NURSING
PROCESS: THE PATIENT UNDERGOING VULVAR SURGERY
The
health history is a valuable tool for establishing rapport with the patient.
The reason the patient is seeking health care is appar-ent. What the nurse can
tactfully elicit is the reason why a delay, if any, occurred, in seeking health
care—for example, because of modesty, economics, denial, neglect, or fear
(abusive partners sometimes prevent women from seeking health care). Factors
in-volved in any delay in seeking health care and treatment may also affect the
patient’s recovery. The patient’s health habits and lifestyle are assessed, and
her receptivity to teaching is evaluated. Psychosocial factors are also
assessed. Preoperative preparation and psychological support begin at this
time.
Based
on all the assessment data, the patient’s major nursing di-agnoses may include
the following:
· Anxiety related to the
diagnosis and surgery
· Acute pain related to
the surgical incision and subsequent wound care
· Impaired skin integrity
related to the wound and drainage
· Sexual dysfunction
related to change in body image
· Self-care deficit
related to lack of understanding of perineal care and general health status
Based
on assessment data, potential complications may include the following:
· Wound infection and
sepsis
· Deep vein thrombosis
· Hemorrhage
The major
goals for the patient may include acceptance of and preparation for surgical
intervention, relief of pain, maintenance of skin integrity, recovery of
optimal sexual function, ability to perform adequate and appropriate self-care,
and absence of complications.
The
patient must be allowed time to talk and ask questions. Fear often decreases
when a woman of childbearing age who is to un-dergo wide excision of the vulva
or vulvectomy learns that the possibility for subsequent sexual relations is
good and that preg-nancy is possible after a wide excision. The nurse must know
what information the physician has given the patient about the surgery to
reinforce that information and address the patient’s questions and concerns.
Skin
preparation may include cleansing the lower abdomen, in-guinal areas, upper
thighs, and vulva with a detergent germicide for several days before the
surgical procedure. The patient may be instructed to do this at home.
Because
of the wide excision, the patient may experience severe pain and discomfort
even with minimal movement. Inadequate pain re-lief will inhibit the patient’s
mobility and increase the likelihood of complications. Therefore, analgesic
agents are administered preventively (ie, around the clock at designated times)
to relieve pain and increase the patient’s comfort level. Patient-controlled
analgesia may be used to provide pain relief and promote pa-tient comfort.
Careful positioning using pillows usually increases comfort, as do soothing
back rubs. A low Fowler’s position or, occasionally, a pillow placed under the
knees will reduce pain by relieving tension on the incision; however, efforts
must be made to avoid pressure behind the knees, which increases the risk for
deep vein thrombosis. Positioning the patient on her side, with pillows between
her legs and against the lumbar region, provides comfort and reduces tension on
the surgical wound.
The
patient may be confined to bed for several days to promote healing of the
surgical and donor sites (if skin grafts were used). A pressure-reducing
mattress may be used to prevent pressure ul-cers. Moving from one position to
another requires time and effort; use of an overbed trapeze bar may help the
patient to move her-self more easily. Ambulation may be attempted on the second
day.
The
extent of the surgical incision and the type of dressing are considered when
choosing strategies to promote skin integrity. Intact skin needs to be
protected from drainage and moisture, and dressings must be changed as needed
to ensure patient com-fort, to perform wound care and irrigation (if
prescribed), and to permit observation of the surgical site. When the patient
returns from the operating room, perineal dressings are more likely to re-main
in place and be comfortable if a T-binder is used.
A skin
graft from the buttocks may have been performed if the edges of the excision
could not be approximated, and drains may have been put in place as well. A
pressure stent may be applied to the grafted site to promote adhesion. Nursing
care includes mon-itoring for suppuration (accumulation of purulent material)
under the graft and assisting the patient to keep the perineal area clean and
dry.
The
wound is cleansed daily with warm, normal saline irriga-tions or other
antiseptic solutions as prescribed. A transparent dressing or Xeroform gauze
may be in place over the wound to minimize exposure to the air and subsequent
pain. The appear-ance of the surgical site and the characteristics of drainage
are as-sessed and documented. After the dressings are removed, a bed cradle may
be used to keep the bed linens away from the surgical site. The nurse must
protect the patient from exposure when vis-itors arrive or someone else enters
the room.
The
patient who undergoes vulvar surgery usually experiences con-cerns about the
effects of the surgery on her body image, sexual at-tractiveness, and
functioning. Establishing a trusting nurse–patient relationship is important
for the patient to feel comfortable ex-pressing her concerns and fears. The
patient is encouraged to share and discuss her concerns with her sexual
partner.
Because
alterations in sexual sensation and functioning depend on the extent of
surgery, the nurse needs to know about any struc-tural and functional changes
resulting from the surgery. Consult-ing with the surgeon will clarify which
changes to expect, and referring the patient and her partner to a sex counselor
may help them address these changes and resume satisfying sexual activity.
