BENIGN PROSTATE

HYPERLASIA
(BPH)

MATRIX NO : 1765
GROUP : 30 (1/2006)
 LEARNING OBJECTIVES
At the end of this case study, I will be able to :
1. Explain the anatomy and physiology of male productive system and male urinary
system
2. State the definition of benign prostate hyperplasia (BPH)
3. List the etiology of BPH
4. Explain the pathophysiology of BPH
5. State clinical manifestation of BPH
6. List the complications of BPH

 
 
 
 
 
 Con’t…
7. State the investigation carried out to patient with BPH
8. Explain the medication for BPH
9. Explain surgery : Transuretheral Resection of Prostate
(TURP)
10. List the complication of the surgery (TURP)
11. Carry out nursing responsibilities pre-operatively as well as
post-operatively
12. Identify the nursing problem and nursing intervention that
carried out for patient with BPH before and after operation
13. Explain health education provided to patient post TURP
 PATIENT’S DATA
Name : Mr.B
R/N : xxxxxx
I/C No : xxxxxx-xx-xxxx
Date of Birth : xx/xx/1949
Age : 58 years old
Sex : Male
Bed No : HD-1
Race : Malay
Religion : Islam
Language : Malay and English
Status : Married
Occupation : Retired as assistant engineer
Date & Time of Admission : 20/11/07 @ 2.15 a.m.
 Con’t…
Reason for Admission :
c/o Syncope (black out) 2 times
c/o Nocturia x 2/52
Frequency & urgency in passing urine x 2/52
Feeling incomplete emptying after passing
urine x 2/52

Provisional Diagnosis :
Transient Ischaemic Attack & Vasovagal Syncopy
Benign Prostate Hyperplasia (BPH)
Past Medical History : Nil
Past Surgical History : Appendicectomy in 2006
Family Medical History : Diabetic (mother)
Allergies : Aspirin
Current Medication : Tab. Xatral 2.5mg BD
 CONDITION ON ADMISSION
Mr.B came to Tawakal Specialist Hospital on 20th
November 2007 at 2.15 a.m. He was conscious and
well orientated. At first, he came to A&E due
to complaint of syncope (black out) 2 times at home,
nocturia since 2 weeks, frequency and urgency in
passing urine since 2 weeks and feeling incomplete
emptying after passing urine since 2 weeks. Then he
was admitted to the High Depency Unit.  
 
 Con’t…
During the admission time in the ward, observation of
the vital sign was taken and below, listed the vital sign
that has been taken on him.
 
Vital signs
Temperature : 36.0 0C
Pulse rate : 60 bpm
Respiration rate : 21 bpm
Blood pressure : 102/62 mmHg
Weight : 67.7 kg
Mode of admission : wheelchair
Level of consciousness : conscious
Mental status : orientated
Emotional status : calm
ACTIVITY OF DAILY LIVING
BREATHING, EATING & DRINKING
Normal

BOWEL ELIMINATION
Daily

BLADDER ELIMINATION
•Nocturia (2/52)
•Frequency and urgency in pass urine (2/52)
•Feeling incomplete emptying after pass urine (2/52)

SLEEPING
Disturbance of sleep caused by nocturia (2/52)

MOBILITY
Normal
 Con’t…
PERSONAL HYGIENE
He is able to take over of his personal hygiene by himself

SAFE ENVIROMENT
Siderails, bed level lowered ( prevent fall)

COMMUNICATION
English and Malay

HOBBY
Watch television

VISION, HEARING & SKIN CONDITION

Normal

MENTAL STATUS
Conscious and well orientated
PHYSICAL EXAMINATION
A IV drip P
N N/Saline O
T S
E T
R E
I R
O I
R O
R
 Con’t…
HEAD:
Hair, face, eyes, mouth, ear, neck - Normal

UPPER LIMB:
Arms, fingers, nails - normal

BODY:
Chest - Normal
Abdomen - lower abdomen look distended

LIMB :
Leg, foot, toenail - Normal

PRIVATE PART & SPINE :

Normal
 MALE REPRODUCTIVE
SYSTEM
MALE REPRODUCTIVE ORGAN LOCATION

Scrotum Hangs from body at root of penis

Testes In the sacral sac

Epididymis Posterolateral to upper aspect of each

testis

Vas deferens (ductus deferens) Between the epididymis and the

seminal vesicle forming the ejaculatory
duct

Penis Attached to front and sides of the pubic

arch. Proximal, ventral surface is
directly continuous with the scrotum
 Con’t…
MALE REPRODUCTIVE ORGAN LOCATION

Urethra Begins at bladder and passes through

prostate and penis

Prostate gland Encircles the urethra at the neck of the

bladder

Seminal vesicles Lie on posterior bladder wall

Bulbourethral (Cowper’s) glands Inferior to the prostate

Bulbourethral
gland
 FUNCTION
MALE REPRODUCTIVE ORGAN FUNCTION

Scrotum Contain testes, epididymis and portions

of the vas (ductus) deferens

Testes Produce sperm and testosterone

Epididymis Stores sperm

Promotes sperm maturation
Transports sperm to vas deferens
Vas deferens (ductus deferens) Stores sperm and transports sperm

