NURSING PROCESS

I. ASSESSMENT
A. General Data

Patient’s Initials: J. C. N. Sex: Male

Address: Bacoor, Cavite Civil Status: Married
Age: 64 years old
No. of Days in this hospital: 1 day
Place of Birth: OAS Albay
Date of Admission: August 7, 2010
Order of Patient: Presently confined in St. Dominic Medical Center
Informant: Client himself
Date of History: September 7, 2010
Occupation: Retired Banko Sentral ng Pilipinas Employee

B. Chief Complaint
“Nahihirapan akong Umihi, nakascheduled na ako sa Pagpapaopera” as verbalized
by the patient

C. History of Present Illness

2 months prior to admission – The client is a known Benign Prostatic Hypertrophy and
is on maintenance of medication Tamsulosin of 200 mg and Dutasteride 500 mcg

2 days prior to admission- Client had check-up with AP. Client then advices for
transurethral resection of the prostrate (TURP). Hence scheduled and subsequently
admitted.
 D. Past History
1. Childhood Illness: Unrecalled

2. Adult Illness: Diabetes, Hypertension Stage II, Acute Coronary Heart syndrome

3. Immunization: Incomplete

4. Previous Hospitalization: May 12,2008 ( Cystitis)

5. Operations: Angioplasty (11years ago)

6. Injuries None
7. Medication taken prior to confinement: tamsulosin 200mg/tab and dutasteride 500
mcg
8. Allergies: None

E. Systems Review

1.) HEALTH PERCEPTION-HEALTH MANAGEMENT

Before the client was admitted for his upcoming cysto-transurethral resection of the
prostrate, the client had colds from the past two weeks. The client has a history of heart block
when he was young, experienced Acute coronary syndrome during 2008 and has undergone
angioplasty. The client is also hypertensive and Diabetic. The client is on maintenance of
aspirin 80 mg/tab O.D, leviteracetam(Keppra) 500 mg/tab O.D, Clopidogrel(Plavix) 75 mg,
Olmesartan 20 mg, amlodipine 5 mg, Lanoxin 0.25 mg/tab. Atorvastatin 40mg/tab, Galvusmet
50/850 mg. The client believes that adhering to his maintenance and following his
recommended diet is his way to keep himself healthy. The client believes that he got his present
illness because of his rapid increase of weight until he got obese and being diabetic aggravated
 his condition. Client was diagnosed of Benign Prostatic Hypertrophy since 2005 and was
advised for medications of tamsulosin 200mg/tab and dutasterid 500 mcg that hopefully would
be treated. But the client developed Cystitis last May 2010 until he recalled that he could he
feels intermittent pain while removing the catheter. He was then advised for transurethral
resection of the prostrate (TURP) last July but was not qualified enough because of his high
glucose levels. The client then prepared himself and reduced his diet for TURP on August.
Unfortunately, his doctor went out of town that delayed his operation up to this month. The
client stated that he has his monthly routine of check-up from his doctor at St. Dominic Medical
Center.

Presently, the patient is on Post-Operative Status from cysto- transurethral resection of

the prostrate. The client stated after the few hours of surgery upon waking up as “99.9%
success!” The client was cooperative and believes that the health care team had treated him
successfully. After wearing off of anesthesia from the client, he had usual complaints of pain
with a pain scale of 8/10. The client stated that he feels a uncomfortable with the pain if he is
not medicated that made him shriek in distress.

2.)NUTRITIONAL METABOLIC PATTERN

Before the client was admitted for his upcoming cysto-transurethral resection of the
prostrate, the client stated that he eats 3 times a day adhering on low-salt, low-fat and diabetic
diet. The client has no known allergies, and his favorite meal would be anything with coconut
milk and with some spices. The client stated that he drinks more than 10 glasses of water a day.
He recalled that his last meal was congee with boiled egg. No exces perspiration and foul odor,
has no difficulty on chewing and in dental problems. His wound heals normally as long as his
diabetes is controlled. The client is with BMI of 32.2 (normal value of= 18.5-24.9) indicating
obese. The client stated that he already had loss his weight this time. the client no longer recalled
his previous weight.

