HESI Case Study: Benign Prostatic Hyperplasia

Which instruction should the nurse provide to the client before starting the procedure?

While voiding into a special toilet, urine flow pressure will be monitored. The pressure of the urine flow is measured to determine the degree of obstruction.

Management Issues: Client Care Assignments The client is scheduled to have emergency surgery. His partner is with him, and they are very anxious and upset. While the client is awaiting transport to the operating room, which nursing staff member should be assigned to his care?

A PN who has worked on the unit for 3 years. A PN, with direct RN oversight, has experience in the care of clients on this unit. They have the ability to continue to monitor this unstable client until they are taken to the operating room. The PN should frequently update the RN and/or RN charge nurse of any new developments.

Meet the Client: A client visits the health clinic and reports increasing urinary frequency, dribbling, and nocturia. The client is scheduled for diagnostic tests to detect benign prostatic hyperplasia (BPH).

Case study

During administration of the aminocaproic acid infusion, the nurse monitors the client for adverse effects of the medication. What assessment data would indicate the onset of a thrombotic complication?

Chest pain and dyspnea. Common manifestations of pulmonary embolism are chest pain and dyspnea.

A Complication Occurs The nurse reviews the client's vital signs taken by the UAP and identifies changes from the vital signs that were taken 4 hours earlier. Four hours earlier: blood pressure 112/64 mmHg, heart rate 82 beats/minute, respirations 16 breaths/minute, temperature 98.0° F (36.6o C), O2 saturation 94%. Current vital signs: blood pressure 88/50 mmHg, heart reate 106 beat/minute, temperature 97.2° F (36.2o C), O2saturation 85%. The nurse assesses the client and determines that he is dyspneic, lethargic, pale, and cool and has a large amount of bright red bleeding in his urinary catheter. Which assessment finding warrants intervention by the nurse?

Confused to surroundings. Confusion is an acute symptom of cerebral hypoxia and require immediate intervention.

Diagnostic Tests The client is scheduled for a digital rectal exam, serum prostate-specific antigen (PSA) level, urinalysis, serum creatinine, and blood urea nitrogen (BUN). The client states that he has had the rectal exam and PSA levels done before for prostate screening. He asks why the other lab tests (creatinine and BUN levels) are necessary. Which information is most important for the nurse to include when explaining the need for these tests? (Select all that apply.)

Emphasize to the client that prostate enlargement may result in renal damage which these tests will evaluate. Prostate enlargement may result in kidney damage, which can cause a change in urine production. Inform the client that repeat testing is necessary as an enlarged prostate gland blocks urine flow and causes kidney damage. As the flow of urine is blocked by the enlarged prostate gland, gradual dilation of the ureters (hydroureter) and kidneys (hydronephrosis) can occur, resulting in increased creatinine and BUN levels. Advise the client that it is protocol for the healthcare provider (HCP) to conduct then recheck tests to compare previous results. It is important to monitor progression and degree of kidney damage.

The nurse initiates the infusion of 0.9% sodium chloride and informs the HCP of the client's signs and symptoms of a blood transfusion reactions. The HCP determines that the client is having an acute hemolytic reaction. The nurse instructs the UAP to place the emergency cart bedside. What is the next action the nurse should implement?

Notify the laboratory of the transfusion reaction. The next step in managing the transfusion reaction is to notify the lab so they can begin the transfusion reaction workup.

The client asks if he will need to have any more yearly rectal exams. Which nursing intervention best promotes effective communication regarding follow up care?

Provide the client with written information explaining the need for yearly rectal exams and PSA screenings. Since the prostate gland is only partially removed during TURP, annual rectal exams and PSA screenings for prostate cancer should still be performed.

The nurse recognizes that nonverbal behavior such as lack of eye contact should not be ignored. What action is most important for the nurse to take regarding the partner's minimal eye contact?

Tell the partner you noticed she appeared to look away when you were speaking. Avoiding eye contact or engaging in minimal eye contact should be addressed. This would be a common response when someone is uncomfortable and not handling a stressfull or unknown situation.

Client Teaching: Medication Therapy Test results, along with urodynamic flow studies, indicate that the client prostate gland is significantly enlarged, and treatment is recommended.The client elects to try medical management of his symptoms. He receives prescriptions for oral finasteride and terazosin. The nurse provides instructions about these medications. What information should be included when teaching the client about terazosin?

This medication can cause dizziness so it should be taken at night. Terazosin is an alpha-adrenergic blocking agent and is likely to cause orthostatic hypotension and dizziness, especially when the client first starts the medication. It is recommended to take the medication at night.

Administration of a Blood Transfusion The aminocaproic acid infusion successfully stops the bleeding without complications. The client's hemoglobin and hematocrit decrease as the result of the bleeding, and the HCP prescribes the administration of 1 unit of packed red blood cells (PRBC.) Which action should the nurse implement to reduce the risk for a hemolytic transfusion reaction?

