NURSING
PROCESS: THE PATIENT UNDERGOING A HYSTERECTOMY
The
health history and the physical and pelvic examination are completed, and
laboratory studies are performed. Additional as-sessment data include the
patient’s psychosocial responses, be-cause the need for a hysterectomy may
elicit strong emotional reactions. If the hysterectomy is performed to remove a
malig-nant tumor, anxiety related to fear of cancer and its consequences adds
to the stress of the patient and her family. These women may be at greater risk
for psychological symptoms, physical symptoms, postmenopausal syndrome, and
increased use of health care postoperatively. Other women note improved
physical and men-tal health after hysterectomy.
Based
on all the assessment data, the patient’s major nursing diagnoses may include
the following:
· Anxiety related to the
diagnosis of cancer, fear of pain, pos-sible perception of loss of femininity,
and disfigurement
· Disturbed body image
related to altered fertility and fears about sexuality and relationships with
partner and family
· Acute pain related to
surgery and other adjuvant therapy
· Deficient knowledge of
the perioperative aspects of hys-terectomy and postoperative self-care
Based on assessment data, potential complications may include the
following:
· Hemorrhage
· Deep vein thrombosis
· Bladder dysfunction
The
major goals for the patient may include relief of anxiety, ac-ceptance of loss
of the uterus, absence of pain or discomfort, in-creased knowledge of self-care
requirements, and absence of complications.
Anxiety
stems from several factors: unfamiliar environment, the effects of surgery on
body image and reproductive ability, fear of pain and other discomfort, and,
possibly, feelings of embarrass-ment about exposure of the genital area in the
perioperative pe-riod. Conflicts between medical treatment and religious
beliefs may arise as well. In such cases, the nurse needs to determine what the
experience means to the patient and how to assist her in ex-pressing her
feelings. Throughout the pre- and postoperative and recovery periods,
explanations are given about physical prepara-tions and procedures that are
performed.
Patient
education addresses the outcomes of surgery, possible feelings of loss, and
options for management of symptoms of menopause. Women vary in their
preferences; many want a choice of treatment options, a part in decision
making, accurate and useful information at the appropriate time, support from
their health care providers, and access to professional and lay support
systems.
Recent
findings from the Women’s Health Initiative study of hormone replacement
therapy (HRT) have indicated that HRT does not have long-term cardiac benefits
and may increase the risk for breast cancer. Although HRT has positive effects
on bone density in women, many clinicians and women have concluded that the
risks of HRT outweigh the benefits. However, some be-lieve that short-term use
of HRT (5 years or less) may be used to treat menopausal symptoms (Women’s
Health Initiative, 2002). If the patient is considering beginning HRT, risks
and benefits are discussed preoperatively and medication is started following
surgery. Teaching is provided and the need for monitoring is emphasized.
The
patient may have strong emotional reactions to having a hysterectomy and strong
personal feelings related to the diagno-sis, views of significant others who
may be involved (family, partner), religious beliefs, and fears about
prognosis. Concerns such as the inability to have children and the effect on
feminin-ity may surface, as may questions about the effects of surgery on
sexual relationships, function, and satisfaction. The patient needs reassurance
that she will still have a vagina and that she can experience sexual
intercourse after a temporary postoperative ab-stinence while tissues heal.
Information that sexual satisfaction and orgasm arise from clitoral stimulation
rather than from the uterus reassures many women. Most women note some change
in sexual feelings after hysterectomy, but they vary in intensity. In some
cases, the vagina is shortened by surgery, and this may affect sensitivity or
comfort.
When a
woman’s hormonal balance is upset, as usually occurs in reproductive system
disturbances, the patient may experience depression and heightened emotional
sensitivity to people and situations. The nurse needs to approach and evaluate
each patient individually in light of these factors. The nurse who exhibits in-terest,
concern, and willingness to listen to the patient’s fears will assist in the
patient’s progress throughout the surgical experience.
A
hysterectomy may be performed abdominally or vaginally. The surgeon bases this
decision on the diagnosis and the size of the uterus. An abdominal approach is
used when the patient has can-cer or when the uterus is enlarged. Resultant
pain and abdominal discomfort are common. Analgesic agents are administered as
pre-scribed to relieve pain and promote movement and ambulation.
In
some circumstances, a nasogastric tube may be inserted be-fore the patient
leaves the operating room to relieve discomfort from abdominal distention,
especially if excessive handling of the viscera was required or if a large tumor
was removed. Exci-sion of a large tumor could cause edema because of the sudden
release of pressure. In the postoperative period, fluids and food may be
restricted for 1 or 2 days. If the patient has abdominal dis-tention or flatus,
a rectal tube and application of heat to the ab-domen may be prescribed. When
abdominal auscultation reveals return of bowel sounds and peristalsis,
additional fluids and a soft diet are permitted. Early ambulation facilitates
the return of normal peristalsis.
