INTRODUCTION Hysterectomy is defined as the surgical removal of the uterus (womb).

It is one of the most common of all surgical procedures to cure or alleviate a number of gynaecological complaints including painful and heavy bleeding, endometriosis, fibroids and prolapse of the uterus. There are two main ways to perform a hysterectomy. The most common way is to remove the uterus through a cut in the lower abdomen, the second, less common, way is to remove the uterus only through a cut in the top of the vagina, the top of vagina is then stitched. Each operation lasts between one to two hours and is performed, in hospital, under a general anesthetic. Up to 40,000 hysterectomy operations are carried out on women in the UK every year, this figure means that 1 in 5 of all women will have a hysterectomy at some point in their life. It is what is termed elective surgery this means that in most cases it is a choice that a woman has rather than an emergency procedure. The majority of hysterectomies are performed when a woman is aged between 40 50, however many do occur before and after this age group. Total abdominal hysterectomy bilateral salpingo oophorectomy (TAHBSO) is the removal of entire uterus, the ovaries, fallopian tubes and the cervix. TAHBSO is usually performed in the case of uterine and cervical cancer. This is the most common kind of hysterectomy. Removal of the ovaries eliminates the main source of the hormone estrogen, so menopause occurs immediately known as a surgical menopause. Women who have a hysterectomy that leaves one or both of their ovaries intact have a 50% chance of going through the menopause within five years of their operation, again regardless of their age. Once a hysterectomy has been carried out, a woman will face a major life stage which can be incredibly liberating for many, but can also be heart-rending for others.

DEFINITION OF TERMS Fascia a sheet or band of fibrous connective tissue enveloping, separating, or binding together muscles, organs, and other soft structures of the body Hysterectomy surgical removal of the uterus either TAH (total abdominal hysterectomy), TAHBSO (total abdominal hysterectomy bilateral salpingo oophorectomy), SAH (partial or subtotal hysterectomy) Lymphadenectomy also called lymph node dissection, is a surgical procedure in which lymph glands are removed from the body and examined for the presence of cancerous cells Oophorectomy also called an ovariectomy is the surgical removal of an ovary. If one ovary is removed, a woman may continue to menstruate and have children. If both ovaries are removed, a procedure called a bilateral oophorectomy, menstruation stops and a woman loses the ability to have children Peritoneum thin membrane that lines the abdominal and pelvic cavities, and covers most abdominal viscera. It is composed of layer of mesothelium supported by a thin layer of connective tissue Salpingo refers specifically to the fallopian tubes which connect the ovaries to the uterus

REVIEW OF ANATOMY AND PHYSIOLOGY

FEMALE REPRODUCTIVE SYSTEM The organs of the female reproductive system produce and sustain the female sex cells (egg cells or ova), transport these cells to a site where they may be fertilized by sperm, provide a favorable environment for the developing fetus, move the fetus to the outside at the end of the development period, and produce the female sex hormones. The female reproductive system includes the ovaries, Fallopian tubes, uterus, vagina, accessory glands, and external genital organs.

External Structure Mons Veneris The mons veneris is a pad of adipose tissue located over the symphysis pubis, the pubic bone joint. It is covered by a triangle of coarse, curly hairs. Its purpose is to protect the pubic bone from trauma.

