Florence College of nursing

Irba, Ranchi
Medical Surgical Nursing
A Surgical Care Plan
On
Benign Prostate Hyperplasia
Submitted To: Submitted By:
Ms. Pratibha Bara Sunil Kumar
Head of the Department M. Sc(Nsg) 1st Year
Medical Surgical Nursing Batch- 2020-22
Florence College Florence College
of Nursing of Nursing
INTRODUCTION
As a part of my clinical posting I was posted in the urology word , counter -17 from 10 th oct
2016 I was assigned a patient name Mr. Babu poojary for my care plan. They got admitted at KS
Hegde hospital on 04th oct2016 with the chief complaint of Pain in lower abdomen, increased
urination but can’t pass the unine and also complain of increased night time urination since ten
days.
Later be wan diagnosed as Benign prostate hyperplasia.

PATIENT PROFILE

Name : Mr Baabu poojary

Age : 60 Year.

Religion : Hindu

Address :Shivaaprasad House,

Post- uppala , Kasargoda

Marital station : Married

Education : graduate

Occuption : Business

Date of admission : 04th oct-2016

IP No : 16054436

Ward counter : Urology ward counter- 17

Diagnosis : BENIGN PROSTATIC HYPERPLASIA.

CHIEF COMPLAINTS
Mr. Babu poojary got admitted to K S Hegde hospital with the chief complain of lower
abdominal pain, increased frequency of urination and trouble in passing urine since ten days.

HISTORY OF PRESENT ILLNESS

Mr. Babu poojary had complain of pain in the lower abdomen and was admitted to K S Hegde
Hospital on 04th oct 2016 After the innestigation, as per arport-s he is diagnosed as Benign
Prostatic Hyperplasia

HISTORY OF PART ILLNESS MEDICAL

Mr. Babu poojary is not having any history of childhood illness, audients, But he has history of
Hypertension, Diabetes mellitus type 2. Patient has no history of any drug reaction allergy. He
has no history of blood transfunsion.

SURGICAL
Mr. Babu poojary had underwent transureth resection surgery on 7th oct. 2016 general
anesthesia is used.

FAMILY HISTORY
Mr. Babu poojary having joint family structure. There is no any complaint of communicable
diseare in his family . There is no any recent death in family.

FAMILY HEALTH CHART

S Name of the member Age/ Relation with Education Occupation Health
NO sex patient status
1. Mr. Babu poojary 60yes Patient Graduate Business Unhealthy
2. Mr. Pavitra 58/F Wife 12th std. Housewife Healthy
3. Mr. Narayan poojary 83/M Father 10th std. - Unhealthy
4. Mr. Santhamma 78/F Mother 8th std. - Healthy
5. Mr. Umanath 56/M Brother Graduate Business Healthy
6. Mrs. Saritha 53/F Sister in law 12th std. Housewife Healthy
7. Mr. Rahul 32/M Graduate Job. Healthy
8. Mr. Ajith 40/M Son Graduate Business Healthy
9. Mrs. Anjana 36/F Daughter Graduate Job Healthy

PERSONAL HISTORY
Patient- belongs to the middle class family . He is having mixed diet . He is Maintaining proper
hygiene. His sleep pattern altered as he has having only 4-5 hrs of sleep in a day. His bowel and
bladder pattern is also altered due to disease condition . He doesn’t having the habbit of
chewing to bbacco & drinking alcohol but he smokes sometime since 25 yrs.
 SOCIO ECONOMIC HISTORY
Patient family belongs to middle class family. Mr. Babu poojary and his brother are earning
members of their family. The monthly income is about RS. 40000/-. They are very friendly in
nature and having good relationship with their neighbours and other family members.

PHYSICAL EXAMINATION
1) Anthropometry measurement-
Height = 165 cm.
Weight = 70 kg.
BMI = Weight in Kg.
Height in meter square
= 70
(1.65)2 =25.71 Kg/m2

Mr. Babu poojary is having BMI of 25.71 Kg/m2 He is having slighthy above from normal
range . Normal BMI range 18.5 to 24.9 kg/m2

