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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
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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