Labia Majora The labia majora are two fold of adipose tissue covered by loose connective tissue and epithelium; they are positioned later to the labia minora. Covered by pubic hair, the labia majora serve as a protection for the external genitalia and the distal urethra and vagina. Labia Minora It is located posterior to the mons veneris spread two hairless fold of connective tissue. Before the menarche, these folds are fairly small; by childbearing age, they are firm and full; after menopause they atrophy and again they become smaller. Clitoris The clitoris is a small rounded organ of erectile tissue at the forward junction of the labia minora. It is covered by fold of skin known as the prepuce. It is sensitive to touch and temperature and is the center of sexual arousal and orgasm in the female. Internal Structure Vagina The vagina is a hollow musculomembranous canal located posterior to the bladder and anterior to the rectum. It extends from the cervix of the uterus to the external vulva. Its function is to act as an organ of intercourse and to convey sperm to the cervix so that sperm can meet to the ovum in the fallopian tube. With childbirth it expands to serve the birth canal. When a woman is lying, on her back the course of the vagina is inward and downward. Because of this downward slant and the angle of the uterine cervix, the length of the anterior wall of the vagina is approximately 6-7 cm; the posterior wall is 8-9 cm. At the cervical end of the structure, there are recesses on all the sides of the cervix, termed fornices. Behind the cervix is the posterior fornix; at the front, the anterior fornix; and at the sides, the

lateral fornices. The posterior fornix serves as a place for the pulling of semen after coitus; this allows a large number of sperm to remain close to the cervix and encourages sperm migration into the cervix. Ovaries The ovaries are grayish-white and appear pitted or with minute indentations on the surface. An unruptured, glistening, clear, fluid-filled graafian follicle (an ovum about to be discharged) or 5iniature yellow corpus luteum often can be observed on the surface of the ovary. Ovaries are located close to and on both sides of the uterus and the lower abdomen. The function of the two ovaries is to produce, mature and discharged ova. Ovarian function is necessary for maturation and maintenance of secondary sex characteristics in females. The ovaries are held suspended and in close contact with the ends of the fallopian tubes by three strong supporting ligaments attached to the uterus or the pelvic wall. Fallopian Tubes These are narrow tubes that are attached to the upper part of the uterus and serve as tunnels for the ova (egg cells) to travel from the ovaries to the uterus. Conception, the fertilization of an egg by a sperm, normally occurs in the fallopian tubes. The fertilized egg then moves to the uterus, where it implants to the uterine wall. Uterus The uterus is a hollow, muscular, pear-shaped organ located in the lower pelvis, posterior to the bladder and anterior to the rectum. The function of the uterus is to receive the ovum from the fallopian tube; provide a place for implantation and nourishment during fetal growth; furnish protection to a growing fetus; and, at maturity of the fetus, expel it from the womans body. Anatomically, the uterus consists of three divisions; the body or corpus, the isthmus and the cervix. The body of the uterus is the uppermost part and forms the bulk of the organ. The lining of the cavity is continuous with that of the fallopian

tubes, which enter at its upper aspects. The portion of the uterus between the points of attachment of the fallopian tubes is termed the fundus. During pregnancy, the body of the uterus is the portion of the structure that expands to contain the growing fetus. The fundus is the portion that can be palpated abdominally to determine the amount of uterine growth occurring during pregnancy, to measure the force of uterine contractions during labor, and to assess that the uterus is returning to its non-pregnant state after childbirth. The isthmus is a short segment between the body and cervix. During pregnancy this portion also enlarges greatly to aid in accommodating the growing fetus. The cervix is the lowest portion of the uterus. It represents approximately one-third of the total uterus size and is approximately 2-5 cm long. Approximately, half of it lies above the vagina and half extends to the vagina. A central cavity is termed the cervical canal. The opening of the canal at the junction of the cervix and the isthmus is the internal cervical os; the distal opening to the vagina is the external os. The level of the external os is at the level of the ischial spines.