Penis Excretes semen and urine. Deposits

sperm in female reproductive tract
 Con’t…
MALE REPRODUCTIVE ORGAN FUNCTION

Urethra Serves as passageway for urine or

semen

Prostate gland Contributes to ejaculatory volume

Enhances sperm motility and fertility

Seminal vesicles Contribute to ejaculatory volume

Contain nutrients to sustain sperm and
prostaglandins to facilitate sper
motility

Bulbourethral (Cowper’s) glands Secrete mucus into urethra

Neutralize traces of acidic urine in the
urethra
MALE URINARY SYSTEM
STRUCTU FUNCTION
RE
Kidney Filter the blood, remove the
wastes, and excrete the
wastes in the urine.

Ureters Carry the urine away from

kidneys

Urinary Temporary storage reservoir

Bladder for urine.

Urethra Carries the semen and urine

passes and exits from body.
PROSTATE GLAND
ANATOMY PHYSIOLOGY

Situated under the Add special nourish

bladder, wrapped fluid to the sperm
around urethra before it is ejaculated
Composed :- out
a) Smooth muscle Push semen
b) Glandular containing sperm with
sufficient power
c) Stromal cell
 DEFINITION OF BPH
BPH is a non-cancerous (benign) enlargement of the
prostate gland that can make urination difficult.

2nd edition,
The Merck Manual of Medical Information
 ACCORDING TO AGE
40
37
35

30

25 50 - 60 ye a rs
20
To ta l 20 61 - 70 ye a rs
15
15 71 ye a rs a nd
a bo ve
10

0
Ye a rs

Statistic BPH patient that admitted to TSH with TURP management

(January 2004 – November 2007)
 ACCORDING TO RACE
7%

31%

62%

Ma la y Chine se India n

Statistic BPH patient that admitted to TSH with TURP management

(January 2004 – November 2007)
 ETIOLOGY
1) Unknown

2) Male hormones
a) Androgen – testosterone
-Stimulate cell growth in tissue line the prostate gland
b) Estrogen
older - testosterone level drop and estrogen increase -
possibly triggering prostate growth

3) Aging

4) Family history

5) Ethnic group - African American men

Small nodules in periuretheral gland Nodule hyperplasia and
(inner layer of prostate) glandular hypertrophy

Uretheral canal narrow Prostate enlarged and

tissue expand inward

Obstruction of urine flow

Increase resistance to urinary flow

Develop sign of benign

prostate hyperplasia
 •Nocturia •Frequency & Urgency •Incomplete emptying

CLINICAL MANIFESTATION

•Incontinence •Poor force

•Dysuria •Bladder pain

•Hematuria

•Hesitancy •Dribbling after PU

 COMPLICATION
1) Acute urinary retention (AUR)

2) Urinary tract infections (UTI)

3) Bladder stones

4) Bladder disorder

5) Kidney failure
 INVESTIGATION
• For BPH
1) Digital Rectal Examination
2) Cystoscopy
3) Ultrasound Kidney & Bladder
4) Prostate Specific Antigen (PSA) Blood Test
5) Urine Flow Study

• Other investigation
1) Urine FEME
2) Admission Profile (GP59H)
3) CT Scan Brain
4) MRI Brain
5) EEG
6) ECG
 URINE FEME
DATE : 20/11/07
--Urine FEME (urinalysis)--
EXAMINATIO RESULT UNIT REFERENCE RANGE
N
Appearance, Yellow Yellow/Pale Yellow
urine
Specific gravity, 1.020 1.005-1.025
urine
pH, urine 6.5 4.8-6.7

Protien, urine Negative Negative

Glucose, urine Negative Negative

Ketone, urine Negative Negative

Blood, urine Negative Negative

 Con’t…
--Microscopic examination, urine--
EXAMINATIO RESULT UNIT REFERENCE
N RANGE
WBC, urine 1 /uL 0-5
RBC, urine 1 /uL 0-5
Epithelial cell, Occasional Occasional
urine
Cast, urine Nil Nil
Crystal urine Nil Nil
Bacteria, urine Nil Nil
 ADMISSION PROFILE (GP59H)
DATE : 20/11/07
--Haematology--
EXAMINATIO RESULT UNIT REF. RANGE
N
Haemoglobin 14.4 g/dL 13.0-18.0

Red cell count 4.6 10¹²/L 4.5-5.9

Haematocrit 38 % 41-53

Platelet count 244 10³/uL 150-450

ESR 6 mm/hr 0-15

WBC count 8.9 10³/uL 4.3-10.5

 Con’t…
--White blood cell differential--
EXAMINATION RESUL UNIT REF. RANGE
T
Neutrofil 73 % 40-75