Presently, the client was NPO in the morning and has started eating with congee and boiled
egg during lunchtime with 3 pieces of grapes as dessert. The client consumes 750 ml of water
noted on our 6-12 morning shift last August 8, 2010.

3.)ELMINATION PATTERN
 Before the client was admitted for his upcoming cysto-transurethral resection of the
prostrate, the client urinates on his indwelling Foley catheter for almost 2 weeks. The client
stated that the catheter cannot be removed because he experiences intermittent pain with or
without doing anything. The client stated that he urinated in straw- colored urine. And has a
bowel movement of once a day in soft brown colored stool without difficulty and uses of
laxatives.

Presently, the client is 3-way indwelling Foley catheter with tubing attached on 6,000 ml
of Wilkins for cytoclysis .it was the client’s __ bottle. The client has reddish color of 5400 ml
drained on his urine bag and has no bowel movement noted on our 6-12 morning shift last
August 8, 2010.

4.)ACTIVITY & EXERCISE

Before the client was admitted for his upcoming cysto-transurethral resection of the
prostrate, the clients daily activity would be watching the television and sitting all day or would
sometimes takes a nap. The client would walk around their house early in the morning to
exercise himself.

Presently, the client is on bed-rest and feels pain below his abdomen with complaints of
pain when he tries to move his lower extremities.

5.)COGNITIVE-PERCEPTUAL

The client is conscious and coherent, oriented to time and day and with good sense of
humor. The client understands his prognosis and as well as his wife which is his care-taker. The
client is aware from the procedures that was carried out and cooperates as well harmoniously.
Presently, the client stated that he feels pain all the time, but he believes and is oriented that the
pain felt is initially normal after the surgery. The client is at ease at the knowledge and is looking
forward positively to recover soon.

6.)SLEEP/REST

Before the client was admitted for his upcoming cysto-transurethral resection of the
prostrate, the client sleeps late at night around 10:00 in the evening and wakes up around 7 or
 8:00 in the morning. The client stated that he watches the television at night to make him fall to
sleep, that he usually left the television on when he is dozed off. The client does not use any
sleeping pills. The client stated that he feels good upon waking up and feels rejuvenated. The
client stated that he had also quick naps in the afternoon, after taking his lunch which has been
his routine all day long.

Presently, client stated that his pain has given him light sleeps. He had interrupted sleeps
because of the discomfort felt, the monitoring of his condition. The client stated that taking pain-
relievers helped him put to sleep for at least several hours of without interruption. The client
stated that he still feels tired from the discomforts yet he has still with his good sense of humor.

7.)SELF-PERCEPTION-SELF CONCEPT

The client stated that he has few regrets regarding on his health presently. He stated that
if he was able to control himself from the external factors that have sent him to several
complications such as his vices, diet and lifestyle when he was young back then.

Presently, the patient stated that he is looking forward to be at home, and be with his
family. He stated that he would exert more efforts on exercise and continue on his diet since he
was advised by his family doctor to lose weight. The client stated that he is looking forward to
urinate without any use of an indwelling catheter and would watch movies in the cinema together
with his wife.

8.)ROLE-RELATIONSHIP

The Client is the 5th son of his parents, a father to his five children. He has three
daughters and two sons. the client is a senior citizen and a jolly grand-father. The client exhibits
good interpersonal relationship to his family. He stated that there are no family quarrels so far.
The client is a humorous person, that made gave them openness and good bonds. The client
stated that he decides on the facing family’s major decisions with the help of his wife. The client
stated that he muses with his present life, enjoying his retirement days.

9.)SEXUALITY-REPRODUCTIVE
 The patient is not sexually active and was circumcised at the age of 12. The client is
married with his wife for almost 40 years. The client displays intimate close relationship to his
wife. The client states that he depends most on her wife for taking care of him and in giving him
medication and her attention at him, since he tends to be forgetful. The client could be observed
Romantic, by observing him and his wife holding hands.

10.) COPING/STRESS TOLERANCE

The client stated that the major stresses in life that he have encountered is his present
condition, being diagnosed for benign prostatic hypertrophy, the client adheres to the
medications hopefully be treated without the use of invasive procedures, yet his condition
aggravated that he got cystitis making him difficult to urinate without the use of indwelling
catheter. The client stated that at first, he got weary from disrupting his dally activities and
staying for months with an indwelling catheter. The client stated that he got used to it eventually
and doesn’t depress much about it. He stated that he has a loving family and a caring wife who
always took care of him.

