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Chapter 47 : Management of Patients With Female Reproductive Disorders

Malignant Disorders of the Female Reproductive Tract
Cervical, uterine, vaginal, vulvar, and ovarian cancers.
-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.
Risk Factors
Mult sexual partners
Sexual contact with males whose partners have had cervical cancer
Early childbearing
HBV exposure
Exposure to DES (diethylstilbestrol) in utero
Family Hx
Folate, beta-caretene, vit C deficiencies
Chronic cervical infections
Treatment of Reproductive Malignancies
Surgery, chemotherapy, radiation, or a combination of these.
Treatment may be curative or palliative.
Care of the surgery patient is similar to care of patients with other abdominal surgeries.
Surgical removal of the uterus to treat cancer, dysfunctional uterine bleeding, endometriosis, nonmalignant growths, persistent pain, pelvic relaxation and prolapse, and previous injury to the uterus.
1. Total hysterectomy:
Removal of the uterus, cervix, ovaries
2. Radical hysterectomy
All the above and fallopian tubes, proximal vagina, bilat lymph nodes via abd incision

Types of approaches
Nursing Process: The Care of the Patient Undergoing a Hysterectomy—Assessment
Physical and pelvic exam
Psychosocial and emotional responses
Patient knowledge
Nursing Process: The Care of the Patient Undergoing a Hysterectomy—Diagnoses
Disturbed body image
Acute pain
Deficient knowledge
Anticipatory Grieving
Collaborative Problems/Potential Complications
-d/t vaginal bleeding
`Monitor saturation of pads, abd dressings
-d/t positioning during surg
`Early amb
Bladder dysfunction=
-d/t dmg from Foley
`Monitor U.O
`Abd distention
`Sitz bath
Nursing Process: The Care of the Patient Undergoing a Hysterectomy—Planning
Major goals:
relief of anxiety
acceptance of loss of the uterus
absence of pain or discomfort
increased knowledge of self-care requirements
absence of complications
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
Cancer of the Vulva
-4% of gynecologic cancers; most often seen in postmenopausal women
=Encourage regular pelvic exams, Pap smears, and self-examination for early diagnosis
-Risk factors
s=moking, HPV infection, HIV, immunosuppressant therapy
=Long-standing pruritis and soreness
=May present as a chronic dermatitis, or a lump, ulcer, or mass
=Bleeding, foul-smelling discharge, and pain are late signs
Treatment for vulgar cancer in includes wide excision of the vulva=
-May be done with lymph node dissection
-Additional therapy may include radiation and/or chemotherapy
Preoperative preparation=
-assessment of patient including factors that may have delayed seeking care, health habits, and lifestyle
-include psychological assessment and provide support
Postoperative care=
-addressing issues of anxiety, pain, impaired skin integrity, sexual dysfunction, change in body image; and potential complications including infection, sepsis, DVT, and hemorrhage
Chemotherapy for all GYN Cancers
-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
=neutropenia, thromobocytopenia, nephrotoxicity, neurotoxicity, hair loss, hypersensitivity reactions, nausea, and vomiting
-Paclitaxil (Taxol)
=Contraindicated in pts with neutropenia, cardiac disorders
=Prepare pt for inevitable hair loss
-Carboplatin (paraplatin)
=Initial tx or recurrence
=Caution in pt with renal disease
=Given in 6 cycles
=Goals- nl tumor markers: CA-125, negative CT, nl GYN exam
-Liposomal therapy
What is Taxol?
Taxol is a cancer medication that interferes with the growth of cancer cells and slows their growth and spread in the body.

s/e- cardiac disorders, neutropenia-
Liposomal- allow highest possible dose of chemo directly to the tumor target with a reduction of adverse reactions

Liposomes are drug carrieers- chemo agent given directly into a liposome, allows increased duration of action and better targeting
Radiation Therapy
External radiation therapy.
Intraoperative radiation therapy=
-Applies directly to the area in the OR
-Used for unresectable, inoperable tumors
-Ability to block other organs during tx
Internal (intracavity irradiation)=
-Applicators inserted into the endometrial cavity
-Xrays to confirm plcmt
-Allows for precise control of radiation therapy
-24-72 hrs
-Bedrest, foley cath