Verify the blood type and Rh factor with another nurse. Acute hemolytic reactions are the result of the infusion of incompatible blood products. This risk is reduced if two nurses verify and compare the label on the blood with the client's identification band and the blood bank form. In addition, the transfusion should be started slowly, and the client should be observed carefully during the first 15 to 30 minutes of the transfusion.

The nurse is monitoring the client and preparing client for surgery. Which task is within the scope of practice for the PN to complete?

Prepare a client with renal failure for a scheduled dialysis treatment. This client is stable, and this task does not require the expertise of the RN

The HCP prescribes an infusion of aminocaproic acid. The prescription is for a loading dose of aminocaproic acid IV 5 grams to be infused in 250 mL of 5% dextrose over 1 hour. The tubing drop factor is 15 gtt/mL. How many gtts/minute would the nurse set for the IV rate? (Enter numerical value only. If rounding is necessary, round to the whole number.)

63

When half of the blood is infused, the unlicensed assistive personnel (UAP) tells the nurse that the client is very nervous and has a headache. Which action should the nurse implement first?

Assess the client for additional symptoms. The client is exhibiting signs of a possible transfusion reaction. The nurse should immediately assess the client for additional symptoms, such as the presence of fever or chills, and then obtain vital signs.

The client has continuous bladder irrigation (CBI) infusing with 0.9% sodium chloride. Eight hours after surgery, the urinary drainage is reddish pink. What action should the nurse take?

Document that the CBI is infusing correctly. Normal drainage is reddish pink, clearing to light pink within 24 hours postoperatively. The drainage should be clear yellow by the 4th postoperative day. 0.9% sodium chloride is the desired solution for irrigation because it is isotonic. Hypotonic or hypertonic solutions may result in fluid shifts.

The client's prostate specific antigen (PSA) level is 8 ug/mL (8 ng/mL) , normal is 0-4 ug/mL (0.4 - 4 ng/mL). The client appears distressed and worried he has prostate cancer and wants to know if that is why he is having these symptoms. Which intervention should the nurse implement to address the client's concern?

Explain that PSA levels can be elevated with gland enlargement, as well as cancer, so more tests are needed. Elevated PSA levels are associated with prostate cancer. However, slight elevations may also occur in BPH. PSA levels may also be elevated as the result of infection, or if the prostate gland is manipulated during a digital rectal exam.

The nurse administers oxygen per face mask, ensures that the IV catheter is patent, and notifies the HCP that the client is experiencing overt bleeding and manifestations of hypovolemic shock. Specimens for stat laboratory specimens and arterial blood gases are obtained. Which of the client's serum laboratory values requires immediate intervention by the nurse?

Hematocrit 28 % (0.28) Normal hematocrit is 37 - 46 % (0.37 - 0.46). A low hematocrit would be expected in hypovolemic shock secondary to hemorrhage and requires immediate intervention.

The client tells the nurse that he will have cut back on drinking fluids to reduce their symptoms. Which instruction is most important for the nurse to provide to the client?

Increase fluid intake to decrease the risk of developing a urinary tract infection. Clients with BPH often restrict fluid intake to reduce symptoms, but this should be discouraged because it increases the risk for urinary tract infection.

Early the next morning, the nurse notes that the catheter is draining a large amount of thick, bright red urine. What actions should the nurse take? (Select all that apply.)

Increase the flow rate of the CBI. The flow rate of the CBI should be increased, to decrease the risk for blood clot obstruction to the catheter. Notify the HCP of the findings. Bright red bleeding with increased viscosity is an indication of arterial bleeding. The HCP should be notified immediately to determine the course of action necessary. In addition, the flow rate of the CBI should be increased or manual irrigation performed to decrease the risk for blood clot obstruction of the catheter. Perform manual irrigation. Manual irrigation can be performed to help prevent blood clot obstruction and to resolve obstruction to the catheter.

The nurse assesses that the client's skin is warm and flushed. The client reports having generalized body aches, and he starts experiencing chills. His blood pressure is 114/68 mmHg, heart rate 92 beats/minute, respirations 18 breaths/minute, and temperature 102.2° F (39o C). The nurse suspects that the client is experiencing a febrile transfusion reaction. What action should the nurse take next after stopping the transfusion?

Infuse 0.9% sodium chloride solution through separate IV tubing. After stopping the blood transfusion, the nurse should next infuse 0.9% sodium through a separate IV tubing to maintain IV patency. The client may experience shock and may need additional fluids and medications.

The nurses discuss the components needed to prove professional negligence or malpractice. They discuss breach of duty. What action by the nurse would indicate a breech of duty.

Initial blood transfusion rate 10 mL/min for the first 15 minutes. Breach of duty is the failure to perform according to established standards, such as those define in the Infusion Nursing Society.

