Medical Surgical Nursing

The nurse monitors the drainage tubing and irrigates the system as prescribed to
relieve any obstruction that may cause discomfort. 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 decrease tension 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.
After the patient is ambulatory, he 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
administered with caution to avoid rectal perforation.
Monitoring and Managing Potential Complications
After prostatectomy, the patient is monitored for major complications such as
hemorrhage, infection, DVT, catheter obstruction, and sexual dysfunction.
Hemorrhage
The immediate dangers after a prostatectomy are bleeding and hemorrhagic shock.
This risk is increased with BPH, because a hyperplastic 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 viscosity and numerous clots usually indicates arterial
bleeding. Venous blood appears darker and less viscous. Arterial hemorrhage usually
requires surgical intervention (eg, suturing 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 securely taping the catheter to the
patient's thigh if hemorrhage occurs.
Nursing management includes assistance in implementing strategies to stop the
bleeding and to prevent or reverse hemorrhagic shock. If blood loss is extensive,
fluids and blood component therapy may be administered. If hemorrhagic shock
occurs, treatments described in Chapter 15 are initiated.
Nursing interventions include closely monitoring vital signs; administering
medications, IV fluids, and blood component therapy as prescribed; maintaining an
accurate record of intake and output; and carefully monitoring drainage to ensure
adequate urine flow and patency of the drainage system. The patient who experiences
hemorrhage and his family are often anxious and benefit from explanations and
reassurance about the event and the procedures that are performed.
Infection
After perineal prostatectomy, the surgeon usually changes the dressing on the first
postoperative day. Further dressing changes may become the responsibility of the
nurse or home care nurse. Careful aseptic technique is used, because the potential 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 because of the risk of
injury 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.