6 hysterectomy

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6 Hysterectomy/TAHBSO Nursing CarePlans

Definition Hysterectomy is the surgical removal of the uterus, most commonly performe for malignancies an certain non malignant con itions !e"g", en ometriosis/tumors#, to control life$threatening %lee ing/hemorrhage, an in the event of intracta%le pelvic infection or irrepara%le rupture of the uterus" A less ra ical proce ure !myomectomy# is sometimes

performe for removing fi%roi s &hile sparing the uterus"

Types Subtotal (partial): Bo y of the uterus is remove ' cervical stump remains"

Total: (emoval of the uterus an cervi)"

Total with bilateral salpingo-oophorectomy (TAHBSO): (emoval of uterus, cervi), fallopian tu%es, an ovaries is the treatment of choice for invasive cancer !**+ of

hysterectomies#, fi%roi tumors that are rapi ly gro&ing or pro uce severe a%normal %lee ing !a%out one$thir of all hysterectomies#, an en ometriosis inva ing other pelvic

organs"

Vaginal hysterectomy or laparoscopically assisted aginal hysterectomy (!AVH) may %e one in certain con itions, such as uterine prolapse, cystocele/rectocele, carcinoma in

situ, an high$ris o%esity" These proce ures offer the a vantages of less pain, no visi%le !or much smaller# scars, an a shorter hospital stay an a%out half the recovery time, %ut

are contrain icate if the iagnosis is o%scure"

A very comple) an aggressive surgical proce ure may %e re-uire to treat invasive cervical cancer" Total pelvis e)enteration !TP.# involves ra ical hysterectomy &ith issection

of pelvic lymph no es an %ilateral salpingo$oophorectomy, total cystectomy, an a% ominoperineal resection of the rectum" A colostomy an /or a urinary con uit are create , an

vaginal reconstruction may or may not %e performe " These patients re-uire intensive care uring the initial postoperative perio " !(efer to a itional plans of care regar ing fecal

or urinary iversion as appropriate"#

Nursing Priorities*" Support a aptation to change"

" Prevent complications"

0" Provi e i nformat ion a%out proce ure /prognosi s an treatment nee s"

Discharge Goals*" 1ealing realistically &ith situation"

" Complications prevente /minimi2e "

0" Proce ure/prognos is an t herapeut ic regimen un e rs too "

3" Plan in place to meet nee s after ischarge"

Diagnostic Studies "el ic e#amination: 4ay reveal uterine/other pelvic organ irregularities, such as masses, ten er no ules, visual changes of cervi), re-uiring further iagnostic

evaluation" "ap smear: Cellular ysplasia reflects possi%ility of/presence of cancer"

$ltrasound or computed tomography (%T) scan: Ai s in i entifying si2e/location of pelvic mass"

!aparoscopy: 1one to visuali2e tumors, %lee ing, no&n or suspecte en ometriosis" Biopsy may %e performe or laser treatment for en ometriosis" (arely,

e)ploratory laparotomy may %e one for staging cancer or to assess effects of chemotherapy" &ilation and curettage (&'%) with biopsy (endometrial cer ical): Permits histopathological stu y of cells to etermine presence/ location of cancer"

Schiller s test (staining o* cer i# with iodine): 5seful in i entifying a%normal cells"

%omplete blood count (%B%): 1ecrease hemoglo%in !H%# may reflect chronic anemia, &hereas ecrease hematocrit !Hct# suggests active %loo l oss" .levate

&hite %loo cell ! BC# count may in icate inflammation/infectious process" Se#ually transmitted disease (ST&) screen: Human papillomavirus !HP7# is present in 89+ of patients &ith cervical cancer

Nursing Care Plans:iste Belo& are 6 Hysterectomy Nursing Care Plan (NCP)

Low Self-Esteem4ay %e relate to

Concerns a%out ina%ility to have chil ren, changes in femininity, effect on se)ual relationship

(eligious conflicts

Possi%ly evi ence %y .)pressions of specific concerns/vague comments a%out result of surgery' fear of re;ection or reaction of significant other !SO#

ith ra&al, epression

1esire Outcomes 7er%ali2e concerns an in icate healthy &ays of ealing &ith t hem"

7er%ali2e acceptance of self in situation an a aptation to change in %o y/self$image"