Care of the patient undergoing radiation therapy
Placement of Tandem and Ovoids for Internal Radiation Therapy
Nursing Considerations Related to Intracavity Radiation Therapy
Foley catheter
Absolute bed rest**, positioning restrictions
Diet: low residue
Monitoring of patient
Side effects of therapy
Emotional support of patient
Address potential for isolation
Which statement is true about the way the nursing staff can minimize radiation exposure?
a. Maximize the amount of time near a radioactive source.
b. Minimize the distance from the radioactive source.
c. Use required shielding to minimize exposure.
d. All of the above.

Nursing staff can minimize exposure to themselves by minimizing the amount of time near a radioactive source, maximizing the distance from the radioactive source, and using required shielding to minimize exposure.
Chapter 48:
Assessment and Management of Patients With Breast Disorders
Breast Disorders
Breast cancer is a major health problem

In the U.S., more than 215,000 women and 1450 men develop the breast cancer, and more than 40,000 die of breast cancer annually
Breast Disorders
Breast pain=
-Cyclic- r/t hormonal changes
-Account for 75% of all t56tgcomplaints
-Non-Cyclic- injury or trauma
-Rarely indicative of cancer
-Danazol (Danocrine)
=Used only with sever pain, many side effects
=Decreases pain and nodularity
-Fluid filled sacs
-Exacerbated during premenopause
-Cause- unknown
-Fluctuate in size
-Shooting pain or dull ache
-Firm, round, moveable, benign tumors
-Peak incidence at 30yrs
-May be removed for definitive dx

Benign proliferative breast disease=
-Atypical hyperplasia
=Increase in ducts or lobe cells
=Increases breast risk
-Lobular carcinoma in situ
=Proliferation of cells in the breast lobules
=Cannot be seen on mammogram
=NOT a cancer
=Increases breast cancer risk 8x's
Malignant Disorders
1. Ductal carcinoma
2. Invasive Carcinomas
Invasion of surrounding tissues

-Nodule upper outer quadrant common
-Non tender, non moveable
-Hard, irregular borders
-Advanced disease
=Skin dimpling, skin ulcerations, nipple retraction
Risk Factors for Breast Cancer
-Female gender
=Women older than 60 have a greater risk than do younger women.
-Personal and family history including genetic mutations
=mother, sister or daughter with breast cancer, greater chance of being diagnosed with breast cancer
=majority of people diagnosed with breast cancer have no family history
-Hormonal factors
=Women who take hormone therapy medications that combine estrogen and progesterone to treat the signs and symptoms of menopause have an increased risk
-Exposure to radiation
-History of benign breast disease
-High-fat diet
-Alcohol intake

Inherited genes that increase cancer risk. Certain gene mutations that increase the risk of breast cancer can be passed from parents to children. The most common gene mutations are referred to as BRCA1 and BRCA2. These genes can greatly increase your risk of breast cancer and other cancers, but they don't make cancer inevitable.
The smaller the tumor the better the prognosis
Takes time to develop and double in size
Have time to make decisions after dx
Guidelines for Early Detection of Breast Cancer
Women in 20s-30s: clinical breast exam at east every 3 years, then preferably annually after age 40.
Mammography annually beginning at age 40.
Women at increased risk may have earlier initial screening, shorter screening intervals, or additional screening procedures such as ultrasound or MRI.
Beginning in 20s, teach women the benefits and limitations of breast self-examination (BSE).
Breast Self-Examination
Provide instruction to women regarding BSE.
=Chart 48-3
=Many women find their own breast cancer
=Notify MD if changes

Instructions should be provided to men if there is a family history of breast cancer.