Lymphocyte 23.5 % 20-45

Eosinophil 1.4 % 0-6

Monocyte 10.1 % 1-11

Basophil 0.9 % 0-2

--Diabetes mellitus control--

EXAMINATION RESULT UNIT REF. RANGE

Glucose 5.8 mmol/L 3.9-6.1

 Con’t…
--Renal function & bone metabolism screen--
EXAMINATIO RESULT UNIT REF. RANGE
N
Uric acid 0.42 umol/L 0.20-0.43
Creatinine 102 umol/L 43-115
Urea 4.0 mmol/L 2.0-6.8
Sodium 143 mmol/L 135-155
Potassium 5.1 mmol/L 3.5-5.5
Chloride 99 mmol/L 95-111
Calcium 2.38 mmol/L 2.09-2.55
Phosphate 1.34 mmol/L 0.78-1.50
 Con’t…
--Lipid profile--
EXAMINATION RESUL UNIT REF. RANGE
T
Total Cholesterol 5.5 mmol/L <5.2

Triglycerides 1.18 mmol/L <2.28

HDL Cholesterol 1.58 mmol/L >1.68

LDL Cholesterol 2.5 mmol/L <2.6

%/HDL Chol Ratio 29 % >25

 Con’t…
--Liver function test--
EXAMINATION RESULT UNIT REF. RANGE
Total protien 75 g/L 63-83
Albumin 44 g/L 35-50
Globulin 32 g/L 25-40
A/G ratio 1.4 1.0-2.0
Total bilirubin 7.3 umol/L 2.0-28.0
Direct bilirubin 2.0 umol/L < 6.8
Indirect bilirubin 5.3 umol/L < 20.5
 Con’t…
--Cardiac enzyme--
EXAMINATION RESULT UNIT REF. RANGE
SGOT/AST 23 u/L 7-44
SGPT/ALT 25 u/L 7-48
Creatine Kinase (CK/CPK) 131 u/L 24-204

CKMB 16 u/L < 25

Lactate dehydrogenase, LDH 252 u/L 211-423

Troponin T Negative u/L Negative

Alkaline phosphate 82 u/L 45-122
Gamma GT 18 u/L 11-50
 BLOOD TEST
DATE : 28/11/07
--haematology--
EXAMINATION RESU UNIT REF. RANGE
LT
Bleeding time 2.0 min < 6.0

Clotting time 8.0 min 5.0 – 11.0

Prothrombin time 12.5 sec 11.0 – 15.0

PT control 13.5 sec 11.5 – 15.5

INR 0.91 0.85 – 1.35

 ULTRASOUND
DATE : 20/11/07
PROCEDURE : Ultrasound Kidney & Bladder

The left kidney measures 102 mm long

It appears normal
The right kidney is enlarged
The upper and lower pole appear normal
In the bladder there is enlargement of the median
lobe of the prostate which indents the base of
bladder
 ECG
DATE : 20/11/07

Ventricle rate : 72 bpm

PR interval : 140 ms
QRS duration : 94 ms
QT/QTc interval : 420/432 ms
P/QRS/T axis : 44/15/10
RV 5/SV 1 amp : 1.285/0.580 mv
RV 5+SV 1amp : 1.865 mv
 
1100 Sinus rhythm
9110 **Normal ECG**
 
 CT SCAN BRAIN
DATE : 20/11/07

Unenhanced axial MDCT section are performed

No evidence of a space occupying lesion is seen
The midline is central
Ventricles and sulci are normal
Grey/white matter differentiation is maintained

IMPRESSION : Normal Brain

 EEG
DATE : 20/11/07

The EEG showed a well-modulated & rhythmic

posterior dominant alpha activity at loops, of
median amplitude. It is reactive to eye opening.
Frontal beta fast activity is present. HV was done for
5 min with good build up and no abnormal d/c. PF elicited an
even posterior response. Sleep record not possible

