Definition
Prostatectomy is the surgical removal of the prostate wherein the procedure could include all (radical) or part (simple). Prostatectomy is indicated in the treatment of benign prostatic hyperplasia while radical prostatectomy is indicated in the treatment of prostate cancer.
- Transurethral resection of the prostate (TURP): Obstructive prostatic tissue of the medial lobe surrounding the urethra is removed by means of a cystoscope/resectoscope introduced through the urethra.
- Suprapubic/open prostatectomy: Indicated for masses exceeding 60 g (2 oz). Obstructing prostatic tissue is removed through a low midline incision made through the bladder. This approach is preferred if bladder stones are present.
- Retropubic prostatectomy: Hypertrophied prostatic tissue mass (located high in the pelvic region) is removed through a low abdominal incision without opening the bladder. This approach may be used if the tumor is limited.
- Perineal prostatectomy: Large prostatic masses low in the pelvic area are removed through an incision between the scrotum and the rectum. This more radical procedure is done for larger tumors/presence of nerve invasion and may result in impotence.
Nursing Priorities
- Maintain homeostasis and hemodynamic stability.
- Promote comfort.
- Prevent complications.
- Provide information about surgical procedure, prognosis, treatment, and rehabilitation needs.
Discharge Goals
- Urinary flow restored or enhanced.
- Pain relieved/controlled.
- Complications prevented/minimized.
- Procedure/prognosis, therapeutic regimen, and rehabilitation needs understood.
- Plan in place to meet needs after discharge.
Impaired Urinary Elimination
May be related to
- Mechanical obstruction: blood clots, edema, trauma, surgical procedure
- Pressure and irritation of catheter/balloon
- Loss of bladder tone due to preoperative overdistension or continued decompression
Possibly evidenced by
- Frequency, urgency, hesitancy, dysuria, incontinence, retention
- Bladder fullness; suprapubic discomfort some have used prostagenix to support this but it isn’t everyone.
Desired Outcomes
- Void normal amounts without retention.
- Demonstrate behaviors to regain bladder/urinary control.
| Nursing Interventions | Rationale |
|---|---|
| During bladder irrigation, assess urine output and drainage system. | Retention can occur because of edema of the surgical area, blood clots, and bladder spasms. |
| Assist patient to assume normal position when voiding. Instruct to stand, walk to the bathroom at frequent intervals after catheter is removed. | Promotes sense of normality and encourages passage of urine. |
| Regularly check the dressing, incision and drainage for excessive bleeding. Watch out for signs of bleeding and infection. | Reopening of sutures can occur. |
| Record time, amount of voiding, and size of stream after catheter is removed. Note reports of bladder fullness, inability to void, urgency. | The catheter is usually removed 2–5 days after surgery, but voiding may continue to be a problem for some time because of urethral edema and loss of bladder tone. |
| Encourage patient to void when urge is noted but not more than every 2–4 hr per protocol. | Voiding with urge prevents urinary retention. Limiting voids to every 4 hr (if tolerated) increases bladder tone and aids in bladder retraining. |
| Measure residual volumes via suprapubic catheter, if present, or with Doppler ultrasound. | Monitors effectiveness of bladder emptying. Residuals more than 50 mL suggest need for continuation of catheter until bladder tone improves. |
| Encourage fluid intake to 3000 mL as tolerated. Limit fluids in the evening, once catheter is removed. | Maintains adequate hydration and renal perfusion for urinary flow. Reducing fluid intake at the right schedule decreases the need to void and interrupt sleep during the night. |
| Instruct patient to perform perineal exercises: tightening buttocks, stopping and starting urine stream. | Helps regain control of the bladder, sphincter, or urinary control and minimizes incontinence. |
| Advise patient that “dribbling” is to be expected after catheter is removed and should resolve as recuperation progresses. | Information helps patient deal with the problem. Normal functioning may return in 2–3 wk but can take up to 8 mo following perineal approach. |
| Maintain continuous bladder irrigation (CBI), as indicated, in early postoperative period. | Flushes bladder of blood clots and debris to maintain patency of the catheter and urine flow. |
Risk for Deficient Fluid Volume
Risk factors may include
- Vascular nature of surgical area; difficulty controlling bleeding
- Restricted intake preoperatively
- Postobstructive diuresis
Possibly evidenced by
- Not applicable. A risk diagnosis is not evidenced by signs and symptoms, as the problem has not occurred and nursing interventions are directed at prevention.
