6 Hysterectomy/TAHBSO Nursing Care Plans

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
*" /" 0" Support a aptation to change" Prevent complications" Provi e information a%out proce ure/prognosis an treatment nee s"

Discharge Goals
*" /" 0" 3" 1ealing realistically &ith situation" Complications prevente /minimi2e " Proce ure/prognosis an therapeutic regimen un erstoo " Plan in place to meet nee s after ischarge"

Diagnostic Studies

evaluation"

"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

"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 loss" .levate &hite %loo cell !6BC# 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-Esteem
4ay %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# 6ith ra&al, epression 1esire Outcomes 7er%ali2e concerns an in icate healthy &ays of ealing &ith them" 7er%ali2e acceptance of self in situation an a aptation to change in %o y/self$image"
Nursing Interventions Rationale

Provi e time to listen to concerns an fears of patient an SO" 1iscuss Conveys interest an concern' provi es opportunity to correct patient<s perceptions of self relate misconceptions, e"g", &omen may fear loss of femininity an to anticipate changes an her se)uality, &eight gain, an menopausal %o y changes" specific lifestyle" Assess emotional stress patient is e)periencing" = entify meaning of loss for patient/SO" .ncourage patient to vent feelings appropriately" Provi e accurate information, reinforcing information previously given" Ascertain in ivi ual strengths an i entify previous positive coping %ehaviors" Provi e open environment for patient to iscuss concerns a%out se)uality" Note &ith ra&n %ehavior, negative self$tal,, use of enial, or over concern &ith actual/perceive changes" (efer to professional counseling as necessary" Nurses nee to %e a&are of &hat this operation means to patient to avoi ina vertent casualness or over solicitu e" 1epen ing on the reason for the surgery !e"g", cancer or long$term heavy %lee ing#, the &oman can %e frightene or relieve " She may fear loss of a%ility to fulfill her repro uctive role an may e)perience grief" Provi es opportunity for patient to -uestion an assimilate information"

Helpful to %uil on strengths alrea y availa%le for patient to use in coping &ith current situation" Promotes sharing of %eliefs/values a%out sensitive su%;ect, an i entifies misconceptions/myths that may interfere &ith a ;ustment to situation"

= entifies stage of grief/nee for interventions

4ay nee a itional help to resolve feelings a%out loss"

Impaired Urinary Elimination

May be related to

4echanical trauma, surgical manipulation, presence of local tissue e ema, hematoma Sensory/motor impairment> nerve paralysis Possibly evidenced by Sensation of %la er fullness, urgency

Small, fre-uent voi ing or a%sence of urinary output Overflo& incontinence Bla Desired Outcomes .mpty %la er regularly an completely"
Nursing Interventions Note voi ing pattern an monitor urinary output" Rationale 4ay in icate urinary retention if voi ing fre-uently in small/insufficient amounts er a%ove

er istension

Palpate %la er" =nvestigate reports of Perception of %la er fullness, istension of %la iscomfort, fullness, ina%ility to voi " symphysis pu%is in icates urinary retention"

Provi e routine voi ing measures, e"g", privacy, normal position, running Promotes rela)ation of perineal muscles an may facilitate &ater in sin,, pouring &arm &ater voi ing efforts" over perineum" Provi e/encourage goo perianal cleansing an catheter care !&hen present#" Assess urine characteristics, noting color, clarity, o or" Promotes cleanliness, re ucing ris, of ascen ing urinary tract infection !5T=#" 5rinary retention, vaginal rainage, an possi%le presence of intermittent/in &elling catheter increase ris, of infection,especially if patient has perineal sutures"

. ema or interference &ith nerve supply may cause %la er Catheteri2e &hen in icate /per atony/urinary retention re-uiring ecompression of the protocol if patient is una%le to voi or %la er"Note: =n &elling urethral or suprapu%ic catheter may %e is uncomforta%le" inserte intraoperatively if complications are anticipate " 6hen large amount of urine has accumulate , rapi %la er ecompression releases pressure on pelvic arteries, promoting venous pooling"

1ecompress %la

er slo&ly"

4aintain patency of in &elling Promotes free rainage of urine, re ucing ris, of urinary catheter' ,eep rainage tu%ing free of stasis/retention an infection" ,in,s" Chec, resi ual urine volume after voi ing as in icate " 4ay not %e emptying %la er completely' retention of urine increases possi%ility for infection an is uncomforta%le/painful"