Instructional materials can be obtained from ACS and The National Cancer Institute.
Teaching Breast Self-Exam (1 of 2)
Best performed days 5-7 after first day of menses or once monthly for postmenopausal women.
Review the feel of normal breast tissue and ways or identify changes.
Routine BSE will help patient become familiar with her own "normal abnormalities."
Demonstrate the examination technique.
Learners then should perform a BSE demonstration on themselves or a breast model.
Teaching Breast Self-Exam (2 of 2)
Part of the examination may be done in the shower with soapy hands to glide over the breast and focus on underlying tissue.
Note the importance of including the area between the breast and underarm, and the underarm itself.
Discuss reporting of any changes.
Describe the goals, methods of instruction, and methods of evaluation for a teaching plan for BSE.
List resources for information and materials.
Is the following statement True or False?

The average percentage of women who perform breast self-examination is about 35%.

The average percentage of women who perform breast self examination is about 25%, not 35%.
Diagnostic Tests
-imaging the breast ducts
Magnetic resonance imaging (MRI)
-Percutaneous: fine-needle aspiration, core biopsies
-Surgical biopsies: excision, incision, needle localization
Surgical Management: Breast Cancer
Breast conservation treatment=
Total mastectomy=
-Does not include lymph nodes
-Localized breast cancer
Modified radical mastectomy=
-Tx of invasive breast ca
-Removal of entire breast tissue, portion of lymph nodes
-Pectoralis major and minor remain in place
Sentinel node biopsy and axillary lymph node dissection=
-Tx of early stage
-Potential morbidity
-Lymph edema
-Decreased arm mvmt

Sentinal node is the first node that recieves drainage from the breast.
Breast Reconstruction Surgery
Enhances well being
Both physical and psychosocial reasons
Breast Reconstruction with Tissue Expander
Refer to fig. 48-6 A and B
Followed by a permanent implant
Simplest and most common
Underlying muscle is stretched (tissue expansion)
Balloon-like device under the pectoralis muscle
Nonsurgical Management of Breast Cancer
Radiation therapy—external beam, brachytherapy=
-Decreases the chance of recurrence by eradicating residual microscopic cells
-Stg I&II with radiation
-For lymph node involvement and tumor >1cm
-Most common before after surgery and before radiation
-3-6 months
Hormonal therapy=
-Estrogen and progesterone receptor assay
-Selective estrogen receptor modulators (SERMs)— tamoxifen
-Aromatase inhibitors—anastrazole, letrozole, exemestane
Targeted therapy=
Chemo Drugs
Flouracil(5FU), methotrexate, cyclophsphamide (CMF)= For pts at low risk of recurrence and for those at HRF cardiac toxicity

Paclitaxel, docetaxel= For larger lymph node cancers

S/E= Nausea, vomiting, bone marrow suppression, weight gain-cause unknown, hair loss, taste change, smucositis
Nursing Process: The Care of the Patient Undergoing Breast Cancer Surgery— Assessment
How is the patient responding to her diagnosis?
What coping mechanisms does she find helpful?
What psychological or emotional supports doe she have and use?
Is there a partner, family member, or friend available to assist in making treatment choices?
What are her educational needs?
Is she experiencing any discomfort?
Nursing Process: The Care of the Patient Undergoing Breast Cancer Surgery— Preoperative Diagnoses
Deficient knowledge
Risk for ineffective coping
Decisional conflict
Nursing Process: The Care of the Patient Undergoing Breast Cancer Surgery— Postoperative Diagnoses
Disturbed sensory perception
Disturbed body image
Self-care deficit
Risk for sexual dysfunction
Deficient knowledge
-Drain management
-Arm exercises
-Hand and arm care
Collaborative Problems/Potential Complications
-10-30% of patients
-Lower in pts who undergo axillary lymph node dissection
-Results if functioning lymph channels are inadequate to ensure flow into the general circulation (collateral circulation)
-Can be chronic
-Tx- antibiotics, exercises, compression sleeve
Hematoma/seroma formation=
-After mastectomy at surgical site
-Compression wrap to incision
-Seroma- collection of serous fluid
--c/o heaviness, swelling, discomfort