Presently, the client complains of severe pain and tenderness around the abdomen. The
client uses medications to help him tolerate the pain. The client would utter jokes and watch
television when he is awake to divert his attention.

11.) VALUES/BELIEFS

The Client is a Roman Catholic. The client is a Bicolano and loves food with coconut
milk and spices as what he got used to from his born province. The client stated that he barely
attends the church because of his health condition.

F. Family Assessment
 Name Relation Age Sex Occupation Educational
Attainment

Wife Wife 54 Female Housewife

Daughter Daughter 28 Female Med. Rep.

Daughter Daughter 27 Female Insurance

Company

Daughter Daughter 26 Female None

Son Son 22 Male None

Son Son 20 Male 4th year 4th year

college college

1st Grand Grand 1yr & 2mos Female None

Daughter Daughter

2nd Grand Grand 5 months Female None

Daughter Daughter

G. Heredo-Family Illness;
Maternal –
The Mother side of Patient’s JCN is known to have inherited illness of Cervical Cancer

Father-
The Father side of Patient’s JCN is known to be hypertensive, Diabetic and kidney diseases.
II. DEVELOPMENTAL HISTORY
Theorist Age Task
Erickson’s 30-65 years old
Psychosocial middle age Erikson's analysis of this stage
Development was strongly oriented towards
parenting. Generatively
potentially extends beyond
Generativity one's own children, and also to
vs.Stagnation all future generations, which
gives the model ultimately a
very modern globally
responsible perspective. Having
children is not a prerequisite for
Generativity, just as being a
parent is no guarantee that
Generativity will be achieved.
Caring for children is the
common Generativity scenario,
but success at this stage actually
depends on giving and caring -
putting something back into
life, to the best of one's
capabilities.
Stagnation is an extension of
intimacy which turns inward in
the form of self-interest and
self-absorption. It's the
disposition that represents
feelings of selfishness, self-
indulgence, greed, lack of
interest in young people and
future generations, and the
wider world.
Adults need to create or nurture
things that will outlast them,
often by having children or
creating a positive change that
benefits other people. Success
Patient Description
The client is presently
enjoying himself at his senior
years. The client is a retired
bangko snetral employee and
have earnings that he is
presently muses for. The
client is well established
from raising all his children
and now presently working
except for his youngest son
that will be graduating this
coming may. The client has 2
granddaughters that he is
very happy to see them while
he is still alive as he stated.
The client stated the he had
lived his life productively.
The client exhibits
generativity from Erickson’s
psychosocial development.
The client stated that he had
worked hard on his younger
years to have a stable life
upon his retirement. The
client raised his children well
and has himself two
granddaughters.
He stated that he doesn’t
have anything to ask for,
except to have longer life to
spend his golden years with
his beloved family.
 leads to feelings of usefulness
and accomplishment, while
failure results in shallow
involvement in the world.

I.) PHYSICAL EXAMINATION

REGIONAL EXAMINATION

A. SKIN
Brown skin, (-) Swelling, pitting edema, (-) Lessions, Intact skin turgor, Warm to touch,
Dark dry scaly skin on lower extremities

B. NAILS
(-)Clubbing, pink nail bed, smooth, firm, fingernails at 160 degrees angle.

C. HEAD AND FACE

Clear scalp,(-) parasites, Symmetrical and round head, smooth, firm, (-) Lesions,
presence of gray hairs, presence of grey facial hairs.

