A 68-year-old male client with benign prostatic hyperplasia (BPH) is scheduled for a transurethral resection of the prostate (TURP). Which nursing intervention should the nurse prioritize in the immediate postoperative period?
1Encourage early ambulation to prevent deep vein thrombosis
2Encourage the client to perform Kegel exercises every hour while awake to strengthen pelvic floor muscles
3Monitor for signs of transurethral resection syndrome and maintain continuous bladder irrigation✓ 정답
4Provide dietary teaching about high-fiber foods to prevent constipation
해설
Monitoring for TURP syndrome and maintaining continuous bladder irrigation are critical to prevent life-threatening complications like hyponatremia and ensure proper drainage. Other options are important but not the immediate priority.
Understanding the Immediate Postoperative Priority After TURP
Following a transurethral resection of the prostate (TURP), the immediate postoperative period presents a unique set of physiological challenges that directly guide the nurse's priority assessments and interventions. The correct answer is to monitor for signs of transurethral resection syndrome and maintain continuous bladder irrigation.
The rationale is rooted in the pathophysiology of the two most critical and time-sensitive complications after this surgery: transurethral resection (TUR) syndrome and postoperative hemorrhage with clot retention.
The Critical Threat of TUR Syndrome
TUR syndrome is a potentially life-threatening complication specific to monopolar TURP, where a hypotonic, electrolyte-free irrigation fluid (like glycine or sorbitol) is used. During the procedure, this fluid can be absorbed directly into the patient's systemic circulation through open prostatic venous sinuses. The rapid absorption of large volumes of hypotonic fluid causes a triad of severe problems:
- Dilutional Hyponatremia: Serum sodium levels drop precipitously, leading to cerebral edema and neurological symptoms ranging from confusion and nausea to seizures and coma.
- Fluid Volume Overload: The sudden increase in intravascular volume can precipitate hypertension, pulmonary edema, and heart failure in a patient population often already at cardiovascular risk.
- Solute Toxicity: The irrigation fluid itself (e.g., glycine) can be toxic, causing visual disturbances and further neurological effects.
The research by Gholipour et al. [2] underscores the significance of this risk, noting that monopolar TURP "carries a risk of significant complications, particularly transurethral resection (TUR) syndrome leading to hyponatremia and fluid overload." Their randomized clinical trial specifically investigated a prophylactic intervention to prevent this exact complication. While the newer bipolar TURP technique uses isotonic 0.9% saline as an irrigant, effectively eliminating the risk of dilutional hyponatremia, it introduces a different metabolic concern. As Jia et al. describe, absorption of large volumes of saline can lead to hyperchloremia from the supraphysiological chloride load, which their study found to be associated with an increased risk of acute kidney injury (AKI) in elderly patients. Therefore, regardless of the TURP modality used, vigilant monitoring for signs of fluid absorption and electrolyte imbalance is a non-negotiable nursing priority. The nurse must closely monitor level of consciousness, vital signs, respiratory status for signs of pulmonary edema, and intake and output, while also ensuring serum electrolytes are checked as ordered.
The Priority of Continuous Bladder Irrigation (CBI)
The second component of the priority intervention is maintaining continuous bladder irrigation (CBI). Postoperative bleeding is an expected outcome of TURP, and the formation of blood clots within the bladder is a primary concern. Clots can obstruct the urinary catheter, leading to bladder distension, painful bladder spasms, and increased venous bleeding due to the tamponade effect of the distended bladder on the prostatic fossa. Maintaining a continuous flow of irrigant and ensuring the catheter is draining freely is the nurse's direct responsibility to prevent this cascade. The systematic review by Padval and Kaur highlights the clinical importance of managing catheter-related discomfort, including bladder spasms, which are a common and distressing symptom linked to indwelling catheters and bladder distension from clots. The nurse's role in manually irrigating the catheter to clear clots and carefully titrating the CBI flow rate to keep urine output light pink ("rose-colored") without clots is fundamental to preventing hemorrhage and ensuring patient comfort.
