Management of Patients With Female Reproductive Disorders
Management of Patients With Female Reproductive Disorders Pelvic Organ Prolapse ??? Weakening of vaginal walls allows the pelvic organs to descend and protrude into the vaginal canal – Risk factors: age, parity, delivery of large babies, possible hormone deficiency – Cystocele – downward displacement of bladder – Rectocele – rectum pouches upward and pushes the posterior vaginal wall forward – Signs/symptoms: pelvic pressure and urinary problems (Cysto), rectal pressure and bowel problems (recto), dyspareunia ??? Medical Management – Kegel exercises (cysto) – Pessaries ??? Surgical management – Colporrhaphy – repair of anterior vaginal wall Posterior colporrhaphy – repair of rectocele Pelvic Floor Relaxation Copyright 2008 Lippincott Williams & Wilkins.
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Complete Prolapse of the Uterus Uterine Prolapse ??? Structures that support the uterus weaken and the uterus works its way down the vaginal canal (prolapse) and may protrude out of the vagina (procidentia) – May begin to pull the bladder and rectum with it ??? Signs/symptoms: pressure and urinary problems aggravated by activity; – Hysterectomy ??? Nursing Management – Teach Kegel exercises during the postpartum period – Preoperative teaching ??? Expectations of postoperative period ??? Effect of surgery on sexual function Postoperative care ??? Prevention of infection ??? Voiding ??? Perineal care ??? Stool softener ??? Pain management ??? Teaching Ovarian Cysts (Benign Ovarian Tumors) ??? May be enlargements of ovarian constituents, follicle, corpus luteum, or normal growth of the epithelium ??? 98% occur in women under 30 ??? > age 50 – only 50% of cysts are benign ??? Symptoms – acute or chronic abdominal pain;urinary frequency; feeling of fullness; ruptured cyst may mimic an acute abdomen – Often asymptomatic if small ??? Polycystic ovarian syndrome – endocrine condition that results in anovulation and androgen excess Ovarian Cysts Many resolve on their own – Surgical removal if large or suspicious – Oral contraceptives – Possible hysterectomy if ovaries are being removed due to suspicious mass QuickTime”* and a decompressor are needed to see this picture.
Fibroids tumors uterus – May occur in the lining of, the muscle wall and outside surface of the uterus – Usually develop between 25-40, slow growing ??? Clinical manifestations : asymptomatic, abnormal vaginal bleeding, menorrhagia, pelvic pressure, bloating, backache, constipation Fibroids (myomas) Fibroid tumors ??? Medical management – Dependent on size, symptoms, location, woman”s age and reproductive plans Observation, tumor removal, hysterectomy, tumor ablation, medications to shrink the fibroids (induce menopause like state) Endometriosis ??? Presence of normal endometrial tissue in sites outside the endometrial cavity – grow aberrantly – Usually in pelvic area, but may include other areas like the stomach, spleen and lungs ??? Major cause of chronic pain and infertility ??? Familial predisposition; ages 25-35 most common ??? Clinical manifestations: dysmenorrhea, dyspareunia, pelvic pain, radiation of pain to back or legs Depression, loss of work, relationship difficulties Tenderness with pelvic exam ??? Pharmacologic Hormonal therapy (usually OCP initally) – Androgen therapy – induce pesudomenopause – Gonadropin-releasing hormone agonists (GnRH a) ??? Surgical – If conservative measures fail – Laparoscopy, laser surgery, electrocoagulation, laparotomy, hysterectomy, oopherectomy ??? Nursing management – History and physical – Specific symptoms – what, where, how long – Psychosocial care ??? Impaired relationships ??? Fertility problems – Education ??? Seek treatment early ??? Support group referral Malignant Disorders of the Female Reproductive Tract ??? cervical (10??00), utenne (41,000), vaginal (2420), vulvar (3740), and ovarian cancers (25,000) **new cases/yearly in the USA ??? Early disease may not have symptoms. ??? Signs and symptoms depend upon location and may include vaginal discharge, pain, bleeding, and systemic symptoms (weight loss and anemia). ?? Prevention, screening, and early detection are vital. Cervical cancer ??? Squamous cell cancer; strongly associated with certain strains of human papillomavirus ??? Less common now – early detection by Pap smear ??? Prevention – Regular pelvic exams and Pap smears to identify preinvasive lesions ??? Begin 3 years after intercourse, by age 21 ??? Every 2-3 years for average risk; more for high risk Preventive counseling -delay first intercourse, avoidance of HAI, smoking cessation, HPV vaccination for ages 9-26 ??? Clinical manifestations – Often asymptomatic – May include discharge, irregular bleeding, pain after sexual intercourse ??? If symptoms – usually advanced disease gynecologic care! Symptoms of advanced disease may also include leg pain, rectal bleeding, dysuria, extremity edema, back pain – Survival rate for carcinoma in situ may be up to 100%, but decreases dramatically for