The
location and extent of the surgical site and incision put the patient at risk
for contamination of the site and infection and sep-sis. The patient is
monitored closely for local and systemic signs and symptoms of infection:
purulent drainage, redness, increased pain, fever, and an increased white blood
cell count. The nurse assists in obtaining tissue specimens for culture if
infection is sus-pected and administers antibiotic agents as prescribed. Hand
hygiene, always a crucial infection-preventing measure, is of par-ticular
importance whenever there is an extensive area of exposed tissue. Catheters,
drains, and dressings are handled carefully and with gloves to avoid
cross-contamination. A low-residue diet pre-vents straining on defecation and
wound contamination. Sitz baths are discouraged after a wide excision because
of the risk for infection.
The
patient is at risk for deep vein thrombosis because of the po-sitioning
required during surgery, postoperative edema, and the usually prolonged
immobility needed to promote healing. Elas-tic compression stockings are
applied, and the patient is encour-aged and reminded to perform ankle exercises
to minimize venous pooling, which leads to deep vein thrombosis. The patient is
encouraged and assisted in changing position by using the over-head trapeze.
Pressure behind the knees is avoided when posi-tioning the patient because this
may increase venous pooling. The patient is assessed for signs and symptoms of
deep vein throm-bosis (leg pain, redness, warmth, positive Homans’ sign) and
pul-monary embolism (chest pain, tachycardia, dyspnea). Fluid intake is
encouraged to prevent dehydration, which also increases the risk for deep vein
thrombosis.
The
extent of the surgical incision and possibly wide excision of tissue increase
the risk of postoperative bleeding and hemorrhage. Although the pressure
dressings that are applied after surgery minimize the risk, the patient must be
monitored closely for signs of hemorrhage and resulting hypovolemic shock.
These signs may include decreased blood pressure, increased pulse rate,
decreased urine output, decreased mental status, and cold, clammy skin.
If
hemorrhage and shock occur, interventions include fluid re-placement, blood
component therapy, and vasopressor medica-tions. Laboratory results (eg,
hematocrit and hemoglobin levels) and hemodynamic monitoring are used to assess
the patient’s re-sponse to treatment. Depending on the specific cause of
hemor-rhage, the patient may be returned to the operating room. The patient who
experiences hemorrhage is anxious and apprehensive. Providing brief
explanations of the procedures being performed and offering reassurance that
the problem has been identified and is being taken care of may reduce the
anxiety and fears of the pa-tient and her family.
Preparing
the patient for hospital discharge begins before hospital admission. The
patient and family are informed about what to expect during the immediate
postoperative and recovery periods. Posthospital care requires giving complete
instructions to a fam-ily member or significant other who will help care for
the patient at home and to the home care nurse who will provide follow-up care.
Depending on the changes resulting from the surgery, the pa-tient and her
family may need instruction about wound care, uri-nary catheterization, and
possible complications. The patient is encouraged to share her concerns and to
assume increasing re-sponsibility for her own care. She is encouraged and
assisted in learning to care for the surgical wound.
Shortened
hospital stays may result in the patient’s discharge dur-ing the early
postoperative recovery stage. Thus, home care refer-ral or discharge to a
subacute facility may be indicated. During this phase, the patient’s physical
status and psychological re-sponses to the surgery are assessed. Additionally,
the patient is as-sessed for complications and healing of the surgical site.
During home visits, the patient’s environment is assessed to determine if
modifications are needed to facilitate patient care. The home care nurse uses
the home visit to reinforce previous teaching and to as-sess the patient’s and
the family’s understanding of and adherence to the prescribed treatment
strategies. Follow-up phone calls by the nurse to the patient between home
visits are usually reassur-ing to the patient and family, who may be
responsible for per-forming complex care procedures. Attention to the patient’s
psychological responses is important because the patient may be-come
discouraged and depressed because of alterations in body image and a slow
recovery. Communication between the nurse involved in the patient’s immediate
postoperative care and the home care nurse is essential to ensure continuity of
care.
Expected
patient outcomes may include:
1) Adjusts to the trauma of
the surgical experience
a) Uses available resources
in coping with and alleviating emotional stress
b)
Asks questions related to postoperative
expectations
c)
Demonstrates willingness to discuss alternative
ap-proaches to sexual expression
2) Obtains pain relief
a)
Reports progressive decline in pain and discomfort
b)
Assumes position of comfort
3) Maintains skin integrity
a)
States rationale for use of a special mattress or
other device
b)
Uses overhead trapeze to change position frequently
c)
Exhibits healing of surgical site without
excoriated skin
d)
Cares for incision and surgical site as instructed
4) Exhibits positive
outlook about sexuality and sexual func-tioning
a)
Verbalizes concerns and anxieties about sexual
func-tioning
b)
Discusses options and alternative approaches to
sexual intercourse
5) Increases participation
in self-care activities
a)
Demonstrates self-care activities as instructed
b)
Identifies signs and symptoms of complications that
should be reported to the nurse or physician
c)
Properly cleans the surgical site after voiding and
defe-cation
6) Absence of complications
a)
Is free of any signs and symptoms of infection: has
nor-mal vital signs (temperature, blood pressure, pulse rate); has no purulent
discharge
b)
Identifies activities to prevent deep vein
thrombosis: avoids crossing legs or sitting with pressure against knees;
exercises ankles and legs
c)
Exhibits no signs or symptoms of deep vein
thrombosis (leg pain, redness, edematous or swollen extremities)
d)
Demonstrates no signs or symptoms of haemorrhage
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