Nursing Process: The Patient Undergoing a Hysterectomy

NURSING PROCESS: THE PATIENT UNDERGOING A HYSTERECTOMY

Assessment

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.

Diagnosis

NURSING DIAGNOSES

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

COLLABORATIVE PROBLEMS/POTENTIAL COMPLICATIONS 

Based on assessment data, potential complications may include the following:

·      Hemorrhage

·       Deep vein thrombosis

·       Bladder dysfunction

Planning and Goals

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.

Nursing Interventions

RELIEVING ANXIETY

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.

IMPROVING BODY IMAGE

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.

RELIEVING PAIN

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.

MONITORING AND MANAGING POTENTIAL COMPLICATIONS

Hemorrhage

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.

Deep Vein Thrombosis

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.

Bladder Dysfunction

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.

PROMOTING HOME AND COMMUNITY-BASED CARE

Teaching Patients Self-Care

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.

Continuing Care

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.

Evaluation

EXPECTED PATIENT OUTCOMES

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