D. EYES
Pupils Equal, Round, Reactive to light and accommodation.
Blinking symmetrical, involuntary, transparent, smooth and moist cornea, presence of
arcus senilis

E. EARS
 In equal size, smooth, mastoid process easily palpated, (-) tenderness, warm,(-) Lessions,
(-) Discharges

F. NOSE
Solid placement, (-) nodules, (-) masses,(-)tenderness, (-) swelling. Color same as face,
smooth, symmetrical appearance, and no changes in nares with respiration. Pink mucosa,
moist without lesions. Nontender on palpation of sinuses

G. MOUTH AND PHARYNX

Pink lips, moist, smooth, (-) lesions of buccal mucosa, pink gums, moist smooth pink
tongue, pearly white teeth,(-) ulceration,(-) Redness,(-) swelling,

H. NECK
Smooth, controlled movements, Range of motion from upright position: Flexion = 45
Extension = 55 Lateral abduction = 40 Rotation = 70, thyroid in midline, cervical lymph
nodes not palpable.(-) tenderness,

I. SPINE
Not assessed

J. THORAX AND LUNGS

40 breathes per minute, Tachypneic, symmetrical expansion, (-) pain, (-) Tenderness.

K. CARDIOVASCULAR/ HEART
98 Beats per minute (Apical), regular. blood pressure of 130/90

L. BREAST
Symmetrical, (-) Tenderness,(-) Lessions,(-) Masses.

M. ABDOMEN
 Abdominal distention, Round (-) Rashes, (-) Lessions, Symmetrical, Smooth, (-)
Tenderness and rebound tenderness, (-) Masses

N. EXTREMETIES
Limited range of Full Range of Motion, (-) Tenderness, (-) Joint Pains, Equal in Size,

O. GENITALS
Three-way indwelling Foley catheter inserted between the scrotums for urination and
Cystoclysis. (-) Redness, (-) Lesions, (+) Drained Pinkish discharges of 5,400 ml.

P. RECTUM AND ANUS

Not assessed
Q. NEUROLOGICAL EXAM
Alert and awake, responds appropriately, relaxed posture, good eye contact; speech is
clear with moderate pace, smooth coordinate movements.

II.) PERSONAL / SOCIAL HISTORY

Habits: The patient has the habit of taking a nap in the afternoons, watch the television all
day.
Rank/Order in the family: 5th
Vices: The client stated that he is an occasional drinker and smokes minimally during at his
teenage years.
Travel: Unrecalled
Education Attainment: Bachelor of Fine Arts
Occupation: Retired Bangko Sentral employee
Social Affiliation: Senior Citizen’s Association
Client’s usual day like: Always at home watching television, taking naps during the
afternoons, talks with his relatives, silently pacing out himself on the environment or
sometimes looks after his grand children.
 Lifestyle: The patient has static lifestyle, sitting or laying all day. Interacting with his
relatives, watching movies or reading his news paper is his daily activity

III.) ENVIRONMENTAL HISTORY

The client lives together with his family composed of 9 house hold members. The two-
storey house with 209 square meters is owned by the patient residing near the highway.
The client narrated that it is a cemented house with 3 bedrooms and 3 bath room. The house
is fully ventilated and well lit of 8 windows on the first floor and 6 windows on the second
floor for the size of 2x2 meter. Their doors for about the size of 180X1 meter. The client
stated that their surroundings are well-sanitized. Their electricity supply comes from Meralco
and their water supply are from Deep well. They order Mineral water for drinking. The
client’s residence is advantageous, since it is near the public market, transportation, at school
and Hospital.

IV.) OB GYNE HISTORY (NOT APPLICABLE)

V.) PEDIATRIC HISTORY

MATERNAL AND BIRTH HISTORY

Birth date: November 25, 1945 Hospital: OAS Albay (Lying-Inn)

Birth weight: Unrecalled
Type of delivery: Normal Spontaneous Delivery
Condition after birth: In fine stable condition

Mother:
Complications of delivery: None
Anesthesia drug guring labor: Unrecalled
Exposure to Teratogenic Agents during Pregnancy: None

A. LABORATORY RESULT OR FINDINGS: (None)

I.) OTHER SOURCES OF INFORMATION

DRUG STUDY
 Drugs Name Indication Dosage Action Side Effect/ Nursing Patient Teachings
Adverse Effect Consideration