SURGICAL PROCEDURE The patient is brought to the Operating Room with an IV in place. Anesthesia is induced,after which the patient is examined, prepped and draped. A vertical midline incision is made in the lower abdomen and fascia is divided. The peritoneum is entered and washings are obtained. The abdomen is explored with findings as noted. A retractor is placed and bowel is packed. Clamps are placed on the broad ligament for traction. The retroperitoneal spaces are opened by incising lateral and parallel to the infundibulopelvic ligament. The round ligaments are isolated, divided, and ligated. The peritoneum overlying the vesicouterine fold is incised to mobilize the bladder. Retroperitoneal spaces are then opened, allowing exposure of pelvic vessels and ureters. The infundibulopelvic ligaments are isolated, divided, and doubly ligated. The uterine artery pedicles are skeletonized, clamped, divided, and suture ligated. Additional pedicles are developed on each side of the cervix, after which tissue is divided and suture ligated. When the base of the cervix is reached, the vagina is cross-clamped and divided, allowing removal of the uterus with attached tubes and ovaries. Angle stitches of o-Vicryl are placed, incorporating the uterosacral ligaments and the vaginal vault is closed with interrupted figure-of-eight stitches. The pelvis is then irrigated. Retractors are repositioned to allow exposure for lymphadenectomy. Metzenbaum scissors are used to incise lymphatic tissues. Borders of the pelvic node dissection included the common iliac bifurcation superiorly, the psoas muscle laterally, the cross-over of the deep circumflex iliac vein over the external iliac artery inferiorly, and the anterior division of the hypogastric artery medially. The posterior border of dissection is the obturator nerve, which is carefully identified and preserved bilaterally. Ligaclips are applied where necessary. Retractors are again

repositioned to allow exposure of para-aortic nodes. Lymph node tissue is mobilized, Ligaclips are applied, and the tissue is excised. The pelvis is again irrigated. All packs and retractors are removed and the abdominal wall is closed using a running Smead-Jones closure with #1 permanent monofilament suture. Subcutaneous tissues are irrigated and a Jackson-Pratt drain is placed. Fascia is closed with a running stitch and skin is closed with a running subcuticular stitch. All counting of sponges, needles and instruments is accurately performed at the completion of the procedure. The patient is then awakened from anesthetic and taken to the PACU in stable condition.

INSTRUMENTATION The Hysterectomy Surgical Instrument Set is composed of operating room grade instruments which are made from German stainless steel in Germany. These instruments have a satin finish and come with a lifetime warranty. Instrument Set Contents:

Foerster Sponge Forceps Str 9-1/2"

Allis Tissue Forceps 5x6 Teeth 9-1/2"

Mixter Rt Angle Forceps

Schnidt Curved Hemostat

Heaney Needle Holders

Heaney Clamps

Heaney-Ballentine Clamps Str

Heaney-Ballentine Clamps Curved

Rochester-Ochsner Forceps Str 8"

Rochester-Ochsner Forceps Curved 8"

Mayo Dissecting Scissors Curved 6-3/4"

Metzenbaum Scissors Curved

Thumb Forceps

Tissue Forceps

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Adsons Forcep

Debakey Forcep

Scalpel Handle #3Lu

Deaver Retractor 1" x 9"

Army Navy

Richardson

Balfour

Bladder Blade Retractor

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PERIOPERATIVE NURSING RESPONSIBILITIES Preoperative Nursing Care Assess patient. The health history and the physical and pelvic examinations are completed and the laboratory tests are performed. Encourage patient to share details of her menstrual history, the date of her last menstrual period, the events leading up to admission and the current degree of vaginal blood loss or discharge. Assess clients knowledge of her condition and the surgery. Perform skin operation: The lower half of the abdomen and the pubic and perineal area may be shaved and these areas may be cleaned with soap and water. To prevent contamination and injury to the bladder or intestinal tract, the bladder and intestinal tract need to be empty before the patient is taken into the OR. The patient who has previously been prescribed with oral contraceptive drug will have to stop taking the drug 6 weeks prior to operation. Preoperative medications may be administered before surgery to help the patient relax. The patient must be allowed time to talk and ask questions. The nurse must know what information the physician has given the patient about the surgery. Encourage patient to practice foot and leg exercises before operation to understand how to carry out the exercises while in bed after surgery. Let the patient will wear anti-embolism socks to prevent venous stasis during the operation. Provide education: Loss of fertility if ovaries are to be removed in conjunction with the operation. Discuss surgical menopause. Discuss how sexual intercourse may change. Client whose ovaries are removed may complain of a decrease in libido.

