Nursing Care Plan for Prostatectomy

Nursing diagnosis: acute Pain related to irritation of the bladder mucosa; reflex muscle spasm associated with surgical procedure or pressure from bladder balloon
(traction)

Possibly evidenced by
Reports of painful bladder spasms
Facial grimacing, guarding, restlessness
Autonomic responses

Desired Outcomes/Evaluation Criteria—Client Will
Pain Level
Report pain is relieved or controlled.
Appear relaxed and sleep and rest appropriately.
Pain Control
Demonstrate use of relaxation skills and diversional activities, as indicated, for individual situation.

Nursing intervention with rationale:
1. Assess pain, noting location, intensity (0 to 10 scale), and characteristics.
Rationale: Changes in pain reports may indicate developing complications requiring further evaluation and intervention. Note: Sharp, intermittent pain with urge to void and passage of urine around catheter suggests bladder spasms, which tend to be more severe with suprapubic or TUR approaches and usually decrease within 48 hours.

2. Maintain patency of catheter and drainage system. Keep tubing free of kinks and clots.
Rationale: Maintaining a properly functioning catheter and drainage system decreases risk of bladder distention and spasm.

3. Promote intake of up to 3,000 mL/day, as tolerated.
Rationale: Decreases irritation by maintaining a constant flow of fluid over the bladder mucosa.

4. Give client accurate information about catheter, drainage, and bladder spasms.
Rationale: Allays anxiety and promotes cooperation with necessary procedures.

5. Provide comfort measures, such as position changes, back rub, Therapeutic Touch, and diversional activities. Encourage use of relaxation techniques, including deepbreathing exercises, visualization, and guided imagery.
Rationale: Reduces muscle tension, refocuses attention, and may enhance coping abilities.

6. Provide sitz baths or heat lamp, if indicated.
Rationale: Promotes tissue perfusion and resolution of edema and enhances healing in perineal approach.

7. Administer antispasmodics, such as the following: Oxybutynin (Ditropan), flavoxate (Urispas), B & O suppositories
Rationale: Relaxes smooth muscle to provide relief of spasms and associated pain.

8. Administer Propantheline bromide (Pro-Banthine).
Rationale: Relieves bladder spasms by anticholinergic action. Usually discontinued 24 to 48 hours before anticipated removal of catheter to promote normal bladder contraction.