■ cefuroxime ■ Treatment of: ■ ■ Bind to CNS: seizures _Assess for _Instruct patient to
Respiratory tract bactrial cell wall (High doses). infection of take medication
infectios, skin and membrane, GI: wound,sputum, around the clock at
skin structure
causing cell Pseudomembran urine and stool evenly spaced times
infections, Bone and
joint infections, death. ous colitis, at beginning and to finish the
Urinary tract and Therapeutic diarrhea, nausea, and during medications
gynecologic effects: vomitting, theraphy completely
infections. Bactericidal cramps.
action. _Before _Advise patient to
Derm: rashes, initiating report signs of
Spectrum: urticaria, theraphy, obtain superinfection(furry
Similar of the Hemat: blood a history to overgrowth on the
first generation dyscrasias, determine tounge,vaginal
cephalosporins
hemolytic previous use of itching or
but have high
activity agains anemia. and reactions to discharge,loose or
other gram- penicillins or foul-smelling stools)
Local: pain at cephalosporins. and allergy
negative
pathogens. IM site, Persons with a
phlebitisat IV negative _Instruct patient to
site. sensitivity may notify health care
still have an professional if fever
Misc: Allergic and diarrhea develop,
reactions allergic
including response. esppecially if stool
anaphylaxis and contains blood,pus or
serum sickness, _Assess patient mucus.advise patient
superinfection for renal not to treat diarrhea
dysfunction and without consulting
adjust doe health care
accordingly. professional.
Monitor for
dose-related
adverse CNS
events.

_Observe
patient for signs
of and
 Drugs Name Indication Dosage Action Side Effect/ Nursing Patient Teachings
Adverse Effect Consideration

■ Tramadol ■ Moderate to ■ ■ Binds to mu- CNS: Seizzures, _Assess _ Instruct patient on

moderately severe opoid receptors. dizziness,headach type,location how and when to ask
pain Inhibits reuptake e,somnolence,anxi and intensity of for pain medication
of serotonin and ety, CNS pain before and _May cause dizziness
norephrine in the stimulation,confus 2-3 hr after and drowsiness.
CNS ion,coordination administration Caution patient to avoid
disturbance,eupho _Assess bowel driving or other
ria,malaise, function activities requiring
nervousness, sleep routinely. alertnessuntil
disorder, Prevention of responseto medication
weakness EENT: constipation of known
visual should be _Advise patient to
distrubances instituted with change position slowly
CV: vasodilation increase intake of to minimize orthostatic
GI: constipation, fluids and bulk hypotension
nausea, abdominal with laxatives to _Caution patient to
pain,anorexia, minimize avoid concurrent use of
diarrhea,dry constipating alcohol or other CNS
mouth,dyspepsia,f effects. depressants with
latulence, _Monitor thismedication
vomitting patient for _Encourage paiient to
GU: menopausal seizures. May turn, cough and breathe
symptoms, urinary occur in deeply every 2 hr to
retention/frequenc recommended prevent atelectais.
y Derm:pruritus, dose range.
sweating _Assess blood
Neuro: hypertonia pressure and
Misc: physical respiratory rate
dependence, before and
psychological periodically
dependence, during
administration.
tolerance
_Assess previous
analgesic history.
Tramadol is not
recommended for
patients
dependent on
opoids or who
have previously
received opoids
for more than 1
week.
_May cause
increase serum
 Drugs Name Indication Dosage Action Side Effect/ Nursing Patient Teachings
Adverse Effect Consideration

■Amlodipine ■Hypertension; ■5 mg 1 tab PO ■Inhibits influx ■palpitations ■Assess ■Teach patient to use
chronic stable angina; OD of calcium ion ■peripheral cardiorespirator as directed even if
vasospastic across cell edema y status: anginal feeling better; may be
(prinzmetal or variant) membranes to ■syncope pain, BP, pulse, taken with other
angina. produce ■tachycardia RR, ECG cardiovascular drugs
relaxation of ■bradycardia ■Assess (nitrate, beta blokers),
coronary ■arrhythmias hydration and food helps decrease
vascular smooth ■ventricular fluid volume stomach upset
muscle (dilation asystoles status: input and ■Advise patiet to
of coronary ■headache output ratio, avoid hazardous
arteries), ■dizziness presence of activities until
decrease ■lightheadednes edema, stabilized on drug and
peripheral s distended neck dizziness is no longer
vascular ■fatigue veins, lung a problem.
resistance of ■nausea crackles, ■Advise patient to
smooth muscle adequate pulses comply in all areas
(decrease blood and skin turgor of medical regimen:
pressure) and ■Monitor liver diet, exercise, stress
increases function: ALT, reduction, smoking
myocardial AST, bilirubin cessation and drug
oxygen delivery ■Monitor if therapy
in patient’s with platelet count is
vasospastic <150, 000/
angina mm3; drug is
usually
discontinued
and another
drug started.
 Drugs Name Indication Dosage Action Side Effect/ Nursing Patient Teachings
Adverse Effect Consideration

