Nursing Care Plan for Risk for Delayed Surgical Recovery and

Acute Pain (Secondary Diagnosis)

by Susanti Santalia, 1706039345

Medical Surgical Nursing II – A

Case:

65 years old man just had TURP (Transutheral Resection of the Prostate) surgery due
to urological problem he had since past one year. He often experienced urinating
urgency but when he urinates he often feel the feeling of can’t fully empty his
bladder. After finished urinating, the urine still dripped. His weight is 80 kg with 158
cm of height. He got his PSA checked and the result is 5.5ng/mL. 1 day post the
TURP he had three-way catheter on him with 0.9% NaCl irrigation. The urine looks
reddish. The client also feels hesitant to move due to post surgery stitches. BP 130/80
mmHg, pulse: 95x/mins, and RR 18x/mins. He also experiences pain in his lower
abdominal area (scale:7).

According to data given, the client’s Prostate-specific Antigen (PSA) was over the
limit for man in his age (4ng/ml). His medical diagnosis is Benign Prostatic
Hyperplasia (BPH). One of available surgeries to treat BPH is using the TURP
method. This method uses electricity with high frequency through resectoschope
inserted to client’s urethra to resect excessing tissue by making it coagulate (Black &
Hawks, 2009). The client has gotten TURP procedure as mentioned in the case, so it
can be said that the nursing care plan is the post-surgery one.

Assessment
Subjective Assessment - Client feels hesitant and afraid to
move because of the surgery wound
 - The client feels so in pain in his
lower abdominal area (scale: 7)

Objective Assessment - 65 year-old

- Male
- BP 130/80mmHg
- Pulse 95x/mins
- RR 18x/mins
- Reddish urine
- Client’s weight and height:
80kg/158cm

By the conditions above, we can decide that the secondary diagnosis for the case is
Risk for Delayed Surgical Recovery. The client is suspected to needs longer
postoperative days before he can initiate activities as usual because he’s in real pain
and have difficulties moving. Other secondary diagnosis is Acute Pain due to
obstruction along urinary tract related to invasive procedure (the TURP). The client
experienced scale 7 pain in his lower abdominal area.

Here are the care plans:

Dx: Risk for Delayed Surgery Recovery

Planning Intervention Rationale Outcomes

Client have better Review to client Client get Client have better
understanding implications of provided the base understanding
regarding his procedure done information. regarding his
wound and the and future wound and the
procedure he had. expectations procedure he had
 Inform client on Client will not get
activity restrictions worse pain and
e.g. no heavy will not do
lifting, no restricted activity
prolonged sitting to
avoid worse pain
Inform client to tell Client will get
healthcare unit if appropriate
there is any pain medication to
exist caused by relieve pain, and
medication given. get no allergy
reaction.
Client start to have Teach patient The wound is in Client start to have
better mobility relaxation lower abdominal better mobility
level, client may techniques such as so client is level, client may
be able to start deep breathing expected to feel be able to start
moving. more relaxed and moving
start moving a bit
with his hands
Client’s nutrition Provide and help Providing client Client’s nutrition
well maintained client to have good with diet may help well maintained
during diet and in good due to the risk of during
postoperative nutritional based delayed surgery postoperative
recovery diet. recovery, besides, recovery
e.g. thrice a day, client is in risk of
non having loss
contraindicatory appetite.
diet Client is also in
extreme age so he
 needs more
assistance.
Client’s Provide limb care Good cleanliness Client’s
cleanliness still daily; level may prevent cleanliness still
maintained Independently or infections, also maintained
help client clean facilitates client to
their limbs promote his range
of motion

Dx: Acute Pain due to obstruction along urinary tract related to invasive procedure
(the TURP).

Planning Intervention Rationale Outcomes

If prescribed, Analgesic and Client reports
Client is expected administer antispasmodic may relieved pain or
to have better analgesic and be prescribed due controlled pain.
comfort level soon antispasmodic to side effect of the (decreased pain
and comfort level agents to reduce procedure. level)
keep increasing in pain Client appears
2 or 3 days post Encourage the Better fluid level relaxed.
TURP surgery. client to maintain may help dilutes
his fluid intake urine and flushing
(unless off lower urinary
contraindicated) tract.
Help client to use Warm towel helps
warm towel to relieves local area
relieve pain in his discomfort, it also
lower abdominal relaxes.
area
Main evaluation nurse can do is regarding the pain level. Nurse can evaluate client’s
pain level regularly (e.g. per 4 hours.). Regarding the risk of delayed surgery
recovery, nurse can assess client’s independence, especially his moving ability and
his wound.

Bibliography
Black, J. M., & Hawks, J. H. (2009). Medical-surgical nursing : clinical management for
positive outcomes. Philadelphia: Elsevier.

Bulechek, G. M., & et al. (2013). Nursing Interventions Classification 6th ed. Missouri:
Elsevier Mosby.

Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2010). Nursing Care Plans: Guidelines for
Individualizing Client Care Across the Life Span. Philadelphia: F. A. Davs.

Herdman, T. H., & Kamitsuru, S. (2018). NANDA International, Inc. Nursing diagnoses &
classification 11th ed. New York: Thieme.

Smeltzer,, S. C., Bare, B. G., Hinkle, J. L., & Cheever, K. H. (2010). Brunner & Suddarths
textbook of medical-surgical nursing, 12th ed. Philadelphia: Wolters Kluwer.