Student Nurses Community

NURSING CARE PLAN Benign Prostatic Hypertrophy

ASSESSMENT

SUBJECTIVE:
The patient may
verbalize difficulty in
urinating.
OBJECTIVE:
Patient may manifest
one or more of the
following:
- (+) nocturia
- (+) incontinence
- (+) dysuria
- (+) facial grimaces
upon urination
- (+) edema
- pt may also be seen
with an indwelling
catheter connected
with the urine bag.

NURSING
DIAGNOSIS
Impaired
urinary
elimination r/t
increase
urethral
occlusion

PLANNING

INTERVENTIONS

RATIONALE

After 3 hours of
nursing
intervention the
patient will be
able to manage
the
manifestation of
the disease

1. Monitor vital
signs closely.
Observe for
hypertension,
peripheral/depende
nt
edema, changes in
mentation. Maintain
accurate I&O.

- Loss of kidney
function results
in decreased
fluid elimination
and
accumulation of
toxic wastes may
progress to
complete renal
shutdown.
- Increased
circulating
fluid maintains
renal perfusion
and flushes
kidneys, bladder,
and ureters of
sediment and
bacteria.
Note: Initially,
fluids may be
restricted to
prevent bladder
distension until

2. Encourage oral
fluids up to 3000
mL
daily, within cardiac
tolerance, if
indicated.

EVALUATION

-Does the
patient able to
manage the
manifestations
of the disease;
a. nocturia
b. dysuria
c.
incontinence
d. hesitancy to
urinate?

adequate urinary
flow is
reestablished.

- may minimize
over distension
of the bladder.
3. Encourage
patient to void
every 2-4 hours and
when urge is noted.
4. Encourage
meticulous catheter
and perineal care

- reduces risk
of ascending
infection

GOAL: Improved physical mobility

ASSESSMENT
Subjective:
The patient
may verbalize
body malaise.
Objective:
Patient may
manifest one or
more of the
following:
- (+) body
malaise
- (+) facial
grimaces upon
moving
- (+) edema

NURSING
DIAGNOSIS
Activity
intolerance r/t
body malaise.

PLANNING
After 3 hours of
nursing intervention
the patient will be able
to verbalize
understanding of the
health teachings given
to increase muscle
strength.

INTERVENTIONS
1. Monitor vital
signs.

2. Encourage to
increase fluid intake.
3. Encourage to eat
foods rich in vitamin
C and intake of
nutritious food.
4. Encourage pt to
perform PROM as
tolerated.

RATIONALE

- To know the
present status of
the patient
- To optimize
hydration status
- To increase
body resistance

- To promote
proper blood
circulation

5. Encourage pt to
change position
every 2 hours.

-To optimize
circulation to all
tissues and to
relieve pressure

6. Encourage pt to

- To prevent

EVALUATION
a. Does the
patient able
to
understand
the health
teachings
given?
b. Does he
able to
increase
muscle
strength?

use appropriate
assistive devices.

injury

GOAL: Reduce or prevent risk of infection

ASSESSMENT
Subjective:
The patient may
verbalize body
malaise.
Objective:
Patient may be
seen with an
indwelling
catheter
connected with
the urine bag.
- (+) nocturia
- (+) body
malaise

NURSING
DIAGNOSIS
Risk for
infection r/t
periodic
catheterizati
on.

PLANNING
After an
hour of nurse
patient
interaction,
the patient
will be able
to verbalize
understandin
g on the
health
teachings
given.

INTERVENTIONS
1. Monitor vital signs
for fever.

2. Encourage to
increase fluid intake.

3. Emphasize good
hand washing
technique for all

RATIONALE

- Indicators of sepsis
requiring prompt
evaluation and
intervention.
- To maintain renal
function and prevent
development
infection.
- Prevents crosscontamination,
reduces risk of

EVALUATION
a. Does the
patient
understand
individual
causative or risk
factors?
b. Does the patient
able to identify
interventions to
reduce or
prevent risk of
infection?