VITAL SIGNS

S.N Vital Signs Normal value Patient- finding Reward

01 Temperature 98.6-100.4.F Day1-> 99.6.F Normal
Day2-> 98.8.F Normal
Day3-> 98.8. F normal
02 Pulse 60-100 bets per Day1-> 78bpm Normal
minute Day2-> 72bpm Normal
Day3-> 78bpm Normal
03 Respiration 16-24 beath/ min Day1-> 16 breath/min Normal
Day2-> 22 breath/min Normal
Day3-> 20 breath/min Normal
04 Blood Pressure 120/60 mm. of Hg Day1-> 150/80mm of Hg Mild
Day2-> 150/70mm of Hg Mild
Day3-> 160/80mm of Hg High

SYSTEM ASSESSMENT
Subject Data Object Data
a) General constitutional Sympotms. Appearance
. Body is moderately built
. Well nourished.
. Health status-sick
. Well groom hygiene
. Mental status – conscious
. Hydrated.
b) Head
.Scalp- Normal, no dules & lesion are
absent
.Hair- Black in colour & equally
Distribution no hair loss
. Dandruff pediculosis are not present.
.Textine is fine
1) Face
. Oedema – not present
. Puffiness – not present
. No any skin discolouration
. Scan is not present anywhere in the
Face
. Facial expression altered due to
Anxiety
2) Ear, Nose & Throat Inspection
a) Ear.  External Ear
. Appearance is normal
. No use of having aids
. No discharge or lesions
. No any swelling
 Internal Ear
. Weber test – patient able to hear
vibration on both to ears Equally
( Negative)
. Renne’s Test – Air conduction is
twice, as long as bone conduction.
b) Nose. . Both sides are symmetrical
. Nasal septum not deviates
. Normal airflow patency
. Tenderness is not present –
. Polyp & sinus is not present
c) Throat - ( Neck)
Muscles
 Inspection –
 . No abnormal swelling or mass
. Trauma and spasm , stiffness is
not present
. equal muscle strength
Palpation
. No enlargement of thyroid gland
. Messes are not present
. Scan marks , nodules , redness
are not present
. Lymph node = not palpable.

Inspection
Eyes  No uses of glasses
Decreased eye vision  No uses of contact lines
 Eye brow is symmetrical equally
distributed
 Sclera are white and no cyanosis
 Eye lashes are equally distributed
 Eye lids : Absence of drooping
Periorbital edema.
 Eye balls – Absents of exopthal
mas and no sunken
eye.
 Pupil – pupils are equally round
and reacting to lights&
accomodation {PERLA}

Mouth  No bad odour

No any dental problems  Lips are hydrated
 Gum : normal , no any bleeding
 Teeth are well alignment
 Dental hygiene is good
 Tongue is hydrated
 Palate – pale and normal
 Ovula – normal position
 Oropharynx and tonsils:-
No any enlargement or discharge.

Inspection
. Breathing pattern is quite &
rhythemic
Chest . Normal shape
. No any respiration secretion
 . chase normal & symmetrical
. Spinal alignment colore is straight
. No any scar marks
. Intarl skin integrity,
Palpation
. Symmetric respiratory exertion
. Symmetric Tactile trimitur
.corodit antary palpation - normal
Percussion
. Symmetric both sides
. Symmetric respiration Rate – 20
. No sign of dysnea
Aus cultation
. Normal breathing sound
. Posten’or thorax
. Heart rate – 72 beats per minute
Inspection
. Normal skin integrity
Abdomen
. No any skin manles
. Normal shape of abdomen
. Normal abdominal movements
Palpation
. Pulse is so beats /min
. Regular quality of pube
. Blood pressure – 120/80 mm of Hg.
.Tenderness is not present.
Aus cultation
.Normal sound
. Bowel sound hend : normal
Percussion
. Resonance heand

Genitalia
. Voiding pattern is normal
. No any report of paiful burning
micturation
Inspection
. No any lesions
. Appearance of urine normal
. 24 hr Urine output – normal
. color – pale yellow color
. Normal specific gravity

Neurological Assessment . Patient is corsous

. well oriented to time place & person
. well interaction with others
. well coordination
Rest & sleep
Sleeping pattern is disturbed due to . Duration of sleep 3 – 4 hrs/ day
pain Factor – Pain