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Tell the client that once healing has occurred, intercourse should be pain free. Let the patient relax on bed until she leaves the ward escorted by her nurse who completes a safe transfer to the operating theater staff.

Intraoperative Nursing Care Prepare and assist for anesthesia. Maintain homeostasis and asepsis. Assist the surgeon and the whole team Assist in transferring the patient to the Operating table in a supine position. Ask patient to remove any jewelry or other objects that may interfere with the procedure. Ask patient to remove clothing and be given a gown to wear. Check for patency of the IV system. Monitor clients HR, BP and breathing and report abnormalities. The skin over the surgical site will be cleansed with an antiseptic solution

Postoperative Nursing Care Perform usual post operative assessments. Evaluate psychological manifestations Monitor proximity of the bladder to the reproductive organ. Monitor Foley catheter to prevent susceptibility to UTI and temporary urinary retention Assist GI functions by listening to bowel sounds. Note distention and palpate whether abdomen is soft or firm Assess abdominal incision for bleeding and intactness. Assess vaginal bleeding. There is no distinct diet. Simple, strong, distinct flavors rather than complicated and multi-flavored dishes seem to be preferred with anything with smaller-than-usual portions. Its best to avoid gassy foods like beans, broccoli and cabbage and/or foods that typically cause gas for you. Many suggest 13

avoiding extra-spicy foods. Remember that all postop surgical patients need protein to aid in healing. Include fiber in your postop diet, drink lots of water, and consume caffeinated drinks sparingly. If pain is experienced during sexual intercourse let the patient manipulate the penetration. Avoid heavy lifting for about 6 weeks to prevent straining the abdominal muscles and surgical sites. Avoid activities that increase pelvic congestion such as aerobics activity, horseback riding and prolonged standing. Report any fresh bleeding and any abnormal vaginal discharge to surgeon. Return for follow-up care as requested by the surgeon. Postop pain and discomfort are common, therefore the nurse should assess its intensity and administer analgesics as prescribed. If the patient has abdominal distention or flatus, rectal tube and application of heat to the abdomen may be prescribed Encourage patient to contact nurse or surgeon when bleeding is excessive. Encourage early ambulation o facilitate the return of normal peristalsis Montior and manage potential complications such as: Hemorrhage: Count perineal pads used, assess the extent of saturation with blood and monitor vital signs. Guidelines for activity restriction are given above to promote healing and prevent post operative bleeding. Deep Vein Thrombosis: Encourage and assist patient to change position frequently and exercise leg and feet while in bed. Instruct patient to avoid prolonged sitting in the chair with pressure on the knees, sitting cross legs and inactivity.

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DRUG STUDY Generic Brand Name Name Cefuroxime Kefurox sodium Classificatio n Antibiotic Mechanism of action Semisynthetic second generation cephalosporin antibiotic that binds to one or more of the penicillinbinding protein (PBP) located on cell walls of susceptible organisms. This inhibits third and final stage of bacterial cell wall synthesis, killing the bacterium. Indication Surgical prophylaxi s reducing or eliminating infections caused by susceptible organisms in the lower respiratory tract, urinary tract, skin and skin structures. Contraindication Hypersensitivity to cephalosporin and related antibiotics, pregnancy and lactation. Adverse Dosage Reactions Body as a 200-500 whole: mg PO thrombophle- q12h bitis, pain, burning, superinfection GI: diarrhea, nausea, colliitis Skin: rash, pruritus, urticaria Urogenital: increase serum creatinine and BUN, decreased creatinine clearance Nursing Responsibilities Determine history of hypersensitivity to cephalosporins, penicillins, and Obtain history of allergies Perform culture and sensitivity test before initiation of therapy Report onset of loose stool or diarrhea Monitor for manifestations of hypersensitivity Monitor I & O rates pattern Monitor periodically BUN and creatinine clearance

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Generic Brand Name Name Metoclopra- Plasil mide Hydrochloride

Classificatio n Antiemetic

Mechanism of action Potent central dopamine receptor antagonist. Appears to sensitize GI smooth muscles to effects of acetylcholine by direct action.

