status, fluid and nutritional status, patency of the urinary drainage system, wound and nutritional status) and provides catheter and wound care, if indicated. The nurse reinforces previous teaching and assesses the ability of the patient and family to manage required care. The home care nurse encourages the patient to ambulate and to carry out perineal exercises as prescribed. The patient may need to be reminded that return of bladder control may take time.
The patient is reminded about the importance of participat-ing in routine health screening and other health promotion ac-tivities. If the prostatectomy was performed to treat prostate cancer, the patient and family are also instructed about the im-portance of follow-up and monitoring with the physician.
Expected preoperative patient outcomes may include:
· Demonstrates reduced anxiety
· States that pain and discomfort are decreased
· Relates understanding of the surgical procedure and post-operative course and practices perineal muscle exercises and other techniques useful in facilitating bladder control
Expected postoperative patient outcomes may include:
1) Relates relief of discomfort
2) Exhibits fluid and electrolyte balance
a) Irrigation fluid and urinary output are within parame-ters determined by surgeon.
b) Experiences no signs or symptoms of fluid retention
3) Participates in self-care measures
a) Increases activity and ambulation daily
b) Produces urine output within normal ranges and con-sistent with intake
c) Performs perineal exercises and interrupts urinary stream to promote bladder control
d) Avoids straining and lifting heavy objects
4) Is free of complications
a) Maintains vital signs within normal limits
b) Exhibits wound healing, without signs of inflammation or hemorrhage
c) Maintains acceptable level of urinary elimination
d) Maintains optimal drainage of catheter and other drainage tubes
e) Reports understanding of changes in sexual function