NUR 103 Practical Nursing III NAME______________________ __ Sign and/or Symptoms of Biophysical Alteration Significant Medical/surgical history Potential Post-Op Complications Pneumonia Pulmonary Embolism Atelectasis Hyo!olemia Hemorr"age Hyo!olemic #"oc$ Urinary retention Urinary tract in%ection Nausea &omiting Constiation 'ymanites Woun( In%ection Woun( )e"iscence Woun( E!isceration *la((er sasms 'ransuret"ral syn(rome *loc$age o% cat"eter Transurethral Resection of the Prostate-TURP NAME_____________________ Wayne Community College NUR#IN+ 103, Practical Nursing III )ata Collection-Clinical Prearation
Allergies________________________________ Co(e #tatus _____________________________ *aseline )ay 1 )ay . AP AP AP RP RP RP *P *P *P RR RR RR ' ' ' )e!elomental 'as$_________________________________ 1/ Client0s Primary *io"ysical Alteration,____________________________ ./ *asic Etiology o% Primary *io"ysical Alteration 1inclu(e re%erence source 2 ara"rase etiology3 3/ )escribe basic Pat"o"ysiology o% Primary bio"ysical Alteration 1inclu(e re%erence source 2 ara"rase Pat"o"ysiology3 4/ *rie%ly (escribe surgery relate( to t"e client0s bio"ysical alteration 1i% any surgery3, Parts o% t"e rostate 5ill be remo!e( by a tool calle( resectoscoe 5"ic" is inserte( into t"e uret"ra Transurethral Resection of the Prostate-TURP CURRENT COMPUTER KARDEX DOCTORS ORDERS Date Ordered Order Transurethral Resection of the Prostate-TURP Lab Test ormal Patient!s ursing "mplications if abnormal Potassium 163 #o(ium 1Na3 C"lori(e 1Cl3 P"os"orous 1P3 Magnesium 1Mg3 Calcium 1Ca3 *UN Creatinine #erum 7smolality Albumin W*C R*C Platelets 1Plts3 Hemoglobin 1Hgb3 Hematocrit 1Hct3 Cultures 1Woun(8 urine8 sutum8 bloo(8 etc/3 '"eraeutic bloo( le!els, )igo9in Antibiotic Pea$-'roug" 7t"er,_____________ Urinalysis *ilirubin Ammonia Heatic En:ymes 1A#'8 A;'3 Car(iac En:ymes 1'ro8 C6M*8 CP63 P' P'' INR M#$"CAT"OS Transurethral Resection of the Prostate-TURP M#$"CAT"O %Brand ame & 'eneric ame( CLASS")"CAT"O* therapeutic & pharmacologic* +eason ,hy $rug is Prescribed for Client Safe dose Patien t dose +O-T # )re.uenc y S"$# #))#CTS %most common and life threatening( ursing "mplications %Top priority( M#$"CAT"OS Transurethral Resection of the Prostate-TURP M#$"CAT"O %Brand ame & 'eneric ame( CLASS")"CAT"O* therapeutic & pharmacologic* +eason ,hy $rug is Prescribed for Client Safe dose Patien t dose +O-T # )re.uenc y S"$# #))#CTS %most common and life threatening( ursing "mplications %Top priority(
Transurethral Resection of the Prostate-TURP P+"O+"T"/# ursing "nter0entions #0aluation* Based on recogni1ing the effecti0eness $ata collection 2ith +!s of nursing inter0entions 2ith Assistance +!s Assistance Pro!i(e e(ucation on t"e surgery to client to re(uce %ears Check lab values for abnormalities Provide adequate hydration and nutrition to promote healing Collect consent form from client for surgery and care to be given Keep client NP as rdered Keep client on bedrest as ordered Keep strict !" measurement #oley to gravity $ith continuous bladder irrigation of N% at rate to keep urine clear &onitor neurovascular status q'hq (ducate client on use and purpose of catheter Pre-op care Post-op care Transurethral Resection of the Prostate-TURP P+"O+"T"/# ursing "nter0entions #0aluation* Based on recogni1ing the effecti0eness $ata collection 2ith +!s of nursing inter0entions 2ith Assistance +!s Assistance (ncourage turn) cough and deep breathing e*ercises (ncourage use of an incentive spirometer q+h ,dminister pain meds as needed &onitor post-op lab values -et client to ambulate as ordered to prevent ./T