Adverse Reactions Nausea Sensitivity or Body as a and intolerance to whole: vomiting of metoclopramide, glossal or central and history of periorbital peripheral seizure disorder, edema origin mechanical GI CNS: associated obstruction or fatigue. with perforation. headache, surgery. mild sedation, insomnia GI: nausea, constipation, diarrhea, dry mouth Skin: urticaria, rash Endocrine: galactorrhea , amenorrhea, impotence

Indication

Contraindication

Dosage 10 mg IVTT q8h PRN

Nursing Responsibilities Determine hypersensitivity reactions Report immediately the onset of restlessness, rigidity or tremors Monitor periodically serum electrolyte Monitor for possible hypernatremia and hypokalemia Avoid alcohol and other CNS depressants Report signs and symptoms of acute dystonia such as trembling hands and facial grimacing

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Generic Name Morphine Sulfate

Brand Name Avinza

Classificatio n Analgesic

Mechanism of action Natural opium alkaloid with agonist activity by binding with the same receptors as endogenous opiod peptides. Analgesia at supraspinal level, euphoria, respiratory depression, and physical dependence : analgesia at spinal level, sedation and miosis.

Indication Symptomatic relief of severe acute and chronic pain after non-narcotic analgesics have failed.

Contraindication Hypersensitivity to opiates, increased intracranial pressure, convulsive disorders, acute bronchial asthma, chronic pulmonary diseases, severe respiratory depression.

Adverse Dosage Reactions Body as a 2.5-15 whole: mg IVTT hypersensitivity, q4h sweating, cold clammy skin, hypothermia CNS: euphoria, insomnia, visual disturbances, dysphori, tremor, delirium, dizziness CV: bradycardia, palpitation, flushing GI: constipation, anorexia, dry mouth, nausea and vomiting

Nursing Responsibilities Obtain baseline respiratory rate, depth, rhythm and size of pupils before administration Observe patient closely to be certain pain relief is achieved Assess VS at regular intervals Be alert or elevated pulse or respiratory rate Monitor for respiratory depression Encourage changes in position, deep breathing and coughing unless contraindicated Be alert for nausea and orthostatic hypotension Monitor I & O ratio and pattern

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NURSING CARE PLAN Problem

S/O> pain scale rate of 7-9 out of 10 > grimace > restless > irritable > guarding behavior noted > redness and localized swelling of the surgical incision in the lower abdomen A> Alteration in comfort: Acute Pain r/t surgical incision secondary to post TAHBSO

Scientific Basis
Pain serves a biological function. It signals the presence of damage or disease within the body. Due to surgical procedure done that needs a surgical incision there will be presence of trauma in the area that signals an actual tissue damage and inflammation, this damage will cause an inflammation of the nerves resulting to pain. The goal of management is to reduce or eliminate pain and discomfort with minimum side effects. Postop pain relief must reflect the needs of the patient and the ultimate determinant of adequacy of pain management depends on the patients own perception. Smeltzer, S. et al (2010). Mediacl-Surgical

Goal
After 4 hours of nursing interventions, the patient will be able to report relief of pain and demonstrate relaxation skills.

Nursing Intervention
INDEPENDENT 1. Perform a comprehensive assessment of pain taking note on changes from previous reports 2. Monitor vital signs 3. Encourage verbalization of feelings 4. Teach and encourage use of relaxation exercises such as focused breathing 5. Provide comfort measures such as back rub, changes in position or use of hot/cold 6. Encourage diversional activities such as watching TV, listening to music 7. Review procedures and expectations and tell client when treatment will hurt DEPENDENT 1. Administer analgesics as

Rationale

Evaluation
Goal Met After 4 hours of nursing intervention, the patient reported relief of pain with pain scale of 4/10 from 8/10.