Desired Outcomes
- Maintain adequate hydration as evidenced by stable vital signs, palpable peripheral pulses, good capillary refill, moist mucous membranes, and appropriate urinary output.
- Display no active bleeding.
| Nursing Interventions | Rationale |
|---|---|
| Monitor I&O. | Indicator of fluid balance and replacement needs. With bladder irrigations, monitoring is essential for estimating blood loss and accurately assessing urine output. Note: Following release of urinary tract obstruction, marked diuresis may occur during initial recovery period. |
| Monitor vital signs, noting increased pulse and respiration, decreased BP, diaphoresis, pallor, delayed capillary refill, and dry mucous membranes. | Dehydration or hypovolemia requires prompt intervention to prevent impending shock. Note: Hypertension, bradycardia, nausea and vomiting suggests “TURP syndrome,” requiring immediate medical intervention. |
| Investigate restlessness, confusion, changes in behavior. | May reflect decreased cerebral perfusion (hypovolemia) or indicate cerebral edema from excessive solution absorbed into the venous sinusoids during TUR procedure (TURP syndrome). |
| Encourage fluid intake to 3000 mL/day unless contraindicated. | Flushes kidneys and/or bladder of bacteria and debris (clots). Note: Water intoxication or fluid overload may occur if not monitored closely. |
| Anchor catheter, avoid excessive manipulation. | Movement or pulling of catheter may cause bleeding or clot formation and plugging of the catheter, with bladder distension. |
| Observe catheter drainage, noting excessive or continued bleeding. | Bleeding is not unusual during first 24 hr for all but the perineal approach. Continued heavy bleeding or recurrence of active bleeding requires medical evaluation and prompt interventions. |
| Evaluate color, consistency of urine | |
| Bright red with bright red clots. | Usually indicates arterial bleeding and requires aggressive therapy. |
| Dark burgundy with dark clots, increased viscosity. | Suggests the most common type of bleeding: venous source. Usually subsides on its own. |
| Bleeding with absence of clots. | May indicate blood dyscrasias or systemic clotting problems. |
| Inspect dressings and wound drains. Weigh dressings if indicated. Note hematoma formation. | Bleeding may be evident or sequestered within tissues of the perineum. |
| Avoid taking rectal temperatures and use of rectal tubes/enemas. | May result in referred irritation to prostatic bed and increased pressure on prostatic capsule with risk of bleeding. |
| Monitor laboratory studies as indicated: | |
| Hb/Hct, RBCs; | Useful in evaluating blood losses or replacement needs. |
| Coagulation studies, platelet count. | May indicate developing complications: depletion of clotting factors, DIC. |
| Administer IV therapy or blood products as indicated. | May need additional fluids, if oral intake inadequate, or blood products, if losses are excessive. |
| Maintain traction on indwelling catheter; tape catheter to inner thigh. | Traction on the 30-mL balloon positioned in the prostatic urethral fossa creates pressure on the arterial supply of the prostatic capsule to help prevent and control bleeding. |
| Release traction within 4–5 hr. Document period of application and release of traction, if used. | Prolonged traction may cause permanent trauma or problems with urinary control. |
| Administer stool softeners, laxatives as indicated. | Prevention of constipation and/or straining for stool reduces risk of rectal-perineal bleeding. |
Risk for Infection
Risk factors may include
- Invasive procedures: instrumentation during surgery, catheter, frequent bladder irrigation
- Traumatized tissue, surgical incision (e.g., perineal)
Possibly evidenced by
- Not applicable. A risk diagnosis is not evidenced by signs and symptoms, as the problem has not occurred and nursing interventions are directed at prevention.