Impression : Within normal awake EEG

 MRI BRAIN
DATE : 21/11/07

Summary :
No abnormality in the brain, extracranial and intracranial
vasculature
 MANAGEMENT
• Medical treatment • Surgical treatment
1) Alpha- Adrenergic 1) Transurethral Surgery
Receptor Blocker -TURP
2) 5 – Alpha Reductase -TUIP
Inhibitor
2) Open surgery
3) Laser surgery
 MEDICATION
Medication during Stat medication
hospitalization • Tab. Plavix 75mg
• IV Controloc 40mg Daily • Tab. Valium 10mg
• Tab. Plavix 75mg Daily
• Heparine Saline 5mls Daily
• IV Rocephine 1g Daily
• N/Saline Irrigation 3L
• IM Pethidine 50mg PRN Medication for discharge
• IV Maxolon 10mg PRN • Tab. Augmentin 625mg BD
 CONTROLOC
• G.Name : Pantoprazole Na
• Group : Antacids & Antiulcerant
• Drug on & off : 20/11/07 & 23/11/07
• Route : IV
• Dosage : 40mg
• Frequency : Daily
• Indication : Duodenal / gastric ulcer, reflux oesophagitis
• C.Indication : Pregnancy, lactation & renal impairement
• S.Effect : Nausea, upper abdominal pain, flatulence, skin rash, pruritus,
dizziness, edema, fever, headache & diarrhea
 PLAVIX
• G.Name : Clopidogrel Hydrogen Sulfate
• Group : Anticoagulants and antithrombotics
• Drug on & off : 21/11/07 & 22/11/07
• Route : Oral
• Dosage : 75mg
• Frequency : Daily and stat (20/11/07 @ 2.30 a.m.)
• Indication : Prevention of artherothrombotic
• C.Indication : Active pathological bleeding such as peptic ulcer and
intracranial haemorrhage
• S.Effect : GI bleeding, purpura, bruising, haematoma, epitaxis,
haematuria, ocular haemorrhage, abdominal pain, gastritis and
constipation
 HEPARINE SALINE
• G.Name : Heparin Na
• Group : Anticoagulant and antithrombotic
• Drug on & off : 20/11/07 & 22/11/07
• Route : Intravenous
• Dosage : 5mls
• Frequency : Daily
• Indication : Treatment of venous thrombosis, pulmonary embolism
and prevention of cerebral thrombosis
• C.Indication : Haemorrhagic disease, thrombocytopenia, hemophilia
and peptic ulcer
• S.Effect : Transient alopecia, diarrhea and osteoprosis
 ROCEPHINE
• G.Name : Ceftriaxone
• Group : Antibiotic
• Drug on & off : 29/11/07 & 30/11/07
• Route : Intravenous
• Dosage :1grm
• Frequency : Daily
• Indication : Sepsis, meningitis, abdominal infections, infection of the
bones, infection with impaired defence mechanism: renal and urinary
tract infection
• C.Indication : Known hypersensitivity to cephalosporins
• S.Effect : Gastrointestinal complaints, hematological changes and skin
reactions
 N/SALINE IRRIGATION
• G.Name : 0.9% Sodium Chloride Irrigation
• Group : Anticoagulant
• Drug on & off : 29/11/07 & 30/11/07
• Route : Catherization
• Dosage : 3000mls
• Frequency : 24 hours
• Indication : Irrigation during operative procedures, also to improve visibility,
remove blood clots and moisten body tissues
• C.Indication : Not be used during electro-surgical procedures
• S.Effect : Irrigation of internal cavities, especially for prolonged periods, may
result in absorption of fluid and consecutive over dehydration and disorders of
electrolyte balance
 PETHIDINE
• G.Name : Pethidine HCI
• Group : Analgesic and antipyretics
• Drug on & off : 29/11/07 & 29/11/07
• Route : Intramuscular
• Dosage : 50mg
• Frequency : PRN
• Indication : Short term relief of moderate to severe pain.
• C.Indication : Respiratory depression, head injury, raised intracranial
pressure, brain tumour and cardiac arrhytmias
• S.Effect : Respiratory depression, light headedness, dizziness,
sweating, disorientation, hallucination, nausea and vomiting
 MAXALON
• G.Name : Metaclopramide
• Group : GIT regulators, antiflatulence and anti-inflammatories
• Drug on & off : 29/11/07 & 29/11/07
• Route : Intravenous
• Dosage : 10mg
• Frequency : PRN
• Indication : Dyspepsia, flatulence, digestive disorder, peptic ulcer,
reflux, oesophagitis, nausea and vomiting
• C.Indication : -
• S.Effect : Rarely, raised serum prolactin level
 VALIUM
• G.Name : Diazepam
• Group : Anxiolytics
• Drug on & off : 29/11/07 & 29/11/07
• Route : Oral
• Dosage : 10mg
• Frequency : Stat
• Indication : Tension, anxiety and pre-operation medication
• C.Indication : Severe psychoses, 1st trimester of pregnancy and acute
narrow angle glaucoma
• S.Effect : Drowsiness, mental disturbance, respiration depression,
blurred vision and hypotension
 AUGMENTIN
• G.Name : Amoxycillin
• Group : Antibiotic
• Drug on & off : Medication during discharge
• Route : Oral
• Dosage : 625mg
• Frequency : BD
• Indication : Respiratory tract infection, genito-urinary tract infection,
skin and bone infection
• C.Indication : Hypersensitivity to penicillin and possible cross
sensitivity
• S.Effect : Diarrhea, indigestion, nausea, vomiting and rash
 SURGERY
Surgery :
Transuretheral Resection of Prostate (TURP)

Date :
29th November 2007 @ 11.30 a.m.

Definition :
Surgical procedure by which portions of the
prostate gland are removed through the urethra
PROCEDURE

•It performed under spinal anesthesia

•It takes around 40 minutes
•Insertion of an instrument called
resectoscope into the penis through
the urethra.
•Contain light, valves (control
irrigation fluid) , electrical loop
(remove obstructing tissue, blood
vessel)
•Remove the obstructing tissue -
irrigating fluid carry the tissue to
the bladder.
•The debris is removed by
irrigation and any remaining debris
is eliminated in the urine over time
 COMPLICATION
Bleeding (hematuria)

Recurring urinary tract infections (UTI)

Frequent urge to urinate

Semen entering bladder (retrograde ejaculation)

Erection problems

Bladder neck narrowing (stricture)

PRE-OPERATIVE CARE (TURP)
1) Evaluate patient’s understanding regarding the surgery.

