An older adult client is recovering on the surgical unit hours after a transurethral resection of the prostate (TURP) with ongoing continuous bladder irrigation (CBI). While performing a focused assessment, the practical nurse (PN) notes several clinical changes. Which of the following findings represent emergent complications that must be immediately reported to the registered nurse (RN)? Select all that apply.
- The client demonstrates a sudden, new-onset inability to state their location or the current year.Answer
- The client's apical pulse gradually rises to beats per minute with a simultaneous blood pressure reading of mmHg.Answer
- The morning laboratory report indicates a serum sodium concentration of mEq/L.Answer
- DThe client reports a severe, continuous urge to urinate while the catheter drainage tubing remains completely unobstructed.
- EThe calculated fluid balance reveals mL emptied from the collection bag and mL of irrigant infused over the shift.
Answer
The findings requiring immediate escalation are the sudden inability to state location/year, the rising heart rate with falling blood pressure, and the critically low serum sodium of 120 mEq/L.
The correct choices identify emergent, life-threatening complications of a TURP procedure. A sudden change in mental status and a critically low serum sodium level ( mEq/L) are classic indicators of TURP syndrome, caused by the systemic absorption of irrigation fluid leading to dilutional hyponatremia and potential cerebral edema. Additionally, the development of borderline tachycardia ( bpm) and mild hypotension ( mmHg) are early, subtle signs of hypovolemic shock secondary to postoperative hemorrhage. These findings necessitate immediate escalation to the RN for rapid medical intervention.
Step-by-Step Solution
Key Concept
Early recognition of TURP syndrome (dilutional hyponatremia) and hypovolemic shock during continuous bladder irrigation.
Estimated Time:2m 0s