Vaginal
bleeding and hemorrhage may occur after hysterectomy. To detect these
complications early, the nurse counts the perineal pads used, assesses the
extent of saturation with blood, and mon-itors vital signs. Abdominal dressings
are monitored for drainage if an abdominal surgical approach was used. In
preparation for hospital discharge, the nurse gives prescribed guidelines for
activ-ity restrictions to promote healing and to prevent postoperative bleeding.
Because
of positioning during surgery, postoperative edema, and immobility, the patient
is at risk for deep vein thrombosis and pulmonary embolus. To minimize the
risk, elastic compression stockings are applied. Additionally, the patient is
encouraged and assisted to change positions frequently, although pressure under
the knees is avoided. The nurse assists the patient to ambulate early in the
postoperative period, and the patient is encouraged to exer-cise her legs and
feet while in bed. Additionally, the nurse assesses for deep vein thrombosis or
phlebitis (leg pain, redness, warmth, positive Homans’ sign) and pulmonary
embolism (chest pain, tachycardia, dyspnea). Because the patient may be
discharged within 1 or 2 days of surgery, she is instructed to avoid prolonged
sitting in a chair with pressure at the knees, sitting with crossed legs, and
inactivity.
Because
of possible difficulty in voiding postoperatively, an in-dwelling catheter may
be inserted before or during surgery and is left in place in the immediate
postoperative period. If a catheter is in place, it is usually removed shortly
after the patient begins to ambulate. After the catheter is removed, urinary
output is moni-tored; additionally, the abdomen is assessed for distention. If
the patient does not void within a prescribed time, measures are ini-tiated to
encourage voiding (eg, assisting the patient up to the bathroom, pouring warm
water over the perineum). If the patient cannot void, catheterization may be
necessary.
The
information provided to the patient is tailored to her needs. She must know
what limitations or restrictions, if any, to expect. She is instructed to check
the surgical incision daily and to con-tact her primary health care provider if
redness or purulent drainage or discharge appears. She is informed that her
periods are now over but that she may have a slightly bloody discharge for a
few days; if bleeding recurs after this time, it should be reported
immediately. The patient is instructed about the importance of an adequate oral
intake and of maintaining bowel and urinary tract function. The patient is
informed that postoperative fatigue may occur but that it should gradually
decrease.
The
patient should resume activities gradually. This does not mean sitting for long
periods, because doing so may cause blood to pool in the pelvis, increasing the
risk for thromboembolism. The nurse explains that showers are preferable to tub
baths to re-duce the possibility of infection and to avoid the dangers of
in-jury that may occur when getting in and out of the bathtub. The patient is
instructed to avoid straining, lifting, having sexual in-tercourse, or driving
until her surgeon permits her to resume these activities. Vaginal discharge,
foul odor, excessive bleeding, any leg redness or pain, or an elevated
temperature should be re-ported to her primary health care provider promptly.
The nurse should be familiar with information given to the patient by the
surgeon regarding all activities and restrictions to reinforce them and prevent
confusion.
Follow-up
telephone contact provides the nurse with the oppor-tunity to determine whether
the patient is recovering without problems and to answer any questions that may
have arisen. The patient is reminded about postoperative follow-up
appointments. If the patient’s ovaries were removed, HRT may be considered.
Providing information about the findings of the Women’s Health Initiative
(2002) study about the benefits and risks of HRT pro-motes informed decision
making about its use. The patient is reminded to discuss HRT and alternative
therapies with her pri-mary care provider.
Expected
patient outcomes may include:
1) Experiences decreased
anxiety
2) Has improved body image
a)
Discusses changes resulting from surgery with her
partner
b)
Verbalizes understanding of her disorder and the
treat-ment plan
c)
Displays minimal depression or sadness
3) Experiences minimal pain
and discomfort
a)
Reports relief of abdominal pain and discomfort
b)
Ambulates without pain
4) Verbalizes knowledge and
understanding of self-care
a)
Practices deep-breathing, turning, and leg
exercises as instructed
b)
Increases activity and ambulation daily
c)
Reports adequate fluid intake and adequate urinary
output
d)
Identifies reportable symptoms
e)
Schedules and keeps follow-up appointments
5) Absence of complications
a)
Has minimal vaginal bleeding and exhibits normal
vital signs
b)
Ambulates early
c)
Notes no chest or calf pain and no redness,
tenderness, or swelling in the extremities
d)
Reports no urinary problems or abdominal distention
Related Topics
Privacy Policy, Terms and Conditions, DMCA Policy and Compliant
Copyright © 2018-2023 BrainKart.com; All Rights Reserved. Developed by Therithal info, Chennai.