2) Ensure patient nil by mouth

3) Re check consent

4) Inform patient that he will be back with CBI after surgery.

5) Administer pre-medication as prescribed by doctor.

6) Do routine operation check list.

POST-OPERATIVE CARE TURP
1) Monitor vital sign hourly for 6 hours followed by every 6 hourly

2) Strict monitoring and documentation of input and output.

3) Ensure patient complete rest in bed (CRIB)

4) Ensure CBI is flushing well.

5) Observe for the sign of complication.

 NURSING CARE PLAN
PRE-OPERERATIVE
1) Alteration in unable to pass urine related to enlargement of
prostate
2) Alteration in emotional status, anxiety related to surgical
intervention (TURP)

POST-OPERATIVE
2) Potential hemoglobin low related to heavy hematuria
3) Potential ascending infection related to continuos bladder
irrigation
4) Alteration in comfort, pain related to surgical intervention
(TURP)
5) Knowledge deficit related to home care management
 Alteration In Unable To Pass Urine Related To
Enlargement Of Prostate
DATE & TIME : 20/11/07 @ 8.30 a.m.

SUPPORTING DATA :
• Patient verbalize he cannot pass urine as normal since 2 weeks
• Patient’s lower abdomen look distended

GOAL :
Patient will be able to pass urine 1 to 2 hours
after nursing intervention given and during
hospitalization
NURSING INTERVENTION :

1) Assess patient’s characteristic of urine, urinary pattern, frequency pass

urine and color of urine for example colorless, cloudy or hematuria
 To apply appropriate nursing intervention
I I ask the patient how his voiding pattern at home and observe the color
and the amount of urine

2) Insert CBD as ordered by doctor and maintain sterile technique

 To release urinary retention
I I’m not inserted the CBD to Mr.B because Medical Officer will do for
male patient
3) Reassurance and give clear information about his condition
 To get the co-operation when any procedure carry out
I I’m explain to the patient about his disease base on the doctor’s
diagnosis

4) Encourage patient do not take large amount of fluid intake in one time
 Large volume of fluid may result in rapid bladder filling and increase
the urinary retention
I I advise my patient do not take large amount of fluid in one times
5) Monitor and document the amount of output when patient’s CBD is full
each time
 As a comparison and early abnormalities will detected
I I monitor and document each amount when patient’s CBD is full

6) Inform to the doctor for any abnormalities finding that patient’s lower
abdomen still look distended
 For further action plan
I Patient is plan for Transurethral Resection of Prostate (TURP) by Dr.H
DATE & TIME : 20/11/07 @ 10 a.m.

EVALUATION :
Patient able to pass urine after CBD inserted

SUPPORTING DATA :
• Patient verbalize that he feel more comfortable after the CBD
is inserted
• Patient’s lower abdomen was reduce distended
 Alteration In Emotional Status,
Anxiety Related To Surgical Intervention (TURP)

DATE & TIME : 29/11/07 @ 10.30 a.m.

SUPPORTING DATA :
• Patient look anxious before the operation
• Patient asking a lot of question regarding the surgery (TURP)

GOAL :
Patient’s anxiety will be reduced within 1-2 hours
before surgery
NURSING INTERVENTION :

1) Assess patient’s level of anxiety by looking patient’s facial expression.

® As a guide to plan appropriate nursing care.
I : Before giving any information regarding surgery to Mr.B , I
observe patient facial expression and he looks a bit
anxious.

2) Reinforce doctor explanations regarding nature of the surgery

® Patient’s better understanding as well as reducing anxiety
I : I re-inform to him about the surgery base on what the doctor had
inform before, such as purpose, how the surgery will be performed and
how long it will take.
3) Explain to the patient about pre-operation care.
® To allay anxiety and gain cooperation from the patient.
I: I inform the patient purpose of him to Nil By Mouth before
surgery.

4) Inform patient regarding post-operation management.

Eg : he will be back to the ward with CBI, CRIB.
® Reduce anxiety related to post operative care.
I: I informed him that he will back from with the CBI in order to provide
free drainage of blood and he need to CRIB till the CBI been off.
5) Use simple language/word to explain each procedure to
patient
® For easy understanding
I: I explained regarding the surgery to Mr.B using simple word and he
was able to understand it easily.

6) Encourage family members to visit and be with the patient.

® Help in giving moral support to patient.
I: I encouraged family members to be with the patient and I told them
that it will help in reducing patient’s anxiety.

7) Administer pre-medication to patient as ordered be

doctor
® to promote relaxation to patient.
I: I administered Tab. Valium 10mg with supervised by staff nurse.
DATE & TIME : 29/11/07 @ 11.30 a.m.

EVALUATION :
Patient’s anxiety had reduced after 2 hours nursing
intervention given.

