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?

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.

Core Nursing Explanation Key Concept Analysis: This question assesses the priority nursing intervention for a patient immediately after a Transurethral Resection of the Prostate (TURP). The priority is always managing life-threatening complications and ensuring the immediate success of the procedure. For TURP, the two most critical immediate concerns are hemorrhage and Transurethral Resection (TUR) Syndrome.

Answer Rationale: Key Point! Option ③ is correct because it directly addresses these two critical priorities. Continuous Bladder Irrigation (CBI) is maintained postoperatively to flush out clots and keep the catheter patent, preventing bladder distension and controlling bleeding. Simultaneously, vigilant monitoring for TUR Syndrome—a potentially fatal complication caused by the systemic absorption of large volumes of hypotonic irrigation fluid—is essential. Early signs include hyponatremia, bradycardia, hypertension followed by hypotension, confusion, nausea, and visual disturbances. This intervention is a direct, life-preserving action in the immediate postoperative period.

Distractor Analysis: Watch out for confusion! Option ①: While preventing Deep Vein Thrombosis (DVT) is important, early ambulation is typically not encouraged immediately after TURP. The patient often has a urinary catheter with traction and needs bed rest initially to minimize bleeding. Ambulation comes later.
Option ②: Kegel exercises are valuable for long-term urinary control post-recovery, but they are not a priority in the immediate postoperative period. Initiating them every hour could even be uncomfortable or disruptive to healing initially.
Option ④: Preventing constipation is important to avoid straining, which can increase pelvic pressure and provoke bleeding. However, this is a secondary teaching point and not the highest priority intervention when compared to monitoring for acute, life-threatening complications.

Related Concepts: The nursing process dictates that airway, breathing, and circulation (ABCs) and prevention of immediate surgical complications take precedence. Here, CBI maintains "circulation" by controlling hemorrhage, and monitoring for TUR syndrome protects neurological and cardiovascular status. Understanding the pathophysiology of TUR syndrome (fluid overload and dilutional hyponatremia) is key to recognizing its symptoms. Concept Summary

Concept	Key Points
TURP (Procedure)	Surgical treatment for BPH. Resects prostate tissue via urethra. No external incision.
Priority Post-Op Care	1. Manage CBI to prevent clots. 2. Monitor for TUR Syndrome & hemorrhage.
TUR Syndrome	Life-threatening. Caused by absorption of irrigation fluid. Leads to fluid overload, hyponatremia, cerebral edema.
Continuous Bladder Irrigation (CBI)	Three-way catheter system. Irrigant flows in, drains out. Maintains clear, light pink output.
Nursing Actions	Monitor I&O, vital signs, mental status, serum sodium. Ensure catheter patency. Teach to avoid straining.

Side-by-Side Comparison!

Post-Op Complication	Cause	Key Signs & Symptoms	Nursing Action
TUR Syndrome	Absorption of hypotonic irrigation fluid (e.g., glycine).	Hyponatremia, bradycardia, hypertension-then-hypotension, confusion, nausea, visual blurring.	Stop procedure/irrigation. Administer hypertonic saline (3% NaCl) per protocol. Support ABCs.
Post-Op Hemorrhage	Inadequate hemostasis at surgical site.	Bright red urine, clots, increased bladder spasms, decreased Hgb/Hct, tachycardia, hypotension.	Increase irrigation flow rate. Maintain catheter traction if ordered. Monitor vitals. Prepare for possible return to OR.
Urinary Retention (after catheter removal)	Edema, blood clots, or bladder atony.	Inability to void, suprapubic distension/pain, restlessness.	Perform bladder scan. Prepare for straight catheterization per order.

Anatomy, Physiology & Pharmacology Points

• Pathophysiology of TUR Syndrome: The prostate gland has a rich venous network. During resection, these sinuses are opened, allowing the hypotonic irrigation fluid to be absorbed directly into the systemic circulation. This causes hypervolemia and dilutional hyponatremia, leading to cerebral and pulmonary edema.
• Irrigation Fluids: Sterile water is never used because it is extremely hypotonic and causes severe hemolysis if absorbed. Solutions like glycine 1.5% or sorbitol are used—they are isotonic or slightly hypotonic and non-conductive (for electrocautery).
• Catheter Management: Post-TURP, a three-way Foley catheter is placed. One port inflates the balloon, one drains urine, and the third is for continuous irrigation inflow. The balloon may be inflated in the prostatic fossa to apply traction and tamponade bleeding.

Memory Tips

• Acronym for TUR Syndrome Signs: "Bad Headache, Confusion, Nausea" (Think: Brain Has Critical Needs) – points to cerebral edema from hyponatremia.
• Priority Rule: After TURP, think "CBI & TUR-S" (Continuous Bladder Irrigation & TUR Syndrome monitoring) as your #1 job.
• Output Color: Teach that urine should be "pink lemonade," not "burgundy wine." Burgundy = too much blood, notify provider.