Constipation/Diarrhea
Risk 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"
Nursing Interventions Auscultate %o&el soun s" Note a% ominal istension, presence of nausea/vomiting" Assist patient &ith sitting on e ge of %e an &al,ing" .ncourage a e-uate flui inta,e, inclu ing fruit ;uices, &hen oral inta,e is resume " Provi e sit2 %aths" (estrict oral inta,e as in icate " 4aintain nasogastric !NB# tu%e, if present" Provi e clear/full li-ui s an a vance to soli foo s as tolerate " 5se rectal tu%e' apply heat to the a% omen, if appropriate" A minister me ications, e"g", stool softeners, mineral oil, la)atives, as in icate " Rationale =n icators of presence/resolution of ileus, affecting choice of interventions" .arly am%ulation helps stimulate intestinal function an return of peristalsis" Promotes softer stool' may ai in stimulating peristalsis" Promotes muscle rela)ation, minimi2es iscomfort" Prevents nausea/vomiting until peristalsis returns !*A/ ays#" 4ay %e inserte in surgery to ecompress stomach" 6hen peristalsis %egins, foo an flui inta,e promote resumption of normal %o&el elimination" Promotes the passage of flatus"

Promotes formation/passage of softer stool"

Ineffective Tissue Perfusion

Risk 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 Possibly evidenced by ?Not applica%le' presence of signs an symptoms esta%lishes an actual iagnosis"@ 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"
Nursing Interventions Rationale

4onitor vital signs' palpate peripheral pulses, an note capillary refill' assess urinary =n icators of a e-uacy of systemic perfusion, output/characteristics" .valuate changes in flui /%loo nee s, an eveloping complications" mentation" =nspect ressings an perineal pa s, noting color, amount, an o or of rainage" 6eigh pa s an compare &ith ry &eight if patient is %lee ing heavily" Turn patient an encourage fre-uent coughing an eep$%reathing e)ercises" Avoi high$Co&ler<s position an pressure un er the ,nees or crossing of legs" Assist &ith/instruct in foot an leg e)ercises an am%ulate as soon as a%le" Chec, for Homans< sign" Note erythema, s&elling of e)tremity, or reports of su en chest pain &ith yspnea" Pro)imity of large %loo vessels to operative site an /or potential for alteration of clotting mechanism !e"g", cancer# increases ris, of postoperative hemorrhage" Prevents stasis of secretions an respiratory complications" Creates vascular stasis %y increasing pelvic congestion an pooling of %loo in the e)tremities, potentiating ris, of throm%us formation" 4ovement enhances circulation an prevents stasis complications" 4ay %e in icative of evelopment of throm%ophle%itis/pulmonary em%olus"

A minister =7 flui s, %loo pro ucts as in icate " Apply anti em%olism stoc,ings" Assist &ith/encourage use of incentive spirometer"

(eplacement of %loo losses maintains circulating volume an tissue perfusion" Ai s in venous return' re uces stasis an ris, of throm%osis" Promotes lung e)pansion/minimi2es atelectasis"

Sexual Dysfunction
Risk 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# Possibly evidenced by ?Not applica%le' presence of signs an symptoms esta%lishes an actual iagnosis"@ Desired Outcomes 7er%ali2e un erstan ing of changes in 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 Interventions :isten to comments of patient/SO" Rationale Se)ual concerns are often isguise as humor an /or offhan remar,s" 4ay have misinformation/misconceptions that can affect a ;ustment" Negative e)pectations are associate &ith poor overall outcome" Changes in hormone levels can affect li%i o an /or ecrease suppleness of the vagina" Although a shortene vagina can eventually stretch, intercourse initially may %e uncomforta%le/painful" 4ay affect return to satisfying se)ual relationship" Ac,no&le ging normal process of grieving for actual/perceive changes may enhance coping an facilitate resolution" Open communication can i entify areas of agreement/pro%lems an promote iscussion an resolution"

Assess patient<s/SO<s information regar ing se)ual anatomy/function an effects of surgical proce ure"

= entify cultural/value factors an conflicts present" Assist patient to %e a&are of/ eal &ith stage of grieving" .ncourage patient to share thoughts/concerns &ith partner" Pro%lem$solve solutions to potential pro%lems, e"g", postponing se)ual intercourse &hen fatigue , su%stituting alternative means of e)pression, using positions that avoi pressure on a% ominal incision, using vaginal lu%ricant"

