XAVIER UNIVERSITY – ATENEO DE CAGAYAN

COLLEGE OF NURSING

IN PARTIAL FULFILMENT FOR THE REQUIREMENTS OF

NCM 112 – MEDICAL SURGICAL NURSING

A CASE ANALYSIS ON PRE-OPERATIVE CONCEPT

SUBMITTED BY:
MA. THERESE P. BALLARES
BSN 3 – NB

SUBMITTED TO:
MA’AM JESUSA C. GABULE, RN, MN
CLINICAL INSTRUCTOR

JULY 25, 2020

This is a Case of an 83-year-old male diagnosed with Urinary Bladder Malignancy; Benign
Prostatic Hyperplasia; Hypertensive Cardiovascular Disease; Diabetes Mellitus Type 2,
Hypertension stage 2 – Uncontrolled. Schedule for Cystoscopy; Transurethral Resection of
the Bladder Tumor and Transurethral Incision of the prostate.

General Information
Name: Client PAS Age: 83 years old Birthday: November 16, 1993
Occupation: Lawyer Religion: Roman Catholic Chief Complaint: Hematuria

Brief History of Present Illness

 Smoker for 67 years

 Ate chocolates almost every after meal
 Sedentary lifestyle
 Underwent cataract surgery in 2009
 Noncompliance to medications
 Urinary frequency and urgency at least 10 – 15 times per day
 Difficulty in sleeping especially at night.
 Hematuria hence admitted February 17, 2019

Assessment

 Respiratory: 28 breaths per minute Oxygen Saturation: 96 %

 Wheezing sound noted both lung fields Blood pressure: 150/100 mmHg
 Dyspnea upon exertion Pain and Swelling in the lower extremities

Laboratory Findings
RBC 2.92 L Hemoglobin 8.30 g/dl Hematocrit 33.40 % WBC 9.33 L
Platelet count 320 L Bleeding time 2mins 20s Clotting time 4mins29s
Cholesterol 5.72 mmol/L Triglycerides 1.89 mmol/L
HDL .77 mmol/L LDL 4.23 mmol/L Uric Acid 583 umol/L
Chest X_RAY Minimal Fibrosis, Both Lung Apices with residual Atherosclerotic Aorta
Glycosylated hemoglobin 7.9
Color flow doppler study
Concentric left ventricular hypertrophy with segmental wall motion abnormality
Ultrasound of the prostate Weight of the prostate is 20 grams, with 35 cm3 in size.
Questions
1. Based on the case presented, make a specific pre-operative preparations 24 hours
before surgery. (10pts)

During the pre-operative phase, the nurse needs to ensure that the activities needed are
already done 24 hours before the surgery. They include the preoperative assessment of the
patient, health education appropriate to the patient’s needs, verification of the completion of
necessary preoperative diagnostic testing, verification of patient understanding towards the
surgeon’s preoperative orders, discussion of the directive document and drafting of the
discharge planning for the patient’s postoperative care.

Given that the nurse is dealing with a geriatric patient, the frequent assessment of his
respiratory and cardiovascular status should be given considerable emphasis. That is because
the main causes of morbidity and mortality in older adults are complications from these organs.
Apart from this, patient PAS also has an active hypertensive cardiovascular disease,
suggesting an increased demand for oxygen. His blood pressure and medications must be
closely regulated because uncontrolled blood pressure may be one factor in postponing the
operation.

His nutritional condition must also be assessed, as in the post-operative period he is more
vulnerable to dehydration, hypovolemia, constipation and malnutrition. It is also necessary to
ensure that changes are made to ensure that his cardiovascular system is able to meet the
perioperative oxygen, fluid and nutritional needs. As he is also diabetic, it is important to track
frequently the blood glucose levels before, during and after surgery. Dietary limits mist be
increased, as must strict glycemic regulation (80-110 mg/dL), as the patient is at risk of both
hypoglycemia and hyperglycemia during surgery.

Previous and existing medications for his hypertension and diabetes do need to be
evaluated and recorded to anesthesiologists as their impact on anesthesia needs to be
assessed. Antihypertensive drugs, for example, can contribute to the patient’s risk of
hypotension during the surgery. During this period, the nurse must also give the necessary
medications prior to the surgery as prescribed by the doctor or anesthesiologist.

