Medical Surgical Nursing

Chapters 44 and 45).
Providing Instruction
Before surgery, the nurse reviews with the patient the anatomy of the affected
structures and their function in relation to the urinary and reproductive systems, using
diagrams and other teaching aids if indicated. This instruction often takes place during
the preadmission testing 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 type of prostatectomy planned). The nurse also describes the type
of incision, which varies with the 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), and informs the patient about the likely type of urinary
drainage system, the type of anesthesia, and the recovery room procedure. The
amount of information given is based on the patient's needs and questions. The nurse
explains procedures expected to occur during the immediate perioperative period,
answers questions the patient or family may have, and provides emotional support. In
addition, the nurse provides the patient with information about postoperative pain
management.
Preparing the Patient
If the patient is scheduled for a prostatectomy, the preoperative preparation described
in Chapter 18 is provided. Elastic compression stockings are applied before surgery
and are particularly important for prevention of deep vein thrombosis (DVT) if the
patient is placed in a lithotomy position during surgery. An enema is usually
administered at home on the evening before surgery or on the morning of surgery to
prevent postoperative straining, which can induce bleeding.
Postoperative Nursing Interventions
Maintaining Fluid Balance
During the postoperative period, the patient is at risk for imbalanced 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 of 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 whether irrigation
fluid is being retained and to ensure an adequate urine output. An intake and output
record, including the amount of fluid used for irrigation, must be maintained. The
patient also is monitored for electrolyte imbalances (eg, hyponatremia), increasing
blood pressure, confusion, and respiratory distress. These signs and symptoms are
documented and reported to the surgeon. The risk of fluid and electrolyte imbalance is
greater in elderly patients with preexisting cardiovascular or respiratory disease.
Relieving Pain
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 morning, he is assisted to ambulate. If pain is
present, the cause and location are determined and the severity of pain and discomfort
is assessed. The pain 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 caused by 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 ease the spasms, which can be
intermittent and severe; these medications include flavoxate (Urispas) and oxybutynin
(Ditropan). Warm compresses to the pubis or sitz baths may also relieve the spasms.