Desired Outcomes
- Experience no signs of infection.
- Achieve timely healing.
| Nursing Interventions | Rationale |
|---|---|
| Maintain a sterile catheter system. Provide regular catheter and meatal care with soap and water. Apply antibiotic ointment around the catheter site. | Measures to prevent introduction of bacteria that may cause infection or sepsis. |
| Ambulate with drainage bag dependent. | Avoids backward reflux of urine, which may introduce bacteria into the bladder. |
| Monitor vital signs, noting low-grade fever, chills, rapid pulse and respiration, restlessness, irritability, disorientation. | Patient who has had cystoscopy and/or TURP is at increased risk for surgical or septic shock related to manipulation and instrumentation. |
| Observe drainage from wounds, around suprapubic catheter. | Presence of drains, suprapubic incision increases risk of infection, as indicated by erythema, purulent drainage. |
| Change dressings frequently (suprapubic or retropubic and perineal incisions), cleaning and drying skin thoroughly each time. | Wet dressings cause skin irritation and provide media for bacterial growth, increasing risk of wound infection. |
| Use ostomy-type skin barriers. | Provides protection for surrounding skin, preventing excoriation and reducing risk of infection. |
| Administer antibiotics as indicated. | May be given prophylactically because of increased risk of infection with prostatectomy. |
Acute Pain
May be related to
- Irritation of the bladder mucosa; reflex muscle spasm associated with surgical procedure and/or pressure from bladder balloon (traction)
Possibly evidenced by
- Reports of painful bladder spasms
- Facial grimacing, guarding, restlessness
- Autonomic responses
Desired Outcomes
- Report pain is relieved/controlled.
- Appear relaxed, sleep/rest appropriately.
- Demonstrate use of relaxation skills and diversional activities as indicated for individual situation.
| Nursing Interventions | Rationale |
|---|---|
| Assess pain, noting location, characteristic, intensity (0–10 scale). | Sharp, intermittent pain with urge to void or passage of urine around catheter suggests bladder spasms, which tend to be more severe with suprapubic or TUR approaches (usually decrease by the end of 48 hr). |
| Maintain patency of catheter and drainage system. Keep tubings free of kinks and clots. | Maintaining a properly functioning catheter and drainage system decreases risk of bladder distension and/or spasm. |
| Promote intake of up to 3000 mL/day as tolerated. | Decreases irritation by maintaining a constant flow of fluid over the bladder mucosa. |
| Give patient accurate information about catheter, drainage, and bladder spasms. | Allays anxiety and promotes cooperation with necessary procedures. |
| Provide comfort measures. Position changes, back rubs, and diversional activities. Encourage use of relaxation techniques, including deep-breathing exercises, visualization, guided imagery. | Reduces muscle tension, refocuses attention, and may enhance coping abilities. |
| Provide sitz baths or heat lamp if indicated. | Promotes tissue perfusion and resolution of edema, and enhances healing (perineal approach). |
| Administer antispasmodics: | |
| Oxybutynin (Ditropan), flavoxate (Urispas), B & O suppositories; | Relaxes smooth muscle to provide relief of spasms and associated pain. |
| Propantheline bromide (Pro-Banthîne). | Relieves bladder spasms by anticholinergic action. Usually discontinued 24–48 hr before anticipated removal of catheter to promote normal bladder contraction. |
Risk for Sexual Dysfunction
Risk factors may include
- Situational crisis (incontinence, leakage of urine after catheter removal, involvement of genital area)
- Threat to self-concept/change in health status
Possibly evidenced by
- Not applicable. A risk diagnosis is not evidenced by signs and symptoms, as the problem has not occurred and nursing interventions are directed at prevention.