SUPPORTING DATA :
Patient verbalized that he was ready for surgery and
appear calm.
 Potential Low Hemoglobin
Related To Heavy hematuria

DATE : 29/11/07 @ 12.40 p.m.

SUPPORTING DATA :
Continuous bladder irrigation (CBI) are moderately
with blood.

GOAL :
Risk of bleeding will be reduced after 12-24 hours
nursing intervention and during hospitalization.
NURSING INTERVENTION :

1) Assess patient for sign of bleeding that may develop such as patient’s
face look pale
® As a early detection of bleeding to plan appropriate nursing
intervention
I : I assess Mr.B’s general condition for sign of bleeding such as pale skin,
clammy skin and the result is patient stable.

2) Monitor vital sign especially BP and pulse hourly for 4 times and
continue 4 hourly.
® Dropping BP below normal and high pulse rate may indicate patient
having bleeding.
I : I checked Mr.B’s vital sign and record in the observation chart. BP
Mr.B are stable.
3) Observed Continuous bladder drainage.
® Color of urine in will changed from bright red to light pinkish urine
and clear urine.
I : I observed color of urine in drainage bag and found out that the color
had change from bright pinkish to clear urine during CBI in progress
and light pinkish after CBI had been off.

4) Advice patient to complete rest in bed (CRIB)

® Restriction help in reduce risk of bleeding.
I : I advised Mr.B to complete rest in bed (CRIB) till CBI been off.

5) Maintain CBI as per regime according to blood stained from the

drainage.
® To prevent formation of blood clot.
I : I ensure the CBI is dropping as prescribed and change the irrigation
fluid when finished.
6) Strictly input and output chart.
® help in monitor reducing of bleeding by observing color and to ensure
correct amount been administering to patient as well as output of
patient.
I : I chart in IO chart every time change the irrigation and write the
amount and color of output drainage.

7) Encourage fluid intake at least 1.5-2L/day

® Drinking o lot of water will result in increasing of urine output that will
help to flush out the blood and prevent blood clot.
I : I encourage patient to drink a lot of water and explain the purpose of
it. Mr.B verbalized that he understand and will drink a lot of water.
8) Explain to patient the cause of bleeding
® Help to reduce patient’s anxiety about the bleeding that occur.
I : I explain to Mr.B that the bleeding is a main complication of TURP
and will be treat within 12-24 hours. Mr.B verbalize that he understand
my explanation and feel more calm.

9) Inform doctor if patient show sign of bleeding such as dropping in BP

below normal, CBI drainage increasing in redness.
® For further management
I : I inform that Mr.B’s urine changed from clear urine to light pinkish
after CBI had been off and Staff nurse had informed Dr.H when he do
round in ward and Dr.H then advice patient to drink a lot of water.
DATE & TIME : 29/11/07 @ 10.30 p.m.
EVALUATION :
Patient’s bleeding had reduced after 10 hours nursing
intervention
SUPPORTING DATA
• Urine is lightly blood stained and reduced the brightness of color.
• BP patient was stable. 130/70mmHg

DATE & TIME : 30/11/07 @ 10.30 a.m.

EVALUATION :
Patient did not have the complication of surgery :
bleeding.
SUPPORTING DATA :
• Patient’s urine are very light pinkish
• BP was 120/70mmHg
 Potential Ascending Infection
Related To Continuos Bladder Irrigation

DATE : 29/11/07 @ 12.40 p.m.

SUPPORTING DATA :
Patient was on CBI.

GOAL :
Patient did not having any infection and evidence of
infection can be detect early after nursing
intervention given and during hospitalization.
NURSING INTERVENTION

1) Assess patient’s general condition for sign of infection such as itching,

redness, pain and swelling at site of operation.
® As a baseline data and early detection of infection.
I : I asked Mr.B whether he feel any itching or pain at the parineal part
and he verbalized that he feel a bit of pain but did not feel itching.

2) Check patient vital sign especially temperature hourly after surgery for
4 times then continue with 2 hourly vital sign.
® Increasing temperature above normal may indicate patient having
infection
I : I monitor Mr.B‘s temperature and it was 36.4°C post surgery.
3) Ensure the Drainage bag was hanged below level of bladder.
® Prevent from back flow of urine that may cause infection
I : I ensure that the drainage bag was hanged beside the side rail and
below level of Mr.B’s bladder.

4) Advice patient not to touch the CBI unnecessarily

® Reduce risk of ascending infection from CBI.
I : I advice Mr.B not to touch CBI and tell him the purpose. He said that
he understand and will not going to touch it.
5) Administer IV fluid as ordered by doctor or encourage patient to
increase fluid intake.
® Help to flush out blood clot that may cause bleeding as well as
microorganism that may had enter.
I: I ensure IV Dextrose 5% alternate N/Saline that had been ordered by
Dr was in progress and advice Mr.B to drink a lot of water especially
after CBI and drip had been off.
6) Administer medication, antibiotic as prescribed by doctor
® As a prophylactic technique to prevent from infection
I : I observed staff nurse in administering IV Rocephine 1g daily during
my working shift.