Why Other Interventions Are Not the Immediate Priority
The other options represent important but secondary nursing actions. Early ambulation (Option 1) is a key intervention for preventing deep vein thrombosis, but it is not the immediate priority in the first hours after surgery when the patient is on bed rest, possibly sedated, and at highest risk for hemorrhage and TUR syndrome. Kegel exercises (Option 2) are valuable for long-term recovery of urinary continence after catheter removal, not in the immediate postoperative phase with an indwelling catheter in place. Dietary teaching about high-fiber foods (Option 4) is crucial for preventing constipation and the Valsalva maneuver that could trigger a late postoperative bleed, but this teaching is appropriately addressed later in the recovery period. The immediate focus must be on the life-threatening risks of TUR syndrome and the acute complication of hemorrhage with clot retention, making the continuous assessment and intervention in Option 3 the unequivocal priority.
References (research sources)
[2]
Prophylactic Intravenous Furosemide for Reducing Hyponatremia Risk in Monopolar Transurethral Prostate Surgery: A Randomized Clinical Trial.RCT/clinical trialGholipour F, Bahrami Samani H, Assadi A, Behnamfar A, Nazarpour M, Saberi N. (2025) · DOI: 10.30476/ijms.2025.105024.3860
Immediate Postoperative Nursing Priorities After TURP
The first 24 hours after a transurethral resection of the prostate (TURP) are critical for detecting and managing two life-threatening complications: TUR syndrome and hemorrhage with clot retention. Continuous assessment and intervention are paramount.
Priority 1: Monitor for TUR Syndrome
TUR syndrome results from systemic absorption of hypotonic irrigation fluid (e.g., glycine, sorbitol) through open prostatic venous sinuses. This causes acute dilutional hyponatremia and fluid volume overload. Assess for early signs every 15 minutes initially, then with decreasing frequency as the patient stabilizes.
Cardiovascular: Hypertension, bradycardia, dysrhythmias, signs of pulmonary edema (crackles, dyspnea).
Laboratory: Monitor serum sodium levels closely; a rapid drop is diagnostic.
Immediate Action: Notify the surgeon immediately if TUR syndrome is suspected. Interventions include administering hypertonic saline (3% NaCl) cautiously, administering diuretics as ordered, and preparing for possible transfer to a higher level of care.
CBI prevents clot formation and catheter obstruction, which can lead to bladder distension, painful spasms, and disruption of the surgical site. The goal is to maintain light pink to clear urine outflow.
Assess: Monitor the color, consistency, and volume of urine outflow hourly. Ensure the catheter is patent and free of kinks.
Titrate: Adjust the irrigation flow rate to keep urine light pink. Increase the rate for bright red urine with clots; decrease for clear urine.
Troubleshoot Obstruction: If outflow decreases or stops, and bladder distension is present, manually irrigate the catheter with 30-50 mL of sterile normal saline as ordered to dislodge a clot. Do not increase the inflow rate without ensuring outflow patency.
Pain Management: Administer antispasmodics as ordered for bladder spasms, which can impede irrigation outflow.
Key Nursing Considerations
Strict Intake and Output: Calculate actual urine output by subtracting the total irrigation fluid infused from the total Foley catheter output.
Patient Education: Reassure the patient that the sensation of a constant urge to void is normal due to the catheter and irrigation. Instruct them not to void around the catheter.
Activity: Maintain bed rest with the head of the bed elevated no more than 30 degrees until bleeding is controlled and irrigation is discontinued.
Stool Softeners: Administer as ordered to prevent straining during bowel movements, which can trigger bleeding.
Transurethral Resection (TUR) Syndrome — A life-threatening complication of monopolar TURP caused by absorption of hypotonic irrigation fluid, leading to dilutional hyponatremia, fluid volume overload, and potential cerebral edema.
Continuous Bladder Irrigation (CBI) — A postoperative intervention using sterile fluid to flush the bladder and prevent blood clots from obstructing the catheter and causing urinary retention or bladder spasms.
Dilutional Hyponatremia — A decrease in serum sodium concentration resulting from an increase in total body water relative to sodium, a hallmark of TUR syndrome.
Transurethral Resection of the Prostate (TURP) — A surgical procedure to remove prostate tissue via a resectoscope inserted through the urethra, commonly used to treat benign prostatic hyperplasia.
Clot Retention — A postoperative complication where blood clots obstruct the urinary catheter, leading to bladder distension, pain, and potential disruption of the surgical site.