Affected system
Musal osketeletal system Pain
. Patient have no report of member . Pain in the left ankle
. Sensation are present while touching . good sensation
. Patient report of pain in left ankle . Paralysis not present
. Patient report of inability to do daily . Gait – Patient cant work properly.
Activities due to pain in left ankle. . ADL – cant perform ADL
. Difficult with ambulation Effectively
. Use of Supportive devices – present
Eg walker
. Muscle strength – weak in left leg.
Leg. And others are strong.
Reflex Grading.
1. Biceps reflex 2+
2. Brachioradics 2+
3. Triceps reflex 2+
4. Palellar reflex 2+
5. Achilles reflex 2+
6. Planter reflex 2+
7. Abdominal reflex 2+
Integumetry system
Presence of
. Rashes – present ( left ankle)
 . Ulcer – No
. Imflammation – present
. Redness is present
. Wanth is felt

LAB INVESTIGATIONS
Special Investigation Finding

. X – Ray is done of left ankle -> Subluxation of left subtalar joint

Other investigations

Type of investigation Patients value Normal value Remarks.

Biochemistry
. Glucose plasma 83 mg/dl 70 – 150 mg/dl Normal
Random
. Uric acid 3.9 mg/dl 3.4 – 7 mg/dl Normal
Pathology
. Heamogolobin 14.5g/dl 12 – 18 g/dl Normal
.TLC 9100 c/wmm 4000 – 11000 L/wmm Normal
Differental lount (DC)
. Neutrophils (N) 40 – 70%
52% 20 – 40% Normal
. Lenkoiyte (L)
25% 1 – 6% Normal
. Esionophils (E)
20% Normal

DRUG PROFILE
Name of the Drug Dose Route Mechanical of Indicatio Contraindical Side Nurses
Frequency Action n effect Responsibility

Generic Name 10 mg/ .Antidepressant .To . Acute . CNS . Because of

Amitriphyline aeliene recovery Anxiety , anitriptylihis
Hydrochloride Orally / .Amitriptyline depressio phone after MI ataxia, Atropine like
0–0–1 Block serotomin & n hypersenssiti Coma, effects use
Trade Name norepinepbie especially vity to chills, caution if pt
Typtomer Reuptake by anxiety 4 amitriptylins fatigue has history of
adrenergic nawes insomnia fever seizures urine
By doing so, it Headachs retertion
raises serotonin CVS . stay alert for
and Arrhythmi behaviour
norepinephrse
leuds at nere as changes such
synapse Heart an
This action may block hallueination
alovate mood and & .Patient
reduce depression tachycard teaching
ia . Instruct
ECG patient
Changes To take this
EENT medicine at
Abriormal bedfine
teste . Instruct
black patient to
tongue, avoid using
Blurred alcohol
vision dry . urge family
mouth or canegiven
GI no watch
Abdomin patient,
al cramps
comtipati
on
Diarrhea
Vomitting
GU
Impotenc
e
menstrual
iregulanit
cs
Home
born
marrow
depressio
n luck
opening
Name of the Dose Route Mechawism Indication Contraindica Side effect Name Responsibility
Drug Frequency of action
Generic Name 50 mg / . Analgesic . To relieve . Inereawel risk of CNS . . Use diclofenac with
Diclofenac Orally / Anti – pain & adverse renal Aseptie extreme caution and
Sodium 1–1–1` inflammatory inflammation effect with long meningilis for shortert possible
. To relieve term headache time in patients a
Pain & conumenture drowsiness history of GI bleeding
Trade Name inflammation . Increased GI CVS . . Don’t substitute one
in irritublity and Bradycardia from of oral
Emanzen . Osteoarthrites bleeding Arrhythmias diclofenac for another
. rheumatoid . Impaired hypotenrion . Be awance that
arthiritir antihypertemine EENT . serious GI trast
. dysmenorrher Effect Glaucoma ulceration
. To reliance . Increased hearing loss . Assers patient for
mild to diclofinac toxicity tinnitus hypotension of
moderate aute ENDO . patient takes
pain Hypoghycema potassium sparing
GI .Obdomial diuretic check
pain diarrhea elevated serum
dysphagia potassium level
jawdice
nausea
hepatu failine
SKIN . Rash
pruritus toxic
rpidermal
necrolysis
GU. Aute
renal failane
intestinal
nephritis