invasive disease Cervical Cancer ??? Diagnosis made on basis of abnormal pap smear and biopsy – Severe dysplasia (CIN Ill) Carcinoma in situ (???preinvasive cancer”) – Invasive cervical cancer ??? Patient is then staged : TNM staging system – Precursor lesions (LGSIL – CIN I or II) ??? Monitoring, conservative treatment, possible cryotherapy, LEEP – H6SlL (CIN Ill) ??? LEEP, conization – Preinvasive ??? Hysterectomy if childbearing is complete ??? If not, conization may suffice and close monitoring – Invasive ??? Hysterectomy ??? Radiation (treat and prevent recurrence) ??? May be delivered by external beam or brachytherapy: radiation is placed near the tumor ??? Chemotherapy Uterine cancer (endometrial) ??? Most originate in the lining of the uterus ?? Risk factors: *cumulative exposure to estrogen especially unopposed*; also infertility, diabetes, hypertension, smoking, late menopause, obesity – Pregnancy and OCP use are protective ??? Irregular bleeding, often postmenopausal ??? Treatment involves total hysterectomy; adjuvant radiation, progesterone therapy ??? Recurrent cancer or advanced: chemotherapy Ovarian cancer ??? Gynecologic cancer with the highest mortality rate ??? Early detection is difficult – Transvaginal U/S, CA-125 antigen testing ??? Risk peaks in 70s ??? 3-4 fold increased risk for breast cancer; association with BRCA genetic mutations ?? Risk factors: family history, nullparity, infertility, HRT – ? genetic testing? ?? Breast feeding and oral contraceptives may be protective Ovarian Cancer ??? May arise from germ cells, stromal cells, epithelial cells – Most epithelial (90%) – Nonspecific; may include increased abd girth, pelvic pressure, bloating, back pain, constipation, urinary urgency, indigestion, flatulence, leg pain, pelvic pain – Often considered “silent” ??? Diagnosis – Enlarged ovary must be investigated (U/S, CT, MRI) not always definitive – By the time of diagnosis, 75% of tumors are metastatic – Surgical removal of tumor ?? Total hysterectomy; lymph node dissection, peritoneal biopsies – Radiation or chemotherapy ??? High rate of recurrence; may become chronic in nature Hysterectomy (see table 54-13) ??? Surgical removal of the uterus to treat cancer, nonmalignant growths, persistent pain, pelvic relaxation and prolapse, and previous injury to the uterus. ?? Total hysterectomy ??? Radical hysterectomy ??? Types of approaches – Laparoscopic -assisted vaginal hysterectomy – Abdominal Nursing Process: Care of the Patient Undergoing a Hysterectomy: Assessment ??? History, signs and symptoms ??? Physical and pelvic exam ?? Psychosocial and emotional responses ??? Patient knowledge Undergoing a Hysterectomy: Diagnosis ??? Anxiety ??? Disturbed body image ??? Acute pain ??? Ineffective sexuality pattern ??? Deficient knowledge Collaborative Problems/Potential Complications ??? Hemorrhage – Perineal pad count – Monitor vital signs and abdominal dressings – Elastic compression stockings – Change positions; early ambulation ??? Bladder dysfunction – May require indwelling catheter ??? Bowel dysfunction – Monitor for ileus Undergoing a Hysterectomy: Planning ??? Major goals may include relief of anxiety, acceptance of loss of the uterus, absence f pain or discomfort, increased knowledge of self-care requirements, and absence of complications. ?? Preoperative management – Preoperative cleansing, shaving – Enema and antiseptic douche before surgery ??? Postoperative management – Monitor for complications – Pain management Interventions – Allow patient to express feelings. – Explain physical preparations and procedures. – Provide emotional support. ??? Body image – Listen and address concerns. – Provide appropriate reassurance. – Address sexual issues. – Approach and evaluate each patient individually. Chemotherapy ??? Usually administered IV ?? Patients undergoing chemotherapy need specific care to address the side effects and complications of the chemotherapy agent or agents administered. Side effects may include neutropenia, thromobocytopenia, nephrotoxicity, neurotoxicity, hair loss, hypersensitivity reactions, nausea, and vomiting. ?? Paclitaxel (Taxol) ??? Carboplatin (paraplatin) Radiation Therapy ??? External radiation therapy ??? Intraoperative radiation therapy ??? Internal (intracavity irradiation) ??? Care of the patient undergoing radiation therapy Placement of Tandem and Ovoids for Internal Radiation Therapy Intracavity Radiation Therapy ?? Monitor applicator to ensure it does not become dislodged – If this occurs, do not touch the applicator and notify the Radiation Safety Department ??? Foley catheter (prevent bladder wall exposure) ??? Absolute bed rest, positioning restrictions – HOB up to 15*, move side to side with back support ??? Diet: low residue (prevent frequent bowel movements) ??? Monitoring of patient (VS, fever! ) ??? Side effects of therapy (diarrhea, cramping, dysuria) ??? Emotional support of patient ??? Address potential for isolation. Intracavitary Radiation Safety ??? Minimize time near radioactive source (RN –