Nursing Interventions Rationale


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Provi e time to listen to concernsan fears of patient an SO" 1iscuss

patient


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Constipation/DiarrheaRisk actors may include

Physical factors> a% ominal surgery, &ith manipulation of %o&el, &ea ening of a% ominal musculature

Pain/ iscomfort in a% omen or perineal area

Changes in ietary inta e

Possibly evidenced by

?Not applica%le' presence of signs an symptoms esta%lishes an actual iagnosis"@

Desired Outcomes 1isplay active %o&el soun s/peristaltic activity"

4aintain usual pattern of elimination"


Auscultate %o&el soun s" Note a% ominalistension, presence of nausea/vomiting"

=n icators of presence/resolution of ileus, affectingchoice of interventions"

Assist patient &ith sitting on e ge of %e an&al ing"

.arly am%ulation helps stimulate intestinal functionan return of peristalsis"

.ncourage a e-uate flui inta e, inclu ingfruit ;uices, &hen oral inta e is resume "

Promotes softer stool' may ai in stimulating peristalsis"

Provi e sit2 %aths" Promotes muscle rela)ation, minimi2es iscomfort"

(estrict oral inta e as in icate " Prevents nausea/vomiting until peristalsis returns !*ays#"

4aintain nasogastric !N # tu%e, if present" 4ay %e inserte in surgery to ecompress stomach"

Provi e clear/full li-ui s an a vance to solifoo s as tolerate "

hen peristalsis %egins, foo an flui inta e promoteresumption of normal %o&el elimination"

5se rectal tu%e' apply heat to the a% omen, ifappropriate"

Promotes the passage of flatus"

A minister me ications, e"g", stool softeners,mineral oil, la)atives, as in icate "

Promotes formation/passage of softer stool"

Ineffective Tissue PerfusionRisk actors may include

Hypovolemia

(e uction/interruption of %loo flo&> pelvic congestion, postoperative tissue inflammation, venous stasis

=ntraoperative trauma or pressure on pelvic/calf vessels> lithotomy position uring vaginal hysterectomy



Desired Outcomes

1emonstrate a e-uate perfusion, as evi ence %y sta%le vital signs, palpa%le pulses, goo capillary refill, usual mentation, in ivi ually a e-uate urinary output"

Be free of e ema, signs of throm%us formation"


4onitor vital signs' palpate peripheral pulses,an note capillary refill' assess urinaryoutput/characteristics" .valuate changes inmentation"

=n icators of a e-uacy of systemic perfusion,flui /%loo nee s, an eveloping complications"

=nspect ressings an perineal pa s, notingcolor, amount, an o or of rainage" eigh

pa s an compare &ith ry &eight if patient is %lee ing heavily"

Pro)imity of large %loo vessels to operative sitean /or potential for alteration of clotting mechanism!e"g", cancer# increases ris of postoperativehemorrhage"

Turn patient an encourage fre-uentcoughing an eep$%reathing e)ercises"

Prevents stasis of secretions an respiratorycomplications"

Avoi high$ o&ler


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A minister =7 flui s, %loo pro ucts asin icate "

(eplacement of %loo losses maintains circulatingvolume an tissue perfusion"

Apply anti em%olism stoc ings" Ai s in venous return' re uces stasis an ris ofthrom%osis"

Assist &ith/encourage use of incentivespirometer"

Promotes lung e)pansion/minimi2es atelectasis"

Sexual DysfunctionRisk actors may include Altere %o y structure/function, e"g", shortening of vaginal canal' changes in hormone levels, ecrease li%i o

Possi%le change in se)ual response pattern, e"g", a%sence of rhythmic uterine contractions uring orgasm' vaginal iscomfort/pain ! yspareunia#



Desired Outcomes

7er%ali2e un erstan ing of changes i n se)ual anatomy/function"

1iscuss concerns a%out %o y image, se) role, esira%ility as a se)ual partner &ith SO"

= entify satisfying/accepta%le se)ual practices an some alternative &ays of ealing &ith se)ual e)pression"

Nursing I nterventions Rationale

:isten to comments of patient/SO" Se)ual concerns are often isguise as humor an /or offhanremar s"

Assess patient


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7er%ali2e un erstan ing of therapeutic nee s"