NURSING DIAGNOSIS
1. Acute pain related to movement of bone fragments & tissue injury as evidenced by
verbalization.
2. Disturbed sleeping pattern related to pain and hospitalization as evidenced by
verbalization
 3. Impaired physical mobility related to fracture as evidenced by difficulty t o perform daily
activities .
4. Fatigue related to disease condition pain & inadequate sleep as evidenced by Facial
expression .
5. Impaired skin Integrity related to physical immobiuzation as evidenced by local pain &
numbness
6. Anxiety related to hospitalization as evidenced by Facial expression
7. Deficient knowledge related to disease condition as evidenced by verbalizing inaccurate
information .
8. Risk for trauma related to getting up without assistance or movement of bone
fragments.
9. Risk for infection related to inadequate primary dajences broken skin.
10. Risk for peripheral News vascular dysfunetion due to direct vascular dysfunction due to
direct vascular injusy & excerssive edema

Assessment Nsg Diagnosis Objective Plan of Action Rationale Implementation Evaluation

Subjective Acute pain The patient . Assess the Assessment . Assessed the The patient
Data related to gets relief general helps in general got relief from
“ Patient says movement of from the condition of further condition of the pain to a
I am having bone fragments pain patient investigation patient certain extent
pain at the & tissue injury . Provide .Uncomforta . provided as pain scale
site of injury as evidenced by comfortable ble pattern comfortable reading in 5.
Objective verbalization position causes position Eg –
Data On . Elevate and fatigue & Pillow under
observation support may increase sight of injury
pt having injured pain . Elevated and
pain at site of extremity . promotes supported
injury At pain . provide venous Injuned ex
E Scale – 8 alternative return hemity by
comfort decreases keeping pillow
measures Edema and under the injury
(massage back may reduce lg
massage) pain . Provide ex
 . provide calm . Improves alternative
& quite general Comfort
environment circulation measuas
reduces . Provided calm
areas of local & quite
pressure and environment
muscle such as dine
fatigue light and
. Improve restricted move
the comfort visitors
by mental
relaxation

Assessment Nrg Diagnosis Objective Plan of Action Rationale Implementation Evaluation

Subjective Disturbed Patient . Assess the By gathering .Assessed the Patient
Data sleeping pattern maintain current sleep information sleeping pattern maintained
. patient says related to pain adequate pattern history about sleep on assessment adequate
I am not and sleep . Identify the problems patient sleeping sleep of 6 – 7
getting hospitalization factors may help to on 3 – 4 hrs in a hrs a day to a
proper sleep as evidenced by contributing to promote day certain
due to pain verbalization disturbed in sleep to . Indentified the external
sleep pattern patient factors
Objective . Encourage . control contributing
Data on the client to these factor disturbed in
observation use comfort and induced sleep pattern
patient is measunes sleep Eg. Fatigue is
inactive and . Discourage . Promote identified
frequency the patient to relaxation . Encouraged to
yawning & take caffeine and comfort wear light
reduced or large meals to the client weight cloths
sleep only 3 – intake before . caffeine and given back
4 hrs in a day sleeping intake couses massage before
. maintain the insomania sleep
quiet calm . Patient will . Discourage the
environment sleep quietly patient Avoided
without any tea coffee
disturbance before sleep
. Maintained the
clam quiet and
proper
lightening
environment
Assessment Nrs Objective Plan of action Rational Implementati Evaluation
Diagnosis on
Subjective Impaired Patient .Assess and . Isometric control .Assessed & .Patient
Data physical altains the encourage the use muscles without encourage altined the
Patient says mobility ability to of isometric bending joint or the use of ability to
I have pain related to perform exercise moving limbs and isometric perform his
& weakness Fracture as his daily . Provide safe helps to maintain exercises daily
while evidenced activities environment & muscle strength & . Provide safe activities to
standing & by difficulty Assist in self cave mass environment some extent
walking to perform activities . Prevent from fall . Provide side
daily . Teach / check from bad or bad rails
Objective activities proper use / f n of walking . Tought &
Data on adaptive cheuced
observation equipment . proper use of proper use of
. Execute passive equipment equipment
or active
assistance . Exercise enhance . Executed
ROM increased venous passive
exercise to retine prevents assistance
all stiffness and ROM
extremities maintain muscle exercise to all
. Provide the strength & stamina exteremtion
patient of . Rent periods are . Provided
rest periods essential to the patient
in between lonsene energy rest periods
activities in between
the activities