To rule out worsening of underlying condition and development of complication To obtain baseline data, usually altered in acute pain To alter pain and diminish emotional stress To facilitate relaxation and inhibit pain To provide nonpharmacologic pain management To alter pain perception

To reduce concern of the unknown and associated muscle tension

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Nursing. 12th ed. pp. 471

indicated to maximal dosage as needed

To maintain acceptable level of pain

Problem
S/O > cool skin > pallor > cyanotic nailbeds > slow capillary refill CRT 3-4s > shiverring > Temp 35C > RR 50cpm A> Hypothermia r/t effect of anesthesia secondary to post TAHBSO

Scientific Basis
The patient is still at risk for malignant hyperthermia or may experience hypothermia in the postoperative period. Patients who have received anesthesia are susceptible to chills and drafts. Hypothermia is indicated by a core body temperature that is lower than normal (36.6C or less). It may occur as a result of low temperature in the OR, infusion of cold fluids, inhalation of cold gases, open body wounds or cavities, or pharmaceutical agent used (general anesthetic medications). Hypothermia management begun in the intraoperative period extends into the postoperative period to prevent significant nitrogen loss and

Goal
Within my 4 hours span of care, the patient will be able to display and maintain core body temperature within normal range.

Nursing Intervention
INDEPENDENT 1. Monitor vital signs especially body temperature 2. Measure core temperature with low register thermometer 3. Remove wet clothing 4. Assist with surface warming by means of warmed blankets, warm environment, radiant heater 5. Protect skin/tissues by repositioning, applying lotion or lubricant and avoiding direct contact with heating appliance 6. Keep client quiet, handle gently 7. Perform range of motion exercises 8. Turn off warming blankets when temperature is within 1-3 of desired temperature

Rationale

Evaluation
Goal Met At the end of my shift the patient was able to achieve and maintain core body temperature of 37C.

To obtain baseline data and determine changes To obtain accurate measurement To pre further decrease in body temperature To maintain peripheral vasoconstriction Impaired circulation can result n severe tissue damage To reduce potential for fibrillation in cold heart To reduce circulatory stasis To avoid hyperthermia situation

To prevent overload as

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catabolism. Smeltzer, S. et al (2010). Mediacl-Surgical Nursing. 12th ed. pp. 455-456,476

DEPENDENT 1. Administer IV fluids with caution as ordered

the vascular bed expands

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BIBLIOGRAPHY Book References Doenges, M. et al (2004). Nurses Pocket Guide. (9th Ed.). Philadelphia: F. A. Davis Company Karch, A.(2009).Nursing Drug Guide. Lippincott Williams and Wilkins. Kozier, B. & Erb, G. (2008). Fundamentals of Nursing.(8th Ed.).Singapore: Pearson Education South Asia Pte Ltd. Smeltzer, S. et al (2004). Brunner and Suddarths textbook of MedicalSurgical Nursing. (10th Ed.) Wolters Kluwer Health/ Lippincott Williams and Wilkins. Internet References http://en.wikipedia.org/wiki/Female_reproductive_system_(human) http://nurseslabs.com/2010/03/nursing-care-plans/tahbso-nursing-care-plans/ http://www.daviddarling.info/encyclopedia/F/female_reproductive_system.html http://www.hysterectomy-association.org.uk/forums/viewtopic.php?t=2712 http://www.mtsamples.com/site/pages/sample.asp?type=85Surgery&sample=956-Hysterectomy%20(TAH%20-%20BSO) http://www.scribd.com/doc/19482948/Nursing-Care-for-patient-undergoingTAHBSO-for-ovarian-growthhttp://www.scribd.com/doc/25880841/What-is-TAH-BSO-Total-AbdominalHysterectomy-And

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