8 Prostatectomy Nursing Care Plans

Prostatectomy removes part or all of the prostate. Your postop job is hemodynamic stability, comfort, preventing complications, and keeping bleeding and bladder spasms under control.

What is Prostatectomy?

Prostatectomy is surgical removal of the prostate, either all of it (radical) or part. Simple prostatectomy treats benign prostatic hyperplasia; radical prostatectomy treats prostate cancer.

• Transurethral resection of the prostate (TURP): Obstructive tissue of the medial lobe around the urethra is removed with a resectoscope passed through the urethra.
• Suprapubic/open prostatectomy: For masses over 60 g (2 oz). Obstructing tissue is removed through a low midline incision into the bladder. Preferred when bladder stones are present.
• Retropubic prostatectomy: Hypertrophied tissue high in the pelvis is removed through a low abdominal incision without opening the bladder. Used when the tumor is limited.
• Perineal prostatectomy: Large masses low in the pelvis are removed through an incision between the scrotum and rectum. This more radical approach is done for larger tumors or nerve invasion and may cause impotence.

Nursing Care Plans and Management

Care planning covers homeostasis and hemodynamic stability, comfort, complication prevention, and patient teaching on the procedure, prognosis, and treatment.

Nursing Problem Priorities

1. Pain management
2. Prevention and management of complications
3. Promoting urinary continence
4. Monitoring for urinary retention or incontinence
5. Early ambulation and mobility
6. Monitoring for erectile dysfunction
7. Catheter care and removal

Nursing Assessment

Assess for the following subjective and objective data:

• Pain or discomfort at the surgical area
• Urinary frequency, urgency, or difficulty voiding
• Concerns about sexual function and fertility
• Emotional distress or body image changes
• Incision sites for redness, swelling, or infection
• Lower abdominal tenderness or masses
• Urinary output and urine characteristics
• Post-void residual (PVR) volume
• Catheter drainage and any abnormalities

Assess for factors related to the problems patients encounter:

• Mechanical obstruction: blood clots, edema, trauma, the surgery itself
• Catheter or balloon pressure and irritation
• Loss of bladder tone from preoperative overdistension or decompression
• Vascular surgical area with difficult bleeding control
• Restricted preoperative intake
• Postobstructive diuresis
• Instrumentation, catheter, and frequent bladder irrigation
• Traumatized tissue and surgical incision (perineal)
• Painful bladder spasms
• Autonomic responses

Nursing Diagnosis

Build the nursing diagnoses from your assessment and the patient's priorities. The labels matter less than the clinical judgment behind them.

Nursing Goals

Goals and expected outcomes may include:

• The patient will void normal amounts without retention and demonstrate behaviors to regain bladder control.
• The patient will stay hydrated with stable vitals, palpable pulses, good capillary refill, moist membranes, and adequate output.
• The patient will show no active bleeding and no signs of infection, and will heal on time.
• The patient will report relief of pain and rest adequately, using relaxation and diversional skills.
• The patient will understand changes in sexual function that may follow surgery and discuss concerns with partner and caregiver.
• The patient will verbalize understanding of the procedure, potential complications, and therapeutic needs, and correctly perform required self-care.

Nursing Interventions and Actions

1. Improving Renal Function and Urinary Elimination

Removing prostatic tissue disrupts the urinary tract and irritates surrounding tissue, so expect difficulty starting and stopping the stream, urgency, and frequency.

During bladder irrigation, assess urine output and the drainage system. Edema, blood clots, and bladder spasms cause retention.

Have the patient void in the normal position; once the catheter is out, have him stand and walk to the bathroom often. Promotes normal voiding.

Check the dressing, incision, and drainage for excessive bleeding and signs of infection. Sutures can reopen.

After catheter removal, record time, amount, and stream size, and note bladder fullness, inability to void, or urgency. The catheter usually comes out 2 to 5 days after surgery, but voiding can stay difficult from urethral edema and lost bladder tone.

Have the patient void with the urge but no more than every 2 to 4 hr per protocol. Voiding with urge prevents retention; spacing voids to every 4 hr builds bladder tone and aids retraining.

Measure residual volumes via suprapubic catheter or Doppler ultrasound. Residuals over 50 mL mean the catheter stays until bladder tone improves.