Assessment Nrs Objectiv Plan of action Rationale Implementation Evaluation

Diagnosis e
Subject Fatigue Patient . Assess signs . It help to know . Assessed facial Patient got
Data related to gets symptoms of about what are signs & symptoms relief from
Patient says disease relief fatigue the couses of of fatigue fatigue to
I am so condition from . Assess the fatigue . Assessed the some
tired I need pain & fatigue patients . Fatigue may be patient nutritional extent
some rest inadequat nutrstional intake symptom of and given proper
e of calories protein protein calorie diet
Objective Sleep as Minerals & malnutrition . Evaluated the
Data evidenced vitamins vitamin pattern of sleep of
Patient is by faual . Evaluate the deficiencies or patient
lethargic expression patients sleep irondjiciency . maintained
and drowsy patient for quality . Changes in adequate fluid
not inter in quantity time persons sleep intake
environmen taken fall asleep pattern may be
t and feeling upon contribute factor
awakening in the
. Maintain development of
adequate fluid fatigue
intake . To promote
elimination of by
products of
cellular break
dwon

Assessment Nrg Diagnosis Objective Plan of Rationale Implementation Evaluation

action
Subject Data Impaired skin . Patient . Assess . Proper Assessed site Patient
patient says I integrity related maintains site of identification injury Finding maintained
have irritation to physical normal injury of nursing Rashes swelling normal skin
& pain in the immobilization skin . Advised intervention is present in left integrity
left ankle as evidenced by integrity patient to ankle
local pain & limited . To present . Advised
Objective Data numbness mobility more pressure patient to
on ohservation . Identify on the site of limited mobility
Rashes warath signs of injury . walk when
is seen in left itching and . Scratching needed
ankle swelling scratching the skin . Take bed rest
is present . Advised attempts to Identified sign
deif that alleviate of itching &
meets extremeitching scratching &
mutritiond may open skin given to pical
needs lesion & medication as
. Advice increase risk per physician
 the use of for infuction order
pillow & . It promote & . Advised dient
pressive skin wound that meets high
reducing healing calories to
demces . To present patient
pressure injury . Advised the
use of pillow

Assessment Nrg Diagnosis Objective Plan of Rationale Implementation Evaluation

action
Subject Data Anxiety Patient gets . Assess . Anxiety is . Assessed Patient got relief
Patient says I related to relief from patients level highly in patient level of from anxiety at
am worried and hospitalization anxiety of anxiety & diridualized anxiety and some extent
scared as evidenced facial Normal facial
by facial reaction physical & expression
Objective Data expression . Explan the psychological . Explained the
on observation heed for response to need for
By facial frequency in hrnal or frequent
tension & assessment external life assessment
behaviour . Allow euents
patient is patient to . To reduce . Allowed the
worried relax the anxiety patient to relax
.Encouraged by providing . Adviced to
visiting of baric action restion the bed
patients . Relaxation . Encouraged
family reduce the visiting of
member 4 anxiety patient family
friends . IT reduced member &
. Provide anxiety by friends
calm psychological
environment & emotional . Provided calm
Strength environment
. Extranlous . less talk &
noises & distribution by
commotion others
 may
accelerate
anxiety `

HEALTH EDUCATION
Medication

 Advised the patient about drug importance

 Advised the patient to take medication at night time & frequency

Diet

 Education the patient :-

 Diet modification for the patient is calcium & phosphons rich diet and less fats and
carbohydrate
 He can eat mixed diet
 Milk egg whites and nuts must added to diet

Exercise

 Advised the patient to walk with He help of others

 Also advised to use supportive devices such as walker elucthers
 Elery day he have to exercise

Hygiene

 Advised the patient to take regular bath

 Maintain personal hygiene

Rest and sleep

 Advised the patient to take adequate rest & sleep at last 6 -7 hrs
  Follow up
 Advised client to come hospital for regular check ups

CONCLUSION
Mr . Umapathi K E . Age 47 yrs old got admitted to K S Hegde Hospital on 15/09/16 with chief
complain of twisting & pain over the left ankle . After investigation he was diagnosed with
subluxation of left tubtalar joint Now the client is still in hospital . His pain reduced and he is
having normal daily habbits

By giving care to the patient I have learnt about the medication that given to him and also
learnt about subluxation or fracture of subtalar joint I learnt how to manage such patient.

BIBLIOGRAPHY
1. Jones & Bartlett learning , Nurses Drug Handbook 10th Edition 2011 Jones & Bartlett
learning Page No 312, 313, 68, 69

2. Internet
i. WWW. nurselabs. Com
ii. WWW. nanda nursing interventions. blog