Desired Outcomes
- Report understanding of sexual function and alterations that may occur with surgery in individual situation.
- Discuss concerns about possible changes in body image, sexual functioning with partner/SO and caregiver.
- Demonstrate problem-solving skills regarding solutions to problems that occur.
| Nursing Interventions | Rationale |
|---|---|
| Give opportunities or openings for patient and SO to talk about concerns of incontinence and sexual functioning. | May have anxieties about the effects of surgery and may be hesitant about asking necessary questions. Anxiety may have affected ability to access information given previously. |
| Discuss basic anatomy. Be open and honest in answers to patient’s questions. | The nerve plexus that controls erection runs posteriorly to the prostate through the capsule. In procedures that do not involve the prostatic capsule, impotence and sterility usually are not consequences. Surgical procedure may not provide a permanent cure, and hypertrophy may recur. |
| Give accurate information about expectation of return of sexual function. | Physiological impotence occurs when the perineal nerves are cut during radical procedures; with other approaches, sexual activity can usually be resumed in 6–8 weeks Note: Penile prosthesis may be recommended to facilitate erection and correct impotence following radical perineal procedure. Another option that may restore the ability to have an erection is the use of sildenafil citrate (Viagra). |
| Discuss retrograde ejaculation if transurethral or suprapubic approach is used. | Seminal fluid goes into the bladder and is excreted with the urine. This does not interfere with sexual functioning but will decrease fertility and cause urine to be cloudy. |
| Instruct in perineal and interruption and/or continuation of urinary stream exercises. | Kegel exercises promote regaining muscular control of urinary continence and sexual function. |
| Refer to sexual counselor as indicated. | Persistent or unresolved problems may require professional intervention. |
Knowledge Deficit
May be related to
- Lack of exposure/recall; information misinterpretation
- Unfamiliarity with information resources
Possibly evidenced by
- Questions, request for information, statement of misconception
- Verbalization of the problem
- Inaccurate follow-through of instruction, development of preventable complications
Desired Outcomes
- Verbalize understanding of surgical procedure and potential complications.
- Verbalize understanding of therapeutic needs.
- Correctly perform necessary procedures and explain reasons for actions.
- Initiate necessary lifestyle changes.
- Participate in therapeutic regimen.
| Nursing Interventions | Rationale |
|---|---|
| Review implications of procedure and future expectations. | Provides knowledge base from which patient can make informed choices. |
| Stress necessity of good nutrition; encourage inclusion of fruits, increased fiber in diet. | Promotes healing and prevents constipation, reducing risk of postoperative bleeding. |
| Discuss initial activity restrictions: avoidance of heavy lifting, strenuous exercise, prolonged sitting or long automobile trips, climbing more than two flights of stairs at a time. | Increased abdominal pressure and/or straining places stress on the bladder and prostate, potentiating risk of bleeding. |
| Encourage continuation of perineal exercises. | Facilitates urinary control and alleviation of incontinence. |
| Instruct in urinary catheter care if present. Identify sources for support. | Promotes independence and competent self-care. |
| Instruct patient to avoid tub baths after discharge. | Decreases the possibility of infection, introduction of bacteria. |
| Review signs and symptoms requiring medical evaluation, erythema, purulent drainage from wound sites, changes in character or amount of urine, presence of urgency and/or frequency, heavy bleeding, fever, or chills. | Prompt intervention may prevent serious complications. Note: Urine may appear cloudy for several weeks until postoperative healing occurs and may appear cloudy after intercourse because of retrograde ejaculation. |
| Stress importance of follow-up care: PSA testing. | PSA levels are monitored to assess for residual tumor. Persistent incontinence will require additional evaluation or treatment. |
Other Possible Nursing Care Plans
- Urinary Elimination, impaired—loss of bladder tone, possible discharge with catheter in place.
- Sexual Dysfunction—leakage of urine; loss of erectile function following radical procedure.