Encourage fluid intake to 3000 mL as tolerated; limit fluids in the evening once the catheter is out. Maintains hydration and renal perfusion; evening restriction reduces nighttime voiding.

Teach perineal exercises: tighten the buttocks, stop and start the urine stream. Regains bladder and sphincter control and minimizes incontinence.

Tell the patient dribbling is expected after catheter removal and resolves with recovery. Normal function usually returns in 2 to 3 wk but can take up to 8 mo after the perineal approach.

Maintain continuous bladder irrigation (CBI) as indicated in the early postoperative period. Flushes clots and debris to keep the catheter patent and urine flowing.

2. Promoting Adequate Fluid Balance

Surgical blood loss, restricted early intake, and diuretics all put the patient at risk for deficient fluid volume.

Monitor I&O. Indicates fluid balance and replacement needs; with irrigation, this is how you estimate blood loss and true urine output. After obstruction is relieved, marked diuresis may occur during early recovery.

Monitor vitals for increased pulse and respiration, decreased BP, diaphoresis, pallor, delayed capillary refill, and dry membranes. Dehydration or hypovolemia needs prompt intervention. Hypertension, bradycardia, nausea, and vomiting suggest TURP syndrome and require immediate medical intervention.

Investigate restlessness, confusion, and behavior changes. May reflect decreased cerebral perfusion or cerebral edema from solution absorbed into the venous sinusoids during TURP (TURP syndrome).

Encourage fluid intake to 3000 mL/day unless contraindicated. Flushes the kidneys and bladder of bacteria and clots. Watch for water intoxication or overload.

Anchor the catheter and avoid excessive manipulation. Pulling can cause bleeding, clots, and plugging with bladder distension.

Observe catheter drainage for excessive or continued bleeding. Some bleeding is expected in the first 24 hr for all but the perineal approach. Continued heavy or recurrent bleeding needs medical evaluation.

Evaluate urine color and consistency.

• Bright red with bright red clots: arterial bleeding, requires aggressive therapy.
• Dark burgundy with dark clots, increased viscosity: venous bleeding, the most common type, usually self-limiting.
• Bleeding without clots: may indicate a blood dyscrasia or systemic clotting problem.

Inspect dressings and wound drains; weigh dressings if indicated and note hematoma. Bleeding may be visible or sequestered in the perineum.

Avoid rectal temperatures, tubes, and enemas. These refer irritation to the prostatic bed and raise pressure on the capsule, risking bleeding.

Monitor laboratory studies as indicated. See Laboratory and Diagnostic Procedure

Administer IV fluids or blood products as indicated. For inadequate oral intake or excessive losses.

Maintain traction on the indwelling catheter; tape it to the inner thigh. Traction on the 30-mL balloon in the prostatic urethral fossa presses on the prostatic capsule's arterial supply to control bleeding.

Release traction within 4 to 5 hr; document application and release. Prolonged traction can cause permanent trauma or urinary control problems.

Administer stool softeners and laxatives as indicated. See Pharmacologic Management

3. Initiating Infection Control and Minimizing Infection Risk

Surgery and urinary catheters introduce bacteria, so infection is a real and serious complication here.

Monitor vitals for low-grade fever, chills, rapid pulse and respiration, restlessness, irritability, and disorientation. Cystoscopy and TURP raise the risk of surgical or septic shock from instrumentation.

Observe drainage from wounds around the suprapubic catheter. Drains raise infection risk, shown by erythema and purulent drainage.

Maintain a sterile catheter system; give regular catheter and meatal care with soap and water and apply antibiotic ointment at the site. Prevents introduction of bacteria.

Ambulate with the drainage bag dependent. Avoids reflux of urine that introduces bacteria into the bladder.

Change dressings frequently, cleaning and drying skin each time. Wet dressings irritate skin and breed bacteria.

Use ostomy-type skin barriers. Protect surrounding skin from excoriation and infection.

Administer antibiotics as indicated. See Pharmacologic Management

4. Providing Acute Pain Relief

Incision, tissue trauma, inflammation, catheters, and drains all generate pain. Managing it supports comfort and healing.