- (+) hematuria
- (+) febrile

individuals coming in
contact with patient.

acquired infection.

4. Encourage
meticulous catheter
and perineal care.

- Reduces risk of
ascending infection.

5. Provide sterile or
freshly laundered bed
linens/gowns.

- Prevents exposure
to infectious
organisms.

6. Monitor/limit visitors,
if necessary.

- Prevents crosscontamination from

visitors.

7. Administer
antibacterial as
ordered.

- Reduces bacteria
present in urinary
tract and those
introduced by
drainage system.

GOAL: Understanding of the diagnosis and ability to care for self

ASSESSMENT
Subjective:
The patient
may verbalize
concerns
regarding his
condition.
Objective:

NURSING
DIAGNOSIS
Ineffective
therapeutic
regimen r/t lack
of understanding
of disease,
manifestations,
and medical
treatments.

PLANNING
After an hour of
nurse patient
interaction, the
patient will be
able to
understand the
course of his
disease,

INTERVENTIONS
1. Provide
teachings about
BPH regarding the
disease process,
how to prevent
and alleviate its
complications.

RATIONALE

- To diminish
clients anxiety
regarding the
process of his
disease, the effects
of this disease to
his lifestyle, and

EVALUATION
a. Does the
patient able to
understand all
the information
given?
b. Is there a
significant

Patient may
manifest one or
more of the
following:
- frequently
asking about
his condition,
treatment and
diet.
- with worried
gaze
- minimal
response upon
assessment and
questioning

manifestations
and medical
treatments.
2. Encourage fluid
intake.

3. Explain
medications; how
it works, its side
effects and
precautions.

the complications
that the disease
could develop.
- Patient with BPH
tend to limit their
fluid intake to
combat its
manifestion
needless did they
know that a
concentrated urine
exacerbate LUTS
and increase risk of
UTI.

changes that
occur on the
patients
knowledge
regarding:
-disease
condition
-diet
-treatment
-medication
-self-care needs
c. Does the patient
able to comply with
the entire
therapeutic regimen
given?

- To provide
knowledge about
the medications
being given to the
patient.

GOAL: Relief of pain

ASSESSMENT

NURSING
DIAGNOSIS

PLANNING

INTERVENTIONS

RATIONALE

EVALUATION

Subjective:
The patient
may verbalize
pain at
hypogastric
region.
Objective:
Patient may
manifest one or
more of the
following:
- (+) reports of
pain
- (+) narrowed
focus
- (+) grimacing
- (+) distraction
behaviours
- (+) restless
autonomic
response

Pain r/t
progression
of disease
and
treatment
modalities.

After an hour
of nurse
patient
interaction,
the patient will
report pain
relieved/contro
lled, appears
relaxed and be
able to rest or
sleep
appropriately.

1. Assess pain, noting

location, intensity
(scale
of 010), duration.

2. Tape drainage tube

to thigh and catheter
to the abdomen (if
traction not required).
3. Recommend bed
rest as indicated.

4. Provide comfort
measures, e.g., back
rub, helping patient
assume position of
comfort. Suggest use
of relaxation or deep
breathing exercises,
diversional activities.
5. Administer
medications as
indicated.

- Provides information to
aid in determining
choice/effectiveness of
interventions.
- Prevents pull on the
bladder and erosion of
the penile-scrotal
junction.

- Bed rest may be

needed initially during
acute retention phase;
however, early
ambulation can help
restore normal voiding
patterns and relieve
colicky pain.
- Promotes relaxation,
refocuses attention, and
may enhance coping
abilities.

- Given to relieve severe

a. Does the
patient able
to relieve
pain?
b. Is there a
significant
change that
occur on the
patients
quality and
intensity of
pain?
c. Does the
patient able
to comply
with the
entire
therapeutic
regimen
given?

pain, provide physical

and mental relaxation