High-Frequency NCLEX Topics TURP and its complications are a Core urological topic. The NCLEX loves to test: 1. Priority Setting: Choosing monitoring for TUR syndrome over other correct but less urgent interventions. 2. Complication Recognition: Identifying signs of TUR syndrome vs. hemorrhage vs. infection. 3. Patient Education: Teaching about avoiding straining, heavy lifting, and sexual activity post-discharge. Watch Out for Question Variations!

• Shift from Symptom to Action: "The nurse notes a client 2 hours post-TURP is confused and has a blood pressure of 90/50 mmHg. What should the nurse do first?" (Answer: Stop the continuous bladder irrigation and notify the surgeon immediately—suspect TUR syndrome).
• Shift from Post-Op to Pre-Op: "What is the priority teaching for a client scheduled for TURP?" (Answer: Explain the purpose of continuous bladder irrigation and the catheter post-operatively).
• Lab Value Focus: "A client post-TURP has a serum sodium level of 125 mEq/L. The nurse should be alert for which finding?" (Answer: Neurological changes like confusion or seizure).

Nursing Clinical Practice Guide Clinical Scenario: Mr. Johnson, 68, returns to the medical-surgical unit after a 90-minute TURP procedure. He has a three-way indwelling urinary catheter connected to Continuous Bladder Irrigation (CBI) with normal saline (or glycine) and a drainage bag. He is sleepy but arousable.

Nursing Intervention Strategy:

1. Immediate Assessment (First 1-2 Hours):
   • Vital Signs & Neuro Check: Q15min initially. Watch for bradycardia, hypertension (early sign of fluid overload), then hypotension. Assess level of consciousness (LOC) for early signs of cerebral edema (restlessness, confusion).
   • CBI System Management: Ensure the irrigation is flowing at the ordered rate (e.g., to keep output light pink). Check for kinks. Monitor I&O meticulously. Calculate urine output = total drainage minus irrigation input. Output should be >30 mL/hr.
   • Catheter Patency & Output: Observe for bright red blood or clots. If drainage is bloody or clots obstruct flow, you may need to manually irrigate the catheter with a piston syringe (per protocol) and/or increase the irrigation rate.
2. Ongoing Care (Next 24 Hours):
   • Pain Management: Anticipate bladder spasms—a common, cramping suprapubic pain. Administer antispasmodics (e.g., oxybutynin) or analgesics as ordered.
   • Mobility: Assist with turning and deep breathing. Ambulation is usually started the next day once the catheter and irrigation are discontinued and bleeding is controlled.
   • Teaching: Begin teaching about avoiding straining (use stool softeners), not lifting >10 lbs for 4-6 weeks, and drinking 2-3 L of fluids daily unless contraindicated.

Patient Safety and Precautions:

• TUR Syndrome: This is a medical emergency. If suspected (hyponatremia, neuro changes), the irrigation is typically stopped, and the surgeon is notified STAT. Treatment may include diuretics and hypertonic saline infusion.
• Never Clamp the CBI Tubing: This could lead to bladder distension, increased pressure, and severe hemorrhage.
• Traction on the Catheter: If the catheter has traction applied (balloon inflated in fossa), do not release or adjust it without a specific order. It is placed to control bleeding.

Nursing Procedure & Medication Flow Managing Continuous Bladder Irrigation (CBI): 1. Set-Up: Hang the irrigation solution (e.g., 3000 mL bag of normal saline) on an IV pole. Connect via tubing to the "irrigation" port of the 3-way catheter. 2. Regulate Flow: Adjust the roller clamp to the prescribed rate (e.g., "to keep output light pink") or a specific mL/hr rate. 3. Monitoring: Assess color of drainage hourly. If it becomes bright red, increase flow rate temporarily per protocol. If clots are present, may need manual irrigation. 4. I&O Calculation: Record irrigation input volume separately from urinary output volume every hour. True Urine Output = Total Drainage Volume - Irrigation Input Volume.
Medication Alert: Be cautious with sedatives or opioids as they can mask early neurological signs of TUR syndrome. Always assess LOC before and after administration. A Word from Your Senior Nurse "Post-TURP care is a perfect example of where your vigilant assessment skills are the patient's first line of defense. That urinary drainage bag isn't just collecting fluid—it's a vital sign monitor. A sudden change from 'pink lemonade' to 'fruit punch' is your cue to act. And never underestimate a little confusion in an older adult post-procedure; it could be the first whisper of TUR syndrome. In clinicals and on the NCLEX, always ask yourself: 'What can kill my patient first?' That thought process will instantly guide you to the priority. You've got this!"