Assess pain location, characteristics, and intensity (0 to 10 scale). Sharp intermittent pain with the urge to void or urine passing around the catheter suggests bladder spasms, worse with suprapubic or TUR approaches and usually easing by 48 hr.

Keep the catheter and drainage system patent and free of kinks and clots. Reduces bladder distension and spasm.

Promote intake up to 3000 mL/day as tolerated. Constant fluid flow reduces bladder mucosa irritation.

Give accurate information about the catheter, drainage, and bladder spasms. Eases anxiety and promotes cooperation.

Provide comfort measures: position changes, back rubs, diversion, relaxation, deep breathing, and guided imagery. Reduces muscle tension and improves coping.

Provide sitz baths or heat lamps if indicated. Promotes perfusion, resolves edema, and aids healing in the perineal approach.

Administer antispasmodics as indicated. See Pharmacologic Management

5. Improving Sexual Function

Prostate removal puts the patient at risk for erectile dysfunction, decreased libido, and other sexual problems. Education, support, and specialist referral are part of the plan.

Open the door for the patient and partner to talk about incontinence and sexual function. Anxiety and hesitation may have blocked earlier questions.

Discuss basic anatomy and answer questions openly. The nerve plexus controlling erection runs posterior to the prostate through the capsule. Procedures that spare the capsule usually do not cause impotence or sterility. Surgery may not be a permanent cure, and hypertrophy can recur.

Give accurate expectations for return of sexual function. Cutting the perineal nerves during radical procedures causes physiologic impotence; with other approaches, sexual activity usually resumes in 6 to 8 weeks. A penile prosthesis may be recommended after radical perineal procedures, and sildenafil citrate (Viagra) is another option to restore erection.

Discuss retrograde ejaculation with transurethral or suprapubic approaches. Seminal fluid goes into the bladder and out with the urine. It does not affect function but reduces fertility and makes urine cloudy.

Instruct in perineal and urinary stream interruption exercises. Kegel exercises rebuild muscular control of continence and sexual function.

Refer to a sexual counselor as indicated. For persistent or unresolved problems.

6. Initiating Patient Education and Health Teachings

Patients need the procedure, recovery timeline, and self-care clear so they can manage recovery and avoid complications.

Review the procedure and future expectations. Gives the patient a base for informed choices.

Stress good nutrition with fruit and increased fiber. Promotes healing and prevents the constipation that risks postoperative bleeding.

Discuss activity restrictions: no heavy lifting, strenuous exercise, prolonged sitting, long car trips, or climbing more than two flights of stairs at a time. Increased abdominal pressure stresses the bladder and prostate and risks bleeding.

Encourage continued perineal exercises. Supports urinary control.

Teach urinary catheter care if present and identify support sources. Promotes competent self-care.

Tell the patient to avoid tub baths after discharge. Reduces the chance of introducing bacteria.

Review signs needing medical evaluation: erythema, purulent wound drainage, changes in urine character or amount, urgency or frequency, heavy bleeding, fever, or chills. Prompt intervention prevents serious complications. Urine may look cloudy for several weeks during healing and after intercourse from retrograde ejaculation.

Stress followup PSA testing. PSA monitors for residual tumor. Persistent incontinence needs further evaluation or treatment.

7. Administering Medications and Pharmacologic Support

Pain relievers, antibiotics, antispasmodics, and stool softeners support recovery and manage related conditions.

Antibiotics Often given prophylactically because of the increased infection risk with prostatectomy.

Stool softeners and laxatives Prevent the constipation and straining that risk rectal-perineal bleeding.

Oxybutynin (Ditropan), flavoxate (Urispas), B & O suppositories Relax smooth muscle to relieve spasms and associated pain.

Propantheline bromide (Pro-Banthine) Relieves bladder spasms by anticholinergic action. Usually stopped 24 to 48 hr before anticipated catheter removal to allow normal bladder contraction.

8. Monitoring Results of Diagnostic and Laboratory Procedures

CBC, coagulation studies, and platelet count assess hemoglobin, clotting ability, and platelets, flagging bleeding or clotting disorders and guiding transfusion decisions.

Hb/Hct, RBCs Evaluate blood loss and replacement needs.

Coagulation studies, platelet count May indicate developing complications: depletion of clotting factors or DIC.