Introduction
It's said one knows not what he has until it is gone, This common proverb can be applied to the processes involved with Transurethral resection of the prostate( TURP). TURP is done to treat or alleviate "enlargement of the prostate gland (benign prostatic hyperplasia)" (mayoclinic.com, 1). The prostate is situated near the urinary bladder in an adult male. When a person urinates, urine flows from the bladder, through the prostate gland, then the urethra which is enclosed within the penile shaft, leading to the destination. When this process is interrupted, in this case by an enlarged prostate gland blocking the exit out of the bladder; it can cause various urinary tract symptoms. These symptoms can vary from difficulty urinating, to urinary urgency, nocturia, oliguria, urinary retention and others. If these symptoms are intense, a TURP procedure is recommended by the physician as a minimally invasive method of alleviating them
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Nursing Process of Transurethral Resection of the prostate
It's said one knows not what he has until it is gone, This common proverb can be applied to the processes involved with Transurethral resection of the prostate( TURP). TURP is done to treat or alleviate "enlargement of the prostate gland (benign prostatic hyperplasia)" (mayoclinic.com, 1). The prostate is situated near the urinary bladder in an adult male. When a person urinates, urine flows from the bladder, through the prostate gland, then the urethra which is enclosed within the penile shaft, leading to the destination. When this process is interrupted, in this case by an enlarged prostate gland blocking the exit out of the bladder; it can cause various urinary tract symptoms. These symptoms can vary from difficulty urinating, to urinary urgency, nocturia, oliguria, urinary retention and others. If these symptoms are intense, a TURP procedure is recommended by the physician as a minimally invasive method of alleviating them. One does not think of what it entails to actually be able to get the urge to urinate and do so with ease. The pleasure of this almost automatic process has been taken away from clients with benign prostatic hyperplasia, leading to the need for a TURP. This explains the concepts of "not knowing what one has till it's gone" or severely made problematic. A nurse comes into play in this process by using the nursing process of assessment, nursing diagnosis, goals, intervention and evaluation to manage the client through the entire course of treatment. That is the nurse follows the patient from preoperative to Post operative while diligently providing care and teaching. Preventing complications of TURP post operatively is a major part of the procedure, as this determines the success of such procedure. In reference to complication after TURP, Weaver 2001 stated that "prevention must start long before the patient is admitted into the hospital" (p. 1). The nurse needs to ask if the patient recently took Coumadin, Aspirin or any NSAIDs few days before the procedure. These drugs affects blood coagulation and they must have being stopped several days ago before to prevent hemorrhage. Weaver further explained that Coumadin should be discontinued 3-7 days before TURP and patient must have stop taking Aspirin for at least 10 days before (p. 1). During postoperative care, the nurse needs to assess the patient's indwelling catheter for patency continuously. The content of the bag must also be checked. This is because "a change in the urine color and consistency is the first clue to active bleeding."(Weaver 2001, p. 2) The patient's vital signs need to be checked at regular intervals to detect any changes which could be related to bleeding and infection. Particular attention need to place on the patient's laboratory values because a low white blood cell count could also show sign for infection. The patient's input and output must also be assessed due to the continuous bladder irrigation (CBI). After the removal of the catheter, the nurse should assess the patient's urine and explain to the patient that some tingling or burning might be felt and that this is normal. Gilhurst (2006) notes that TURP "...is used for approximately 90% of prostate surgery and that it is considered the 'gold standard'". Although TURP is such a high quality procedure, it is not without its risks. Nurses need to diagnose quickly to prevent further complications or mortality in patients. With this invasive procedure, along with catherization, patients are at high risk for infection. Fluid volume defect, as a result of hemorrhage, is another major diagnosis of concern. Patients doing this procedure would usually exhibit disturbed body image and knowledge deficit, although this varies by individual. The expected goals for TURP are that the patient would not experience TURP syndrome, the patient would not exhibit signs of hemorrhage, the catheter's patency would be maintained without complication, the patient would verbalizes an understanding of the procedure and its desirable / undesirable effect. The nurse should ensure that the patient receives thorough discharge teaching. According to Ng (2004) "continuous bladder irrigation (CBI) is an established procedure designed to prevent the formation and retention of blood clots following transurethral prostatectomy (TURP)." (p . 