A part of the assessment is the patient’s clinical history. It is a method for recognizing the
patient’s past procedures ad reactions to other OR drugs or materials, such as latex gloves.
Given that he has already had a cataract surgery, the nurse must take note of the anesthetic
experience of the patient PAS as well as any notable allergies to ensure safety during the
intra-operative phase. As far as health education is concerned, it must focus on its
preparations for the surgical procedures which it will undergo.

Health guidelines concerning surgery, anesthesia, intra-operative care and post-operative

pain management should be improved one day before the operation. This is required in hopes
of reducing anxiety and physically and emotionally preparing him to reduce the risk of
complications. He also needs to be educated on breathing exercises and using an incentive
spirometer to achieve optimal respiratory function before surgery considering that he is also
experiencing dyspnea and that his respiratory rate is elevated.

Aside from this, he must be aware of his need to quit smoking in order to greatly minimize
risks of pulmonary and wound healing. Finally, in order to mitigate anxiety and encourage
understanding, the informed consent must be obtained and concerns about the surgery should
be entertained. The nurse also needs to have empathic care not only for the patient but for his
family as well.
 2. What will be your focused physical priority assessment before you start your care for
patient PAS? (10pts)
Problems in the respiratory and cardiovascular system are considered the leading causes
of postoperative morbidity and mortality among older adults. Because of this, the two should
be focused on the physical priority assessment. Frequent monitoring of his respiratory and
cardiovascular status will be done by taking vital signs like blood pressure, pulse rate,
respiratory rate, oxygen saturation, and temperature. It should also be taken into account the
fact that he has Stage-2 Uncontrolled Hypertension. If a patient has uncontrolled hypertension,
surgery may be postponed until blood pressure is controlled.
3. Make an interpretations/inferences in every laboratory results of the client and
correlate the significant diagnostic tests findings by making a pathophysiology of the
patient’s condition. (20pts)
Legend: LOWER THAN NORMAL
HIGHER THAN NORMAL

Tests Results Normal Values Interpretation

RBC 2.92 L 4.6x1012 to 6.2x10 per The low level of RBC may
liter be due to Iron, vitamin
B12, or folate deficiency.
Hemoglobin 8.30 g/dL 13.5-18 g/dL This may indicate iron,
vitamin B12, or folate
deficiency.
Hematocrit 33.40% 40-54% This may be due to iron,
vitamin B12, or folate
deficiency.
WBC 9.33 L 4.5 to 11.0 × 109/L WBC count is within the
normal range indicating
there is no sign of
alarming infections.
Platelet Count 320 L 150 - 400 x 109/L Platelet count is normal
which is important for
blood clotting.
Bleeding Minutes-2; Seconds- 2-7 minutes Bleeding time is within the
Time 20 normal range.
Clotting Time Minutes-4; Seconds- 2-8 minutes Clotting time is also within
29 the normal range. This
may be attributed to the
normal platelet count.
Cholesterol 5.72 mmol/L Below 5.2 mmol/L Cholesterol level is
borderline high which
serves as an indicator for
the presence of the
patient’s cardiovascular
disease.
Triglycerides 1.89 mmol/L Below 1.7 mmol/L Considered as borderline
high which shows how
diabetes is poorly
controlled and the
possibility of a heart
disease
 HDL .77 mmol/L Above 1.5 mmol/L Considered as poor;
indicating that there is a
low level of “good”
cholesterol which helps in
removing cholesterol
from arteries.
LDL 4.23 mmol/L < 3.4 mmol/L Considered as high and
signifies the presence of
diabetes and
hypertensive
cardiovascular disease of
the patient.
Uric Acid 583 umol/L 200–430 µmol/L The elevated level of uric
acid is a manifestation of
the presence of diabetes.

Chest X-ray Minimal Fibrosis, Lungs are adequately Pulmonary fibrosis

Both Lung Apices aerated and clear. signifies that lung tissue
with Residual Heart shadow is is thickened making it
Atherosclerotic Aorta normal in size and difficult for the lungs to
configuration. Aorta is work.
normal.
Glycosylated 7.9 Below 6.0% Increased glycosylated
hemoglobin hemoglobin shows how
diabetes is poorly
controlled.
Color Flow Concentric left Results from elevated
Doppler Study ventricular blood pressure levels as
hypertrophy with the patient is diagnosed
segmental wall with hypertensive
motion abnormality cardiovascular disease.
Ultrasound of Weight of the Weight: 7-16 grams Prostate is enlarged due
the prostate prostate is 20 grams, Size: 3 x 3 x 5 cm to Benign Prostatic
with 35 cm3 in size Hyperplasia.