■Digoxin ■Chronic cardiac ■0.25 mg/ tab ■Inhibits ■Anorexia ■Obtain ■Teach patient to
failure with atrial OD sodium- patient’s history take medication at the
fibrillation, ventricular potassium ■GI disturbances of underlying same time each day,
dilation, activated
■CNS effects condition take missed doses
supraventricular adinosine
arrythmias. triphosphitase before therapy within 12 hrs and do
■atrial not double doses.
tachycardia ■Assess Notify physician if
patients and doses are missed for 2
■gynecomastia family’s days or more
knowledge of
drug therapy ■Advise patient to
maintain a sodium-
restricted diet and
potassium
supplements to
prevent toxicity
 Drugs Name Indication Dosage Action Side Effect/ Nursing Patient Teachings
Adverse Effect Consideration

■Clopidogrel ■75 mg PO OD ■Blocks ADP ■GI bleeding ■Assess for ■Advise patient that
■Reduction of receptors, which symptoms of blood work will
atherosclerotic events prevent ■purpura stroke, MI necessary during
(myocardial
infarction, stroke and fibrinogen ■bruising during treatment
vascular death) in binding at that treatment
site and thereby ■hematoma ■Instruct patiwnt to
patient’s with
atherosclerosis reduce the ■Monitor signs take drug as directed
documented by recent ■eye bleeding of bleeding; hct to the physician
possibility of
stroke, myocardial (mainly and hgb
platelet adhesion ■Advise patient to
infarction or conjunctival) periodically
and aggregation. that drug may impair
established peripheral
arterial disease. ■intracranial ■Monitor Liver ability to drive or
Treatment of patient’s bleeding functions operate machinery,
suffering from non- studies: AST, thus avid tasks that
ST segment elevation ■GI disturbances
ALT, bilirubin, require mental
acute coronary
■diarrhea creatinine if alertness
syndrome (unstable
angina or non- Q wave patient is on
■rash long term ■Advise patient to
MI) in combination
therapy; tell physician and
with aspirin. ■pruritus dentist that
thrombocytopen
ia, neutropenia clipidogrel is used
may occur before scheduled
surgery or dental
procedure

NURSING CARE PLAN

 Cues/Needs Nursing Rationale Goals and Interventions Rationale Evaluation
Diagnosis Objectives
Subjective: Impaired TURP is an At the end of 6 _Assess the wound, note _For comparative At the end of 6
“kakatapos lang tissue operation to hours of nursing color,texture,location,turgor and baseline hours of nursing
ng operasyon ko integrity remove some intervention, the vital signs intervention, the
sa sakit ko”as related to of an enlarged client will client wasable
verbalized by the to display
scraping of prostate gland. display behavior _Instruct the patient and _Reduces risk for
patient. behavior
enlarged TURP is changes to patient’s care giver to practice cross-contamination changes to
tissues of the performed promote healing aseptic technique for promote healing
Objective:
prostrate using a and prevent cleansing,dressing,medicating and prevented
>Facial grimace
from cysto- narrow, complications. lesions any
>Damaged
transurethral flexible, tube- complications
tissue
resection of like telescopic _Monitor laboratory studies _For changes
>3-way Foley
the prostate camera called indicative of healing or
Catheter
as evidenced an endoscope. infection/complications
inserted
by inserted The endoscope
between the
3-way Foley is inserted into _Promote optimum nutrition _To optimize healing
scrotum
Cather, your urethra with high quality protein and potential
>Drainage of
reddish (the tube that sufficient
reddish fluid
drainage carries urine calories,vitamins,mineral
from cystoclysis
from from the supplements _To limit metabolic
>Guarding
cystoclysis bladder and demands, maximize
behavior
and facial out through the _Encourage adequate periods of energy available for
grimace. penis). Your rest and sleep healing and meet
V.S
surgeon will comfort needs
BP: 130/90
then cut out
PR:98
and remove the _Promote early mobility if _To promote
RR:40
middle of your patient can tolerate. Assist with circulation and prevent
Temp: 38.3c
enlarged active/passive and assistive excessive tissue
prostate using exercises pressure
specially
adapted _Assess incision area for _These signs indicate
surgical redness,heat,induration,swelling,se possible infection
instruments. paration and drainage