Helps patient return to esire /satisfying se)ual activity"

1iscuss e)pecte physical sensations/ iscomforts, changes in response as appropriate to the in ivi ual"

7aginal pain may %e significant follo&ing vaginal proce ure, or sensory loss may occur %ecause of surgical trauma" Although sensory loss is usually temporary, it may ta,e &ee,s/months to resolve" =n a ition, changes in vaginal si2e, altere hormone levels, an loss of sensation of rhythmic contractions of the uterus uring orgasm can impair se)ual satisfaction" Note: 4any &omen e)perience fe& negative effects %ecause fear of pregnancy is gone, an relief from symptoms often improves en;oyment of intercourse" 4ay nee a outcome" itional assistance to promote a satisfactory

(efer to counselor/se) therapist as nee e "

Knowledge Deficit
May be related to

:ac, of e)posure/recall =nformation misinterpretation 5nfamiliarity &ith information resources Possibly evidenced by Duestions/re-uest for information' statement of misconception =naccurate follo&$through of instructions, evelopment of preventa%le complications Desired Outcomes 7er%ali2e un erstan ing of con ition an potential complications" = entify relationship of signs/symptoms relate to surgical proce ure an actions to eal &ith them"

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

Nursing Interventions Rationale

(evie& effects of surgical proce ure an future e)pectations' e"g", patient nee s to ,no& she &ill no longer Provi es ,no&le ge %ase from &hich patient can ma,e menstruate or %ear chil ren, &hether informe choices" surgical menopause &ill occur, an the possi%le nee for hormonal replacement" 1iscuss comple)ity of pro%lems anticipate uring recovery, e"g", emotional la%ility an e)pectation of feelings of epression/sa ness' e)cessive fatigue, sleep istur%ances, urinary pro%lems" 1iscuss resumption of activity" .ncourage light activities initially, &ith fre-uent rest perio s an increasing activities/e)ercise as tolerate " Stress importance of in ivi ual response in recuperation" = entify in ivi ual restrictions, e"g", avoi ing heavy lifting an strenuous activities !such as vacuuming, straining at stool#, prolonge sitting/ riving" Avoi tu% %aths/ ouching until physician allo&s" (evie& recommen ations of resumption of se)ual intercourse" = entify ietary nee s, e"g", high protein, a itional iron" Physical, emotional, an social factors can have a cumulative effect, &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 is normal an e)pecte uring recovery" Patient can e)pect to feel tire &hen she goes home an nee s to plan a gra ual resumption of activities, &ith return to &or, an in ivi ual matter" Prevents e)cessive fatigue' conserves energy for healing/tissue regeneration" Note: Some stu ies suggest that recovery from hysterectomy !especially &hen oophorectomy is one# may ta,e up to four times as long as recovery from other ma;or surgeries !*/ mo versus 0 mo#" Strenuous activity intensifies fatigue an may elay healing" Activities that increase intra$a% ominal pressure can strain surgical repairs, an prolonge sitting potentiates ris, of throm%us formation" Sho&ers are permitte , %ut tu% %aths/ ouching may cause vaginal or incisional infections an are a safety ha2ar " 6hen se)ual activity is cleare %y the physician, it is %est to resume activity easily an gently, e)pressing se)ual feelings in other &ays or using alternative coital positions" Cacilitates healing/tissue regeneration an helps correct anemia &hen present" Total hysterectomy &ith %ilateral salpingo$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 against osteoporosis, improve moo an cognition" rug!s# Ta,ing hormones &ith meals esta%lishes routine for ta,ing rug an re uces potential for initial nausea"

(evie& hormone replacement therapy !H(T#"

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

1iscuss potential si e effects, e"g", &eight gain, increase s,in pigmentation or acne, %reast ten 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 concurrent estrogen therapy" Cacilitates competent self$care, promoting in epen ence" Provi es opportunity to as, -uestions, clear up misun erstan ings, an etect eveloping complications" .arly recognition an treatment of eveloping complications such as infection/hemorrhage may prevent life$threatening situations" Note:Hemorrhage may occur as late as / &, postoperatively"

(evie& incisional care &hen appropriate" Stress importance of follo&$up care" = entify signs/symptoms re-uiring me ical evaluation, e"g", fever/chills, change in character of vaginal/&oun rainage' %right %lee ing"

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"