(evie& effects of surgical proce urean future e)pectations' e"g", patientnee s to no& she &ill no longermenstruate or %ear chil ren, &hethersurgical menopause &ill occur, anthe possi%le nee for hormonal

replacement"

Provi es no&le ge %ase from &hich patient can ma einforme choices"

1iscuss comple)ity of pro%lemsanticipate uring recovery, e"g",emotional la%ility an e)pectation offeelings of epression/sa ness'e)cessive fatigue, sleep istur%ances,urinary pro%lems"

Physical, emotional, an social factors can have a cumulativeeffect, &hich may elay recovery, especially if hysterectomy&as performe %ecause of cancer" Provi ing an opportunity for

pro%lem solving may facilitate the process" Patient/SO may %enefit from the no&le ge that a perio of emotional la%ility isnormal an e)pecte uring recovery"

1iscuss resumption of activity".ncourage light activities initially,&ith fre-uent rest perio s anincreasing activities/e)ercise astolerate " Stress importance ofin ivi ual response in recuperation"

Patient can e)pect to feel tire &hen she goes home an nee sto plan a gra ual resumption of activities, &ith return to &or anin ivi ual matter" Prevents e)cessive fatigue' conserves energyfor healing/tissue regeneration" Note: Some stu ies suggest thatrecovery from hysterectomy !especially &hen oophorectomy is

one# may ta e up to four times as long as recovery from otherma;or surgeries !* mo versus 0 mo#"

= entify in ivi ual restrictions, e"g",avoi ing heavy lifting an strenuousactivities !such as vacuuming,straining at stool#, prolongesitting/ riving" Avoi tu%

%aths/ ouching until physician

allo&s"

Strenuous activity intensifies fatigue an may elay healing"Activities that increase intra$a% ominal pressure can strainsurgical repairs, an prolonge sitting potentiates ris ofthrom%us formation" Sho&ers are permitte , %ut tu%

%aths/ ouching may cause vaginal or incisional infections anare a safety ha2ar "

(evie& recommen ations ofresumption of se)ual intercourse"

hen se)ual activity is cleare %y the physician, it is %est toresume activity easily an gently, e)pressing se)ual feelings inother &ays or using alternative coital positions"

= entify ietary nee s, e"g", high protein, a itional iron"

acilitates healing/tissue regeneration an helps correct anemia&hen present"

(evie& hormone replacementtherapy !H(T#"

Total hysterectomy &ith %ilateral salpingo$oophorectomy!surgically in uce menopause# re-uires replacement hormones"The long$term %enefits of H(T !particularly estrogen# inclu e a

ecrease inci ence of car iovascular isease, protection againstosteoporosis, improve moo an cognition"

.ncourage ta ing prescri%e rug!s#routinely !e"g", &ith meals#"

Ta ing hormones &ith meals esta%lishes routine for ta ing rugan re uces potential for initial nausea"

1iscuss potential si e effects, e"g",&eight gain, increase s in

pigmentation or acne, %reastten erness, hea aches,

photosensitivity"

1evelopment of some si e effects is e)pecte %ut may re-uire pro%lem solving such as change in osage or use of sunscreen"

(ecommen cessation of smo ing&hen receiving estrogen therapy"

Some stu ies suggest an increase ris of throm%ophle%itis,myocar ial infarction !4=#, cere%rovascular acci ent !C7A#,an pulmonary em%oli associate &ith smo ing an concurrentestrogen therapy"

(evie& incisional care &henappropriate"

acilitates competent self$care, promoting in epen ence"

Stress importance of follo&$up care" Provi es opportunity to as -uestions, clear upmisun erstan ings, an etect eveloping complications"

= entify signs/symptoms re-uiringme ical evaluation, e"g", fever/chills,change in character of vaginal/&oun

rainage' %right %lee ing"

.arly recognition an treatment of eveloping complicationssuch as infection/hemorrhage may prevent life$threateningsituations" Note: Hemorrhage may occur as late as &

postoperatively"

Additional Diagnoses*" Se)ual ysfunctionEaltere %o y structure/function' changes in hormone levels, ecrease li%i o' possi%le change in se)ual response pattern' vaginal

iscomfort/pain ! yspareunia#"" Self$.steem, situational lo&Econcerns a%out ina%ility to have chil ren, changes in femininity, effect on se)ual relationship' religious conflicts"

6 hysterectomy

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