4. Identify at least five priority problem with nursing interventions and rationale. (10pts)
- Impaired Gas Exchange related to Iron-Deficiency Anemia
- Decrease Cardiac Output related to Iron-Deficiency Anemia
- Impaired Urinary Elimination related to Enlarged Prostate
- Risk for Unstable Blood Glucose Level related to Sedentary Activity Level
- Risk for Deficient Fluid Volume related to Physical Immobilit

References:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6515717/#:~:text=These%20preoperative%20preparations%20inc
lude%20patient,of%20preoperative%20metabolism%2C%20prophylaxis%20of

https://emedicine.medscape.com/article/2172316-overview

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1477609/#:~:text=Histologically%2C%20BPH%20describes%20a
%20proliferative,transition%20zones%20of%20the%20prostate.&text=Histological%20BPH%20represents%20a
n%20inescapable%20phenomenon%20for%20the%20aging%20male%20population.
 Benign Prostatic Hyperplasia
Pathophysiology - Non-cancerous
increase of the
prostate gland
Precipitating Factors:
Predisposing Factors:
- Smoker for 67 years
- Age (83 years old) - Ate chocolates almost every after meal
- Gender - Sedentary lifestyle
- Noncompliance to medications

Hormonal Alterations Inflammation & Immune Dysregulation Metabolic Derangements

Increased Increased Increased proliferation of Impaired suppression of Increased body fluid volume
testosterone aromatization immunocompetent cells endogenous glucose production
to DHT of androgens
conversion via to estrogens
5-alpha- via enzyme
reductase P450
aromatase Glycosylated Hyperglycemia and a Vasoconstriction
hemoglobin compensatory increase in insulin
secretion

DHT binds to Estrogen binds Vasoconstriction

AR within to ERs in the Increased peripheral artery
HbA1c: 7.9 resistance
prostate cells, prostate
especially in leading to Resistance to the ability of insulin
transitional altered gene to suppress LDL production
zone expression BP: 150/100 mmHg

Hypertension

Initiation of Cholesterol Increased circulating serum

ER- and AR- Test triglycerides, decreased in HDl If not treated
dependent and formation of atherogenic,
production & small, dense, LDL particles
secretion of
peptide growth Chest Xray:
factors Both lung
apices with
Hardening of the arteries, Prolonged
residual
clogged blood vessels hypertension
atherosclerotic
aorta

Diabetes Mellitus Type 2 Increased workload of the heart

 Stromal proliferation Color Flow Doppler Study:
transdifferentiation, and Concentric left ventricular
extracellular matrix production hypertrophy with segmental wall To increase contractile force, the
motion abnormality left ventricle hypertrophies

Growth of fibroadenomatous
nodules progresses to compress
remaining normal gland RR: 26bpm Oxygen demands increased

Oxygen Saturation: 96%

As it continues to enlarge, it may Dyspnea upon exertion

Hematuria, difficulty sleeping at
extend into the bladder and night due to nocturia, urinary Hypertensive Cardiovascular
obstruct urinary flow frequency and urgency Disease

Benign Prostatic Hyperplasia If not treated

Decreased vascular supply to

prostate causes oxidative stress
Bad Prognosis

Prostate inflammation
Chronic urinary retention

Chronic process of tissue

Urinary bladder malignancy
remodeling activates
hyperproliferative programs via
increase growth factors
Cystosccopy: Transurethral
resection of bladder tumor