7) Encourage high protein diet and vitamin C.

® To increase level of immune system that will help to prevent as well as
fight the infection.
I : I encourage Mr.B to choose diet that high in protein and vitamin C
such as fish and orange juice and tell him the benefit of it.
8) Inform to the doctor if any abnormality detected
® For further the treatment
I : I did not inform the doctor because patient didn’t show
any sign and symptom of infection
DATE & TIME : 30/11/07 @ 10.30 a.m.

EVALUATION :
Patient did not having any infection after nursing
intervention given and during hospitalization

SUPPORTING DATA:
Mr.B's temperature is 36.6 °C and stable.
 Alteration In Comfort,
Pain Related To Surgical Intervention (TURP)

DATE & TIME : 29/11/07 @ 1 p.m.

SUPPORTING DATA :
• Patient verbalized pain after 20 minutes done the surgery
• Patient’s facial expression showed that he is uncomfortable.

GOAL :
Patient’s pain will be reduced within 1-2 hours after
nursing intervention and during hospitalization
NURSING INTERVENTION :

1) Assess patient’s level of pain such as severity, duration, and location.

Assess by using pain scale, mild : 0-3, moderate : 4-7 and severe : 8-10
® As a baseline data to plan appropriate nursing intervention
I : I asked patient severity, location and duration using pain scale and the
result is 4 which is moderate.

2) Monitor patient’s vital sign especially blood pressure every hourly for
6 times then continue 6 hourly observation
® High blood pressure indicate patient is having pain
I I checked Mr. B vital sign and his blood pressure showed in high rate
that is 150/90
3) Administer medication, analgesic as prescribed by doctor
® As a prophylactic technique to reduce pain
I : I administered IM pethidine 50 mg as ordered by Dr H with supervised by the
staff nurse.

4) Teach and encourage patient to do deep breathing exercise (DBE).

® As a relaxation technique that will help in reducing pain.
I : I teach patient to do deep breathing exercise and
encourage patient to demonstrate back

5) Positioning patient in correct and comfortable position.

® Correct position help in promoting comfort as well as reducing pain.
I : I advised patient to lay in supine position and he verbalize that the
position is comfortable.
6) Advice patient to complete rest in bed ( CRIB)
® Restriction movement help to reduce patient’s pain.
I : I advised patient to complete rest in bed till CBI been Off.

7) Explain to patient the cause of the pain

® Help patient to reducing patient anxiety about the cause of the pain
I : I re-explain to Mr.B that the pain is cause by the destruction of the
prostate tissue and patient verbalize that he understand my explanation

8) Inform doctor if pain still persist and did not reduced after all nursing
intervention given.
® For further management
I : I did not informed Dr H because Mr.B had verbalize that the pain has
reduced and he feel more comfortable
DATE & TIME : 29/11/07 @ 3 p.m.

EVALUATION :
Patient’s pain had reduced after 2 hours nursing
intervention given.

SUPPORTING DATA:
• Patient verbalize that the pain had reduced and he feel more
comfortable.
• Patient’s pain scale had reduced to 2.
 Knowledge Deficit
Related To home Care Management

DATE : 1/12/07 @ 10.30 a.m.

SUPPORTING DATA :
Before discharge, patient asked a lot of question
regarding self care at home.

GOAL :
Patient understand health education given to him
and able to take care of himself after discharge.
NURSING INTERVENTION :

1) Assess patient’s level of understanding and knowledge regarding self

care.
® As a baseline data to plan further health education to patient.
I : I asked Mr.B whether he know about self care after discharge and he
verbalize that he is not very clear about it and hope that I can help in
giving information regarding self care.

2) Advice patient in physical activity that suitable for him after discharge
which is light exercise and avoid heavy exercise such as lift heavy
things.
® Heavy exercise may cause increase in intra-abdominal pressure and
lead to bleeding.
I : I advice Mr.B not to do heavy work such as lifting and tell him the
purpose
3) Tell patient that slide blood stained in urine are normal.
® Reduce anxiety that may feel by patient if urine color are slide pinkish.
I : I explain to Mr.B that he may has slide bleeding in urine and tell that it
will stop within few days.

4) Advice patient to monitor urine for few days after discharge especially
color urine.
® Detect complication of surgery which is bleeding that may showed by
increase in redness of the urine.
I : I advice Mr.B to check his urine every time he pass urine and ensure
that color of urine change from pinkish to clear urine after few days.
5) Advice patient to take care of his personal hygiene especially perineal
part every time he pass urine.
® Help in reducing risk of infection that may cause by bleeding
I : I advice Mr.B to clean his perineal part and dry it with clean towel.

6) Encourage patient to increase fluid intake.

® Help to flush out blood clot that may still persist and prevent further
complication such as infection.
I : I encourage Mr.B to drink a lot of water and tell him the benefit. He
verbalized that Dr.H also advice him to do the same thing and tell me
that he will follow it.
7) Explain to patient regarding medication prescribed by doctor after
discharge.
® Clear explanation about medication help in correct way of taking it.
I : I explain to Mr.B regarding his medication that is Tab. Augmentin
625mg BD. I also advice him to take the medication on time.