Nursing Process: The Care of the Patient Undergoing Breast Cancer Surgery- Planning
Major goals:
Increased knowledge about the disease and its treatment
Reduction of preoperative and postoperative fear, anxiety, and emotional stress
Improvement of decision-making ability; improvement in coping skills
Improvement in sexual function
Absence of complications
Preoperative Interventions
Review and reinforce information on treatment options.
Prepare patient regarding what to expect before, during, and after surgery.
Inform patient regarding surgical drain, arm and shoulder mobility, and range-of-motion exercises.
Maintain open communications.
Provide patient with realistic expectations.
Support coping.
Involve or provide information for supportive services and resources.
Support patient decisions.
Postoperative Interventions
Inform patient regarding common postoperative sensations
Maintain privacy
Bra with breast form
Provide information
Support coping and adjustment
Counseling and referral
See Table 48-5 and Chart 48-6
Monitor for potential complications
Hand and Arm Care
Potential for lymphedema formation after ALND.
Prevention is vital; follow guidelines for the rest of life.
No blood pressure, injections, or blood draws in the affected arm.
Perform exercises 3X a day for 20 minutes to increase circulation and muscle strength. Prevents stiffness and contractures, and restores ROM.
A mild analgesic or a warm shower may be helpful prior to exercise.
Initial limitation of lifting (over 5-10 pounds) and activity.
Within what time frame is collateral circulation usually developed in a woman after a mastectomy?
a. 1 week
b. 2 weeks
c. 3 weeks
d. 4 weeks

After a mastectomy, arm exercises facilitate the development of collateral circulation, which decreases lymphedema. Collateral circulation is usually developed within 4 weeks.
Drainage Management
May need home care referral to assist with drain management.
Drains usually removed when less than 30 mL drainage in a 24-hour period; usually 7 to 10 days.
Drain site and incision care.
Is the following statement True or False?

The most commonly encountered breast condition in the male is gynecomastia.

The most commonly encountered breast condition in the male is gynecomastia.
Assessment and Management of Problems Related to Male Reproductive Processes
Includes conditions that affect both reproduction and sexuality and urinary elimination
-Urinary function and symptoms
-Sexual function and manifestations of sexual dysfunction
-Symptoms related to urinary obstruction
=Increased urinary frequency
=Decreased force of stream
="Double" or "triple" voiding
=Nocturia, dysuria, hematuria, hematospermia
-Medications, drug, and alcohol use
-Presence of conditions that may affect sexual function (diabetes, cardiac disease, multiple sclerosis)
Physical Assessment
Digital rectal exam=
-Men >40
-Prostate screening
--Tenderness, nodules
Testicular exam=
-Masses, hernias, hydrocele
-Enc self testicular exam
Diagnostic Tests
Prostate specific antigen (PSA)=
-Produced by the prostate gland
-Levels increase with prostate cancer, BPH, acute urinary retention, TURP, prostatitis
--Detection of masses
Prostate fluid or tissue analysis=
-Cx, transrectal needle bx
Disorders of Male Sexual Function
Erectile dysfunction=
1. Psychogenic causes:
2. Organic causes:
-hematological, and neurologic disorders
-trauma, alcohol, medications, and drug abuse

Medications associated with erectile dysfunction (49-1)=
-Ca++ channel blockers
-Thiazide diuretics antipsychotics
-And many more
Medical Management
Pharmacologic therapy=
1. Oral medications—sildenafil (Viagra)
-Side effects include headache, flushing, dyspepsia, Severe hypotension
-Caution with retinopathy
-Contraindicated with nitrate use
2. Injected vasoactive agents
-Complications include priapism (persistent abnormal erection)
-Urethral suppository

Penile implants
Negative pressure devices
Conditions of the Prostate
Prostatitis: inflammation caused by an infectious agent
anti-infective agents and measures to alleviate pain and spasm