The client tells the nurse that he is uncomfortable with a constant feeling like he has to urinate. The nurse explains that this is the result of the oversize balloon putting pressure on the sphincter of the bladder. Which nursing intervention best promotes effective communication?

Instruct the client to try not to bear down around the catheter. The client could damage the urinary sphincter if he tries to void around the catheter. Bearing down to try to urinate will create more pressure on the sphincter.

Therapeutic Communication Based on his continued lack of symptomatic improvement and high volumes noted during residual catheterization, the client elects to have surgery. A transurethral resection of the prostate (TURP) is performed. While the client is in surgery, his partner brings his belongings to the assigned room on the surgical nursing unit. The nurse assigned to the client care greets them. The nurse asks the client's partner if they have any questions or concerns. They responds calmly that they will be happy when he returns from surgery, and they then turn their head and look away. Aware of the client's partner's body language, what action should the nurse implement?

Let the client's partner know that you will be glad to answer any questions she may have. This response gives the partner the opportunity to choose any further interaction, which include avoidance of physical touch between persons who are not close.

Which nursing interventions promotes effective communication when teaching the client about finasteride? (Select all that apply.)

Liver function studies (LFTs) need to be monitored frequently. Finasteride can cause hepatic dysfunction, so liver function tests results should be reviewed periodically. Most clients see significant change in BPH symptoms in 4 months. It may take 12 weeks to 6 months to achieve the desired response. Protect the medication from light. Finasteride should be protected from the light. Clients can experience breast enlargement. One of the adverse effects of finasteride is breast enlargement and tenderness.

The nurse initiates a physical examination to further investigate the client's symptoms. Which assessment finding would indicate that the client is experiencing urinary retention related to BPH? (Select all that apply.)

Observance of bladder distention. Bladder distention is an assessment finding in urinary retention. Bladder is above the symphysis pubis when gently palpated. A distended bladder will be palpable as an ovid (oval) shape above the symphysis pubis. Observance of dribbling after voiding. This is a symptom of urinary retention.

Postoperative Nursing: TURP After surgery, the client is admitted to the surgical nursing unit for overnight observation and postoperative care. Which postoperative intervention should the nurse perform first?

Observe the urinary drainage. A common postoperative complication that can be potentially life-threatening is bleeding, which will be seen in the urinary drainage.

Ethical-Legal Issues: Malpractice It is determined that the client experienced an acute hemolytic transfusion reaction. This type of reaction occurs when there is an antigen-antibody reaction due to ABO or Rh incompatibilities. In addition to stopping the transfusion, the nurse sends the blood bag, tubing, and a urinalysis to the lab, and administers an antipyretic medication. The nurse is concerned that the client experienced a transfusion reaction and expresses her fear of being sued with the RN charge nurse. Which nursing intervention best promotes effective communication by the charge nurse?

Review blood transfuion interventions with the nurse. This is an assertive response by the charge nurse and offers both nurses an opportunity to review the situation to determine variations from policy and any evidence of negligence.

Discharge Teaching The client is transported to the operating room for emergency surgery to stop the hemorrhage. Following surgery, the client is transferred to the surgical critical care unit (SICU.) Once hemodynamically stable, the client is transferred to the surgical nursing unit, where his condition continues to improve. The client prepares for discharge. The nurse is teaching the client how to perform pelvic floor muscle exercises. The instructions include contracting the pelvic floor muscles for 5 seconds, then relaxing for 5-10 seconds. Which nursing intervention best promotes effective communication while teaching the client about contracting pelvic floor muscles?

Squeeze as if stopping the flow of urine. This best describes how to contract the pelvic floor muscles. After holding the contraction for 5 seconds, the client should relax for 5-10 seconds, and repeat 15-20 times TID. These exercises are also called Kegel exercises.

During the night, the client reports increased bladder discomfort. The nurse's observation of the urinary drainage catheter indicates minimal output for the last 2 hours. What action should the nurse take?

Stop the CBI, and irrigate the catheter. The catheter is most likely obstructed by blood clots and should be manually irrigated with 50 ml of sterile, 0.9% sodium chloride. The nurse should first check to make sure there are no kinks in the drainage tubing or other obvious signs of catheter obstruction!

Which assessment findings warrants immediate intervention by the nurse? (Select all that apply.)

Sudden painful inability to urinate. This is a sign of acute obstruction and requires an indwelling urinary catheter to allow urine to drain. Painful, frequent urination. This is a sign of urinary tract infection that requires antibiotic therapy as soon as possible.

Catheterization The client continues to take his medications for 8 months, but his symptoms do not improve significantly and he is scheduled for a uroflowmetry study. The client arrives at the clinic early for the uroflowmetry test and is asking the nurse to explain the procedure. Which nursing intervention best promotes effective communication?

Uroflowmetry is a non-invasive exam to measure the volume and flow of urine. Uroflowmetry is a simple non-invasive procedure that measures the flow of urine which can indicate the extent of blockage the prostate is creating.