97). This continuous irrigation is established by the use of a three-way Foley catheter. The nurse is responsible for the management of the Foley catheter's patency. To ensure that patency is maintained, continuous assessment and early detection is implemented. It is the nurse's duty to assess the saline irrigations height, volume remaining, and fluid level in the drip chamber. An assessment of the drainage bag for the amount, consistency and the color of the drainage is a necessary intervention in assuring efficiency of the procedure and in alerting to the development of any complications. Ng 2004 listed a few other interventions in the maintaining of catheter patency which include "assess for kinking, traction, and leakage; adjust the clamps to ensure continuous flow rate; and continuously check fluid balance/ bladder irrigation." (p . 98). After a thorough assessment, if blockage is suspected the nurse is to intervene. As stated by Ng 2004 to unblock the catheter the nurse's intervention should be to, "reassure the patient and explain the procedure, turn off the bladder irrigation system; milk the tubing; observe drainage; and assess for a decrease in the patient's level of discomfort." (p . 101). "The most common complication after TURP is hemorrhage", with this in mind the nursing interventions should include checking the patient's vital sign monitoring every four hours (Wasson 2004, p . 5). The color and consistency of the urine should also be checked at two hours interval. "Instruct the patient to remain flat or at a slight incline immediately post-operatively, because sitting may increase venous and bladder pressure causing bleeding," (Wasson 2004, p . 5). While in the hospital, the nurse should inform the physician if there is an increase in the rate of bleeding, and of any drastic change in vital signs. Hypovolemia is a risk factor of extensive bleeding and the nurse should be prepared to intervene with replacements of intravenous fluids and blood products. According to Wasson 2004, the nurse should "instruct the patient to drink at least 12 glasses of water per day and to avoid the use of alcohol, caffeinated beverages, and spicy foods that may over-stimulate the bladder" (p . 5). Another serious TURP related complication is known as TURP syndrome" (Wasson 2004, p. 4). TURP syndrome is described to be "an abnormal vascular absorption of irrigating fluid during surgery which causes severe dilutional hyponatemia and hypervolemia" (Wasson 2004, p . 4). Nursing interventions aimed at preventing TURP syndrome include careful assessment of its symptoms which include; bradycardia, confusion, full bonding pulses, dramatic increase in blood pressure, tachypnea, and temporary blindness. Discharge teaching is important in making certain that TURP is efficient in resolving the patient's condition. The patient should be advised to keep a log of voiding and record the volume of urine, its characteristics, and the frequency. Strenuous activities such as climbing stairs should be avoided during the first few weeks after discharge. The patient should also be encouraged to rest regularly for approximately two to six weeks; this promotes healing of the surgical site. Activity restrictions that enables healing also includes, avoidance of lifting items weighing over five pounds, avoidance of excessive physical exertion, and long walks.
Conclusion
The patient should be taught by the nurse to notify the physician, if bleeding occurs and does not stop within one hour of therapy. A high fiber diet is encouraged during discharge teaching making sure to emphasize that his helps prevent constipation. Also thorough perineal hygiene should be stressed and the patient should be taught that it reduces the risk for infection. Patients should be advised to take antibiotics and any other medication as prescribed by the physician. Teaching kegal exercises is another important nursing intervention as it strengthens the pelvic floor muscles. After the intervention, the nurse will do an evaluation in order to find out if the goal has been achieved and to see if the patient is progressing as planned. The nurse should reassess the patient to ensure that he or she did not experience TURP syndrome, hemorrhage and any other complications previously mentioned. The effectiveness of the patient teaching should be reassessed, the more knowledgeable the patient is about steps to be taken, the greater the probability that the patient will comply. This may help the patient in taking proper care of themselves after discharge and also prevent complications. Therefore, nursing intervention always help the patient to get positive outcomes. (Wasson 2003, p. 12) As with the fore mentioned proverb, having the need or feeling of urinating, or even the ability to go to the bathroom and successfully relieve the pressure created by a full bladder is a gift. A gift that when gone or almost gone as with oliguria or anuria, and then regained with TURP one would realize it value, and develop a brand new appreciation for the process
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