Benign prostatic hyperplasia (BPH, enlarged prostate):
-Effects half of men over age 50 and 80% of men over age 80
-Manifestations are those of urinary obstruction, urinary retention, and urinary tract infections
=Pharmacologic—alpha-adrenergic blockers, alpha- adrenergic antagonists, antiandrogen agents
=Catherization if unable to void
=Prostate surgery
Prostate Cancer
Second most common cancer and the second most common cause of cancer death in men.
Risk factors=
-increasing age, familial predisposition, and African-American race
-Early disease has few/no symptoms
-Symptoms of urinary obstruction, blood in urine or semen, painful ejaculation
-Symptoms of metastasis may be the first manifestations
Early diagnosis is vital; health screening.
Treatment may include prostatectomy, radiation therapy, hormonal therapy, and/or chemotherapy.
Prostate Surgery Procedures
A- transurethral resection- wire inserted through cystoscope to scrape the prostate at the bladder orofice.
B- suprapubic prostatectomy
C- perineal prostatectomy-
D- retropubic prostatectomy- low abd incision
E- transuretheral incision or prostate to reduce pressure on the urethera
Nursing Process: The Care of the Patient Undergoing Prostatectomy—Assessment
Assess how the underlying disorder (BPH or prostate cancer) has affected the patient's lifestyle
Urinary and sexual function
Health history
Nutritional status
Activity level and abilities
Nursing Process: The Care of the Patient Undergoing Prostatectomy— Diagnoses
Acute pain preoperatively
Acute pain postoperatively
Deficient knowledge
Collaborative Problems/Potential Complications
Hemorrhage and shock
Catheter obstruction
Sexual dysfunction
Nursing Process: The Care of the Patient Undergoing Prostatectomy—Planning
Major goals preoperatively=
-adequate preparation and reduction of anxiety and pain.
Major goals postoperatively=
-maintenance of fluid volume balance, relief of pain and discomfort, ability to perform self-care activities, and absence of complications.
Relief of Pain
Monitor urinary drainage and keep catheter patent.
Assessment of pain=
-Bladder spasms cause feelings of pressure and fullness, urgency to void, and bleeding from the urethra around the catheter.
Medication and warm compresses or sitz baths to relieve spasms.
Administer analgesics and antispasmodics as needed.
Encourage patient to walk, but to avoid sitting for prolonged periods.
Prevent constipation.
Irrigate catheter as prescribed.
Reduction of anxiety=
-Establish a professional, trusting relationship
-Provide privacy
-Allow patient to verbalize concerns
-Provide and reinforce information

Provide patient teaching including explanations of anatomy and function, diagnostic tests and surgery, and the surgical experience.
Rehabilitation and Home Care
Patient and family teaching for home care including care of urinary drainage devices and recognition and prevention of complications.
Regain bladder continence=
-Information that regaining control is a gradual process (dribbling may continue for up to 1 year depending upon type of surgery)
Avoidance of straining, heavy lifting, long car trips (6-8 weeks).
Diet: encourage fluids and avoid coffee, alcohol, and spicy foods.
Assessment and referral of sexual issues.
After a protatectomy when should the urine be light pink?
a. 1 day
b. 2 days
c. 1 week
d. 2 weeks

After a protatectomy the urine be light pink within 24 hours.
Testicular Cancer
Most common cancer in men ages 15-40
Highly treatable and curable
Risk factors: undescended testicles, positive family history, cancer of one testicle, Caucasian-American race
Manifestations: painless lump or mass in the testes
Early diagnosis: monthly testicular self-exam (TSE) and annual testicular exam
Treatment: orchidectomy, retroperitoneal lymph node dissection (open or laparoscopic), radiation therapy, chemotherapy
Nursing Management
Assessment of physical and psychological status
Support of coping
Address issues of body image and sexuality
Encourage a positive attitude
Patient teaching
TSE and follow-up care
Is the following statement True or False?

Two tumor markers that may be elevated in testicular cancer are human chorionic gonadotropin and alpha fetoprotein.

Two tumor markers that may be elevated in testicular cancer are human chorionic gonadotropin and alpha fetoprotein.