Cues/Needs Nursing Rationale Goals and Interventions Rationale Evaluation

Diagnosis Objectives
Subjective: Acute pain Unpleasant At the end of 6 INDEPENDENT At the end of 6
“ Ang sakit ng related to sensory hours of nursing hours of nursing
sugat sa ari ko surgical and emotional intervention, the _ Obtain client’s assessment of _For future baseline intervention, the
at sa tyan ko” as experience pain to include location, comparison. client reported
procedure of client will report
verbalized by arising characteristics, onset / duration, alleviation of
the patient cysto-TURP from actual or alleviation of
frequency, quality, intensity, and pain from pain
as evidenced potential tissue pain from the
 Cues/Needs Nursing Diagnosis Rationale Goals and Interventions Rationale Evaluation
Objectives
Subjective: Impaired Urinary Benign prostatic After 2-3 days of Independent: After 2-3
Elimination hyperplasia (BPH) refers Nursing days of
“Ilang buwan na related to to the increase in size of Intervention, The _Review results of _To identify Nursing
akong presence of the prostate in middle- patient will diagnostic studies presence/ type intervention,
nakacathether indwelling aged and elderly men. It is establish normal of elimination the patient
dahil sa hirap catheter induced characterized by urinary problem achieved
akong maka-ihi” by hyperplasia of hyperplasia of elimination as _Encourage fluid normal urine
as verbalized by _Prevents
prostrate prostatic stromal and epith manifested by intake up to 3000 or infection and elimination
the patient obstructing the elial cells, resulting in the absence of ml/day within cardiac as manifested
formation of
>Stated that he urethra that formation of large, fairly Dysuria, Polyuria tolerance Including urinary stones by absence of
hadurinating causes pain as discrete nodules in the and and absence cranberry juice to help dysuria,
with the use of evidenced by periurethral region of the of indwelling maintain renal function Polyuria and
an indwelling dysuria, polyuria prostate. cathether. and of
_Check frequently for _To reduce
catheter for3 and presence of indwelling
When sufficiently large, bladder distention and risk of infection
months indwelling cathether.
the nodules compress observe for overflow. and autonomic
Objective: catheter.
the urethral canal to cause hyperreflexia
>Presence of 3- partial, or sometimes
way Foley virtually complete, _Emphasize
catheter obstruction of the urethra, importance of keeping _To reduce
>Dysuria which interferes the area of skin clean and infection or
>(+) from benign normal flow of urine. It dry Skin Breakdown
prostatic
leads to symptoms of
hypertrophy
>Polyuria urinary hesitancy,
frequent urination, dysuria
_Discuss possible _To reduce
V.S (painful urination),
dietary restrictions risk of infection
BP: 130/90 increased risk of urinary
especially coffee
PR:98 tract infections,
RR:40 ,alcohol, carbonated
and urinary retention
Temp: 38.3c drinks, citrus, tomatoes
and chocolates.
_Instruct to wipe the _ To prevent
area from front to back risk of infection
and take showers and further
rather than tub baths contamination

_Maintain an acidic _To discourage

environment of the bacterial
bladder by the use of growth.
agents such as Vit.C,
Mandelamine (a
urinary antiseptic)
when appropriate

Dependent:

_To provide
_Administer pharmacological
prescribed drugs relief and
hastens patient’s
recovery

Collaborative:

_Refer to Medical
_To determine
Technician for
effectiveness of
diagnostics
drug therapy.
examinations
Ongoing appraisal

The 64 year old client was a known case of Benign Prostatic Hypertrophy since 2005
was advised to medicate tamsulosin 200mg/tab and dutasterid 500 mcg to hopefully be
treated without the use of invasive procedures, no complications was known of until May
2010, the client was confined upon the diagnosis of Cystitis. Afterwards, the client was
confined for difficulty of urinating and pain, thereby confined. An indwelling catheter was
used for several months because the pain would persist upon removal. The client then was
advised for cysto-transurethral resection of the prostate but was delayed due to his high
glucose levels. The client in preparation for preparation of surgery modified his diet to lose
weight and was rescheduled for September 6, 2010 around 9:51 pm for the client’s surgery
on September 7, 2010 at 12:00 noon.

