Care of the Medical-Surgical Client

s/p TAH patient

Objectives• Review risk factors, etiology, and

clinical manifestations of the client scheduled for a total abdominal hysterectomy surgery

• Discuss nursing interventions and outcomes of the post-operative total abdominal hysterectomy client

Our Client• 57 year old female admitted for surgery

o Radical abdominal hysterectomyo ROS

• HEENT – wears bifocals for presbyopia and myopia; no neurological deficits noted; hearing intact; client denies hoarseness; lymph nodes soft, mobile

• Resp – able to climb two flights of stairs w/o SoB; regularly walks for exercise; RR 16

• Breasts – soft, non-tender, no lumps or lesions palpated• CV – pre-hypertensive BP 130/80, HR 81, SpO2 99 RA• MSk – no evidence of DJD• GI – normal bowel habits reported; BMI 27.3• GU – uterine cancer; urinary frequency, functional urinary stress

incontinence; reports post-menopausal bleeding, mild pelvic pain, dyspareunia

• General: client reports mild fatigue and sleep disturbances, denies weight loss, fever, chills, weakness

Risk Factors

Risk factorsNon-modifiable Modifiable

• Age• Gender• Family history• Menarche• Menopause• Breast, Colon

Ovarian cancer• Others?

• Pregnancies• Gynecological

procedures• STDs• Lifestyle choices• Obesity• Oral Contraceptives• Others?

Etiology

Etiology• Unknown, thought to be genetic

mutationo Need for surgery:o Often life threatening (not immediate, but serious enough)

• Invasive cancer of the uterus, cervix, vagina, fallopian tubes, and or ovaries

• Unmanageable infection • Unmanageable bleeding • Serious complications during childbirth, such as a

rupture of the uterus – • See more at:

https://www.nwhn.org/hysterectomy/?gclid=Cj0KEQiAxMG1BRDFmu3P3qjwmeMBEiQAEzSDLsiG4s6G1OYn4wDZJumHlh6LYtLnFyhBtUAgK8i6Vr4aAhRM8P8HAQ#sthash.Ei6tbnTC.dpuf

Pathophysiology• Endometrial cells mutate,

become undifferentiated, invade uterine tissue, forms tumorso Highly likely to metastasize• Pelvic area, vagina• Lungs (most common)• Brain• Liver

Clinical Manifestations

Clinical Manifestations• May be none• Dysfunction uterine bleeding (DUB)

o Fibroids • Infection• Cancer (similar to other solid organ or

tissue S&S)• Pelvic pain• Pain after intercourse (dyspareunia)• Others?

Procedures• Partial or Subtotal Hysterectomy– removes the body of the

uterus, cervix left in place. • Total or Simple Hysterectomy – removes uterus and

cervix. (TAH)• Hysterectomy with Bilateral Salpingo-Oophorectomy –

removes the uterus, cervix and fallopian tubes. (TAH-BSO)• Radical Hysterectomy – removes the uterus, cervix,

ovaries, fallopian tubes and affected lymph glands; possibly upper portions of the vagina.

• See more at: https://www.nwhn.org/hysterectomy/?gclid=Cj0KEQiAxMG1BRDFmu3P3qjwmeMBEiQAEzSDLsiG4s6G1OYn4wDZJumHlh6LYtLnFyhBtUAgK8i6Vr4aAhRM8P8HAQ#sthash.Ei6tbnTC.dpuf

Surgical Approaches• Abdominal

o Pfannenstiel (bikini line scar)o Mid-line laparotomy (radical TAH)

• Vaginalo Technically more difficult, better results for most patients

• Laparoscopic Assisted Vaginal (LAVH)o Majority of dissection performed through laparoscopic

methods, uterus removed through vagina, cuff sutured from inside or through vagina

• Robot Assisted Laparoscopic Vaginal Hysterectomyo Similar to LAVH, robotic manipulation of instruments results in

less tissue damage, faster recovery for patient

Complications

Post-op Clinical Complications

• Pain• Bleeding• Infection• Urinary tract injury• Bowel injury• Dehiscence (why?)• Others?

Nursing Diagnoses

Nursing Diagnoses• Risk for

o Falls (effects of medications)o Infection (compromised skin and

mucous membrane integrity)• Fluid volume deficit related to

blood loss• Others?

Interventions

Interventions• Pain management• Encourage ambulation • Fluids• Advance diet as tolerated• Encourage rest• Client education• Monitor for manifestations of complications• Discharge:

o Follow-up appointments, collaborations, chemotherapy and/or radiation therapies

• Others?

Medications• Pain medications (immediately post-op)• HRT?

o May be contraindicated in client with reproductive tract cancer• Chemotherapy• Radiation therapy• Others?

• Client education on expected therapeutic action, side effects, adverse effects, when to call provider, when to seek urgent/emergent care

Oncology Treatments• Antiemetic prior to initiating chemotherapy• Cool washcloth on back of neck• Emesis basin on hand• Distractions (for pain and discomfort)• Allow client to express feelings• Encourage client to discuss experiences

with others• Assess social support, provide information

about resources

Outcomes

Outcomes• ~ 1/3 of clients may experience urinary

tract complications/symptomso ~ 1/3 of these usually resolve in 12 months or less

• Most clients return to baseline within 1 year or lesso Including

• Sexual activity and health• Reduction of nocturia and stress incontinence• Increased bladder capacity

• Improvement in quality of life (in many patients)• Our client?

Questions?