Ultrasound of
prostate

Legend:
Enlarged
Predisposing/Precipitating Factors prostate

Diagnostic Exams Transurethral W: 20g

incision of the Size: 35cm3
Signs & Symptoms prostate
Pathophysiology
Disease
Medical/Surgical Management
Nursing Care Plan
ASSESSMENT DIAGNOSIS PLANNING IMPLEMENTATION RATIONALE EVALUATION
SUBJECTIVE CUES Impaired Gas Exchange At the end of 8 hours, INDEPENDENT INDEPENDENT After 8 hours, patient was
- Dyspnea upon related to Iron-Deficiency patient will be able to: 1. Note capillary 1. To evaluate able to:
exertion Anemia 1. Verbalize refill, areas of respiratory 1. Verbalized
understanding of pallor/cyanosis insufficiency understanding of
OBJECTIVE CUES causative factors 2. Encourage 2. Promote optimal causative factors
- Difficulty sleeping at and appropriate frequent position chest expansion and appropriate
night (restlessness) interventions changes and and drainage of interventions
- Respiratory: 28 2. Participate in deep-breathing secretions 2. Participated in
breaths per minute treatment exercises treatment
- Smoker for 67 years regimen within 3. Keep 3. To reduce irritant regimen within
- Low level of RBC, level of ability or environment effect on airways level of ability or
Hemoglobin and situation such as allergen/pollutant- situation such as
Hematocrit breathing free breathing
- Chest x-ray shows exercises 4. Encourage 4. To improve lung exercises
minimal fibrosis, patient to stop function
both lung apices with At the end of 24 hours, smoking After 24 hours, patient was
residual patient will be able to: 5. Maintain 5. For mobilization able to:
atherosclerotic aorta 1. Demonstrate adequate intake of secretions and 1. Demonstrated
improved and output avoid fluid improved
ventilation and overload ventilation and
adequate adequate
oxygenation of DEPENDENT DEPENDENT oxygenation of
tissues within 1. Administer 1. To treat tissues within
patient’s normal medications as underlying patient’s normal
limits indicated conditions limits
2. Demonstrate 2. Use sedation 2. To avoid 2. Demonstrated
absence of judiciously depressant absence of
symptoms of effects on symptoms of
respiratory respiratory respiratory
distress such as functioning distress such as
dyspnea and dyspnea and
respiratory rate COLLABORATION COLLABORATION respiratory rate
1. Provide 1. To monitor
supplemental patient’s gas Goals met.
oxygen at lowest exchange status
concentration as
indicated
 ASSESSMENT DIAGNOSIS PLANNING IMPLEMENTATION RATIONALE EVALUATION
SUBJECTIVE CUES Decreased Cardiac Output At the end of 8 hours, INDEPENDENT INDEPENDENT After 8 hours, patient was
- Dyspnea upon related to Iron-Deficiency patient will be able to: 1. Monitor cardiac 1. To not able to:
exertion Anemia 1. Verbalize rhythm effectiveness of 1. Verbalized
knowledge of the continuously medications knowledge of the
OBJECTIVE CUES disease process, and/or devices disease process,
- Blood Pressure: individual risk 2. Promote 2. To maximize individual risk
150/100 mmHg factors and adequate rest by sleep periods factors and
- Sedentary lifestyle treatment plan decreasing treatment plan
- Non-compliance to 2. Participate in stimuli, providing 2. Participated in
medication activities that quiet activities that
- Low level of RBC, reduce the environment reduce the
Hemoglobin, workload of the 3. Avoid the use of 3. May increase workload of the
Hematocrit and LDL heart such as restraints agitation and heart such as
- High cholesterol cessation of whenever increase the cessation of
triglyceride and LDL smoking possible if patient cardiac workload smoking
levels is confused
- Low levels of HDL At the end of 24 hours, 4. Alter 4. To maintain body After 24 hours, patient was
- Color flow Doppler patient will be able to: environment/bed temperature in able to:
study shows 1. Demonstrate linens near-normal 1. Demonstrated
concentric left decreased range decreased
ventricular episodes of 5. Assist with 5. To prevent the episodes of
hypertrophy with dyspnea frequent position development of dyspnea
segmental wall motion 2. Display changes pressure sores 2. Displayed
abnormality hemodynamic hemodynamic
stability such as DEPENDENT DEPENDENT stability such as
blood pressure 1. Use sedation and 1. To achieve blood pressure
analgesics as desired effect
indicated without Goals met.
compromising
hemodynamic
readings
2. Administer fluid 2. To determine
replacement as therapeutic,
indicated adverse or toxic
effects of therapy
COLLABORATION COLLABORATION
1. Perform periodic 1. To avoid further
hemodynamic complications
measurements
as indicated
(CBC)
 ASSESSMENT DIAGNOSIS PLANNING IMPLEMENTATION RATIONALE EVALUATION
OBJECTIVE CUES Impaired Urinary At the end of 8 hours, INDEPENDENT INDEPENDENT After 8 hours, patient was
- Urinary frequency and Elimination related to patient will be able to: 1. Check frequently 1. To reduce risk of able to:
urgency at least 10-15 Enlarged Prostate 1. Verbalize for bladder infection and/or 1. Verbalized
times per day understanding of distention and autonomic understanding of
- Hematuria (admitted condition observe for hyperreflexia condition
February 17, 2019) 2. Identify causative overflow 2. Identified
- Enlarged prostate factors 2. Adhere to a 2. To avoid causative factors
3. Demonstrate regular accidents or 3. Demonstrated
behaviors to bladder/diversion injuries behaviors to
prevent urinary appliance prevent urinary
infection emptying infection
schedule
At the end of 24 hours, 3. Instruct in proper 3. To promote odor After 24 hours, patient was
patient will be able to: application and control able to:
1. Achieve normal care of appliance 1. Achieved normal
elimination to for urinary elimination to
pattern or diversion pattern or
participate in 4. Demonstrate 4. To facilitate participate in
measures to proper drainage/prevent measures to
compensate for positioning of reflux compensate for
defects catheter drainage defects
tubing and bag
5. Recommend 5. Flatus can cause
avoidance of urinary
gas-forming incontinence
foods

