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NANDA NURSING

Saturday, March 5, 2011

Nursing Diagnosis and Nursing Intervention for BPH - Preoperative

Nursing Diagnosis and Nursing Intervention for Benign Prostatic Hyperplasia



  1. Acute or chronic obstruction related to mechanical obstruction, enlarged prostate, muscle destrusor decompensated bladder and an inability to contract adequately.

    Goal :
    Avoid obstruction

    Criteria for outcome :
    Micturition in sufficient quantity, not palpable bladder distension

    Plan of action and rational
    • Encourage the patient to urinate every 2-4 hours and when all of a sudden felt.
      R / Minimize excessive retention of urine in the bladder distension
    • Observation of the flow of urine, note the size and strength of urinary stream
      R / To evaluate the obstruction, and choice of intervention
    • Monitor and record the time and the amount each time urination
      R / Retention of urine increases the pressure in the urinary tract that can affect kidney function
    • Give up to 3000 ml of fluid a day in the heart of tolerance.
      R / Increasing the flow of fluid to increase renal perfusion and cleanses the kidneys, bladder from bacterial growth
    • Give the drug as indicated (antispsamodik)
      R / reduce spasms of the bladder and speed healing
  2. Pain (Acute) related to the irritation of bladder mucosa, bladder distension, renal colic, urinary infection.

    Goal :

    Pain is reduced / lost

    Criteria for outcome :

    Clients reported no pain, showed the skills of relaxation and therapeutic activity according to indications for individual situations. Seemed relaxed, sleep / rest appropriately.

    Plan of action and rational :
    • Review the pain, note the location, intensity (scale 0 - 10).
      R / Pain sharp, intermittent with the urge to urinate / massage urine around the catheter showed bladder spasm, which tends to be more heavily on the approach of TURP (usually decreased within 48 hours).
    • Keep the catheter and drainage system. Keep the hose free of grooves and clot.
      R / Maintaining the function of the catheter and drainage system, reducing distension risk.
    • Maintain bed rest if indicated
      R / required during the early phase during the acute phase.
    • Provide comfort measures (therapeutic touch, changing positions, massage your back) and therapeutic activity.
      R / Reduces muscle tension, back memfokusksn attention and can enhance coping ability.
    • Collaboration in the provision antispasmodik
      R / Eliminates spasm

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