26 Benign prostatic hypertrophy
Diagnostic tests
Hematocrit (HCT) and hemoglobin (HB):
Decreased Hct and Hb values may signal mild anemia from local bleeding.
Postvoid residual volume:
Normal volume is less than 12 mL; higher volumes signal obstructive process.
Nursing diagnosis:
Acute confusion
| ASSESSMENT/INTERVENTIONS | RATIONALES |
|---|---|
| Assess patient’s baseline level of consciousness (LOC) and mental status on admission. Ask patient to perform a three-step task. | Asking patient to perform a three-step task (e.g., “Raise your right hand, place it on your left shoulder, and then place the right hand by your side”) is an effective way to evaluate baseline mental status because patient may be admitted with chronic confusion. |
| Assess short-term memory. | Short-term memory can be tested by showing patient how to use call light, having patient return the demonstration, and then waiting 5 min before having patient demonstrate use of call light again. Inability to remember beyond 5 min indicates poor short-term memory. |
| Document patient’s response. | Patient’s baseline status can then be compared with postsurgical status for evaluation, which will help determine presence of acute confusion. |
| Document patient’s actions in behavioral terms. Describe “confused” behavior. | This ensures that patient’s current/postsurgical status is compared with his normal status. |
| Obtain description of prehospital functional and mental status from sources familiar with patient (e.g., patient’s family, friends, personnel at nursing home or residential care facility). | The cause may be reversible. |
| Identify cause of acute confusion as follows: | |
| Low levels of oxygen can contribute to diminished mental status. | |
| Dilutional hyponatremia can be caused by absorption of irrigating fluid. | |
| Imbalances in electrolytes and the presence of infection (reflected by elevated WBC count) can affect mental status. | |
| Both excess and deficient fluid volumes can affect mental status. | |
| Dependent edema can signal overhydration with poor venous return, which can affect mental status. | |
| Abnormal heart sounds or rhythms and presence of crackles (rales) in lung bases can signal fluid excess, which could affect mental status. | |
| These signs signal fluid deficit, which can affect mental status. | |
| Patients usually require supplementary oxygen at these levels. Decreased levels of oxygen can adversely affect mental status. | |
| These interventions may help reverse acute confusion. | |
| As appropriate, have patient wear glasses and hearing aid, or keep them close to the bedside and within patient’s easy reach. | Disturbed sensory perception can contribute to confusion. |
| Keep patient’s urinal and other commonly used items within easy reach. | Patients with short-term memory problems cannot be expected to use call light. |
| As indicated by mental status, check on patient frequently or every time you pass by the room. | This intervention helps ensure patient’s safety. |
| If indicated, place patient close to nurse’s station if possible. Provide environment that is nonstimulating and safe. | These measures provide a safer and less confusing environment for patient. |
| Provide music, but avoid use of television. | Individuals who are acutely confused regarding place and time often think action on television is happening in the room. |
| Attempt to reorient patient to surroundings as needed. Keep clock and calendar at the bedside, and remind patient verbally of date and place. | These orientation measures help reduce confusion. |
| Encourage patient or significant other to bring items familiar to patient. | Familiar items provide a foundation for orientation and can include blankets, bedspreads, and pictures of family or pets. |
| If patient becomes belligerent, angry, or argumentative while you are attempting to reorient him, stop this approach. Do not argue with patient or patient’s interpretation of the environment. | Arguing with confused patients likely will increase their belligerence. State, “I can understand why you may (hear, think, see) that.” |
| If patient displays hostile behavior or misperceives your role (e.g., nurse becomes thief, jailer), leave the room. Return in 15 min. Introduce yourself to patient as though you have never met. Begin dialogue anew. | Patients who are acutely confused have poor short-term memory and may not remember the previous encounter or that you were involved in that encounter. |
| If patient attempts to leave the hospital, walk with him and attempt distraction. Ask patient to tell you about his destination. For example, “That sounds like a wonderful place! Tell me about it.” Keep tone pleasant and conversational. Continue walking with patient away from exits and doors around the unit. After a few minutes, attempt to guide patient back to his room. | Distraction is an effective technique with individuals who are confused. |
| If patient has permanent or severe cognitive impairment, check on him frequently and reorient to baseline mental status as indicated; however, do not argue with patient about his perception of reality. | Arguing can cause a cognitively impaired person to become aggressive and combative. Patients with severe cognitive impairments (e.g., Alzheimer’s disease, dementia) also can experience acute confusional states (i.e., delirium) and can be returned to their baseline mental state. |
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