DEPENDENT DEPENDENT
1. Monitor 1. To note patient’s
medication response, need
regimen as to modify
indicated treatment

COLLABORATION COLLABORATION
1. Send urine for 1. To observe for
culture and signs of infection
sensitivities as
indicated
 ASSESSMENT DIAGNOSIS PLANNING IMPLEMENTATION RATIONALE EVALUATION
OBJECTIVE CUES Risk for Unstable Blood At the end of 8 hours, INDEPENDENT INDEPENDENT After 8 hours, patient was
- Ate chocolates almost Glucose Level related to patient will be able to: 1. Assist the patient 1. To provide basis able to:
after every meal Sedentary Activity Level 1. Demonstrate in identifying for individualized 1. Demonstrated
- Sedentary lifestyle knowledge on the eating patterns dietary knowledge on the
- Non-compliance to importance of a that need to be instruction importance of a
medication healthy lifestyle modified. healthy lifestyle
- High cholesterol such as avoiding 2. Provide food or 2. To manage such as avoiding
triglyceride, LDL, Uric chocolates after other sources of elevated glucose chocolates after
Acid and HbA1c levels every meal low-glucose levels every meal
3. Educate patient 3. Help the patient
At the end of 24 hours, about the maintain stable After 24 hours, patient was
patient will be able to: importance of blood glucose able to:
1. Demonstrate lab following a 1. Demonstrated
findings in normal prescribed meal lab findings in
range value such plan normal range
as cholesterol, 4. Educate the 4. Patients with value such as
LDL, Uric Acid, patient about the diabetes need to cholesterol, LDL,
and HbA1c levels proper ways of learn about Uric Acid, and
taking prescribed taking insulin HbA1c
medications drugs
5. Instruct patient 5. Food intake is Goals met.
about appropriate in
appropriate most cases of
actions to lower diabetes
blood glucose

DEPENDENT DEPENDENT
1. Administer 1. To lower blood
insulin glucose levels in
medications as type 1 and type 2
indicated diabetes patients

COLLABORATION COLLABORATION
1. Refer the patient 1. Specific
to an exercise exercises can be
physiologist prescribed based
physical on any physical
therapist, or limitations the
cardiac patient may have
rehabilitation
nurse
 ASSESSMENT DIAGNOSIS PLANNING IMPLEMENTATION RATIONALE EVALUATION
OBJECTIVE CUES Risk for Deficient Fluid At the end of 8 hours, INDEPENDENT INDEPENDENT After 8 hours, patient was
- Urinary frequency and Volume related to patient will be able to: 1. Encourage oral 1. To maximize able to:
urgency at least 10 – Physical Immobility 1. Identify intake intake 1. Identified
15 times per day individual risk 2. Monitor intake and 2. To ensure individual risk
- Sedentary lifestyle factors and output balance accurate picture factors and
appropriate being aware of of fluid status appropriate
interventions insensible losses interventions
3. Encourage patient
At the end of 24 hours, to maintain diary of 3. To keep track of After 24 hours, patient was
patient will be able to: food/fluid intake, the status of able to:
1. Demonstrate number and patient’s fluid 1. Demonstrated
behavior or amount of voiding volume behavior or
lifestyle changes and stools lifestyle changes
to prevent 4. Perform serial 4. To note trends to prevent
development of weights development of
fluid volume 5. Establish individual 5. To assure fluid volume
deficit fluid compliance of deficit
needs/replacement fluid intake
schedule Goals met.

DEPENDENT DEPENDENT
1. Provide 1. To prevent
supplemental fluids peaks/valleys in
as indicated fluid level

COLLABORATION COLLABORATION
1. Review laboratory 1. To monitor the
data such as status of
Hb/Hct/electrolyts patient’s fluid
volume