Post-TURP Confusion and a Falling Sodium
Mr. H., 74, had a monopolar transurethral resection of the prostate (TURP) yesterday for benign prostatic enlargement; his preoperative sodium was 138 mmol/L. He has a three-way catheter with continuous bladder irrigation at 80 mL/hr and is receiving cefazolin. At 06:30 he is restless and confused; he says his head hurts and he feels sick. Blood pressure 158/86, heart rate 104, respirations 22, SpO2 96% on room air, temperature 37.9°C. The drainage is pink with small clots, and the irrigant bag has emptied 3 L in the past 2 hours. His abdomen is distended and he has not had a bowel movement. Serum sodium is 129 mmol/L; glucose 142 mg/dL. The night nurse documented "confused, likely sundowning." His wife says he was fully oriented yesterday and has no history of dementia.
1. Identify the most likely cause of the acute change and explain which assessment data support and refute it.
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The leading concern is TUR syndrome: absorption of hypotonic 1.5% glycine irrigant during a prolonged monopolar resection causes dilutional hyponatremia and neurologic symptoms. The sodium fell from 138 to 129 mmol/L, and he has headache, nausea, confusion, hypertension, and tachycardia-classic early findings. The large irrigant volume (3 L in 2 hours) and monopolar technique support this. Sepsis is less likely at 37.9°C without rigors or hypotension, although it must remain on the differential. Clot retention can cause distension and agitation, so check catheter patency and bladder scanning; however, the drainage is pink rather than heavily bloody and the sodium drop is not explained by retention alone. Sundowning is not supported because he was oriented yesterday and has no dementia history. Glucose is only mildly elevated, so hyperglycemia is not the cause. Report immediately rather than waiting for the next vital-sign round.
2. State your immediate nursing actions and the SBAR report you would give.
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Immediate actions: stay with him, call for help, perform a focused neurologic check (GCS, pupils, orientation), vital signs every 15 minutes, continuous SpO2, and ensure patent IV access. Check the catheter for patency and perform manual irrigation only if outflow is poor and the bladder is distended; document return. Maintain strict intake and output, including irrigant in and drainage out. Draw repeat sodium, potassium, chloride, CBC, and coagulation studies as ordered. Do not give hypotonic IV fluids; anticipate orders for hypertonic saline and loop diuretics in symptomatic hyponatremia, but rapid correction can cause osmotic demyelination, so administration must follow provider orders and protocol. SBAR: Situation-acute confusion and sodium 129 after TURP; Background-monopolar TURP, 3 L irrigant in 2 hours, baseline sodium 138; Assessment-suspected TUR syndrome with headache, nausea, hypertension, tachycardia; Recommendation-urgent provider evaluation, repeat electrolytes, and treatment orders.
3. What documentation entries are required, and what should you avoid charting?
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Document the time of onset, exact neurologic findings, vital signs, pain, nausea, intake and output including irrigant volume, catheter patency and drainage character, laboratory values, notifications, orders received, and the patient's response. Record the wife's report of baseline orientation. Avoid conclusory labels such as "sundowning," "anxious," or "noncompliant" without supporting observations. Avoid charting that a provider was notified without the time, method, and response. Do not document assumptions about cause until the provider evaluation supports them, and never alter the night nurse's entry; add a late entry if clarification is needed. Use objective terms such as "disoriented to time and place" rather than "confused." If a rapid response is called, document the time and interventions.