The client was admitted on September 6, 2010 with vital signs of (BP: 110/80, PR: 87,
RR: 17 Temp: 36.2c) for cysto-TURP. The client was asked for consent, clearance, and to
secure 14 bottles of 6,000 ml of Wilkins. The client was infused of D5LR 1L x 30 gtts/min.
the client ‘s medications from the doctor’s order is Clopidogrel 75 mg 1 tab PO OD,
Amlodipine 5mg 1 Tab PO OD, Digoxin 0.25 1 tab PO OD, Atorvastatin 40 mg ½ tab PO
OD, Leviteracatam 500 mg I tab PO OD, Vidaglipitin + Metformin (Galvusmet) 50/850 mg
PO, Glimeperide 1 mg PO OD.

September 7, 2010. The client is on NPO with D5Lr 1L x 30gtts/min infusing well. With
vital signs of (BP: 110/80, PR: 68, RR:22 Temp: 36c) taken around 12 noon prior to
transferring to the operating room. The surgery started around 12:35 pm and ended 1:05 pm.
The client is with 3-way Foley Catheter for cytolysis draining in bloody fluid. The client is
with oxygen inhalation via nasal cannula at 2 liters per minute. The client was given
Keterolac and infused with D5LR 1 LX30 gtts/min. with vital signs of (BP: 110/80, PR:10,
RR: 20 Temp: 36c) under Q15. Afterwards, client’s blood pressures increase to 140/90 with
increased respiratory rate and pulse rate. The client experienced episodes of fever and was
stabilized in the evening. The client complained of pain with pain scale of 8/10.

Presently, the client remains NPO and just received his meal during lunchtime. The
client is on PNSS 1L X 12 h infusing well on his left hand, with CBG monitored every 6
hours on Diabetic diet and monitoring Vital signs every 2 hours. The client is febrile and
tachypneic, complains of pain with pain scale of 8/10 and medicated with Tramadol 50mg
every 8 hours. The client is on 9th galloon of Wilkins for his Cystoclysis drained 5,400 ml in
reddish color. Client’s latest vital signs were (BP: 130/90, PR: 98, RR: 40, Temp: 38.3). the
client’s present medication are Cefuroxime 500mg 1 tab, BID, Amlodipine 5mg 1 tab PO
OD, Digoxin 0.25 mg PO OD, Clopidogrel 75 mg PO OD, Leviteracetam 500mg 1 tab PO
OD. Temporarily withholding the rest of his medications.
B. Discharge Plan

• Medication

 Instruct patient to take medication around the clock and to finish the drug
completely and to finish the drug completely as directed, even if feeling better.
Advise patients that sharing of this medication may be dangerous

 Instruct the patient’s parents pr caregivers to administer medication after meals

for better absorption and to reduce gastri intestinal discomfort.

• Exercise

 Encourage client to participate in morning exercise. Promote client for daily

routine of exercise within client’s capability and interest.

• Health Education

 Instruct client to avoid from strenuous activities, constipation and sexual activities
Following after cysto-TURP

• ODP Follow-up

 Encourage and emphasize the importance of the patient’s follow-up check up for
continuous care and determine effectiveness of treatment.

• Diet

 Encourage client to continuously adhere in low-salt and low-fat diet.

 Encourage client to increase fluid and bulk intake , Constipation must be avoided
following after cysto-TURP.
  Encourage client to adhere on Diabetic diet, to maintain client’s glucose levels

• Signs and Symptoms

 Instruct client to notify health care professional if symptoms of Benign Prostatic

Hypertrophy such as nocturia, dysuria, polyuria, and urgency persist