8) Explain to patient the complication of surgery (TURP) that may

develop.
® Help patient to detect if any complication occur after discharge.
I : I explain to Mr.B that the complication of TURP is retro ejaculation,
urethral stricture, incontinence, and epididimytis.
9) Remind patient to came for follow up as schedule or if any
complication occur
® To monitor progress of patient as well as treat complication if occur

I : I remind Mr.B to come for follow up on 7/12/2007 or if sign of

complication occur such as difficulty in passing urine and incontinence
DATE & TIME : 1/12/07 @ 11.30 a.m.

EVALUATION :
Patient understand health education that been given
able to take care of himself after discharge

SUPPORTING DATA :
Patient verbalized that he was more clear about self
care after health education given by me.
 HEALTH EDUCATION
1) Activity
• Healing process : 4 - 8 weeks
• Good rest
• No strenuous activity and heavy lifting.
• Cycling are not allowed (bleeding)

2) PU + BO
• Keep bowel movement regular.
• Possibility sign & symptom of urgency, passing out
small blood clot in urine, burning sensation.
3) Diet
• A lot of fluid (8-10 glass per day)
• High protein diet (healing)
• High fiber diet (bowel movement)
• Vitamin C (increase immune system)
• Avoid taking any cigarette or alcohol.

4) Medication
• Type of the drugs, indication, frequency, amount, side effect.

5) Follow Up
• On 8/12/2007
• Came to hospital if sign of the complication occur
 DISCHARGE
On 1st November 2007 at 12.15 p.m.

Medication to Mr.B which is :

• Tab. Augmentin 625mg BD

Vital sign is stable :

• TEMPERATURE  36.2 ºC
• PULSE  78 bpm
• RESPIRATION  20 bpm
• BLOOD PRESURE  120/70 mmHg
 FOLLOW UP
On 8th December 2007

He still feel urgency and frequency in pass urine sometimes

but it is not as much as before the operation.

Dr.H explained that the symptom will go off several week

after the operation.

Dr. H not prescribed any medication during follow up

Drink a lot of water & avoid heavy activity.

 SUMMARY
Mr.B, 58 years old admitted to Tawakal Specialist Hospital from
20th November 2007 – 1st December 2007

Complain of :
• Syncope (black out) 2 times at home
• Nocturia (2/52)
• Frequency & urgency in passing urine (2/52)
• Feeling incomplete emptying after pass urine (2/52)
 Con’t…
Investigation for him in clinic which is:-
• Urine FEME
• Admission Profile (GP59H)
• CT Scan
• MRI Brain
• EEG
• ECG
• Ultrasound Kidney & Bladder

TURP done on 29th November 2007

Discharge : 1st December 2007
Follow up : 8th December 2007
 CONCLUSION
In a nutshell, I’m very glad because at last I managed to finish my
case study. I have learned a lot of new things and experienced. Other
than that, I had put a lot of effort and time to complete my case
study.
 
I’m very lucky because I get an opportunity to go to operating
theatre to see how the Transurethral Resection of Prostate procedure
done by the Urologist. My case study had helped me much in every
aspects, not only I can get new knowledge but it also helped me how
to make a good rapport with everyone surround us, especially in the
hospital environment.
 
 Con’t…
I would like to take this opportunity to express a thousands of thanks
to everyone who had helped me much especially to Dr. H and all the
Nurse Instructor. I hope that I can achieve my learning objective for
my case study.
 
Finally, I hope that my case study will give adequate information to
all of the viewers.

Thank you so much.

 
BOOKS :

• Walsh M.,(2004) Watson’s Clinical Nursing and Related Sciences (6thEdition),

Baillire Tindall, New York. (page 1240 - 1246 ).

• Waugh A., and Grant A., (2002) Rose and Wilson, Anatomy and Physiology (9th
Edition), Churchill Livingstone, New York (page 339 - 360)

• Fundamentals Of Nursing (Concept, Process, and Practice), (6th edition),

Barbaara Kozier, Glenora Erb, Audrey Jean Berman, Karen Burke, New Jersey
(page 1350 - 1356)

• Dimensions of Medical Surgical Nursing (10Edition) Brunner & Suddath (page

1538 - 1546)

• MIMS Annual Malaysia, Dims, P.J,(Full prescribing information) 16th Edition

(2004) Sdn. Bhd.
INTERNET :
• CELEBRATELOVE –
www.celebratelove.com/glossary.htmL
(1/12/07 @ 3 p.m.)
 
• UKHEATHCARE - www.ukhealthcare.uky.edu/patient/glossary/glossary
(1/12/07 @ 3 p.m.)
 
• ECOHELATH –
www.ecohealth101.org/glossary.html
(8/12/07 @ 5 p.m.)
 
• HEALTH SUPERSTORE –
www.healthsuperstore.com/hni/glossary-b2.asp
(8/12/07 @ 5 p.m.)