NCLEX-RN: Medical–Surgical Nursing

Medical–Surgical Nursing: Genitourinary System

Focus topic: Medical–Surgical Nursing

Medical–Surgical Nursing: Male Genitourinary Disorders

Focus topic: Medical–Surgical Nursing

Medical–Surgical Nursing: Prostatitis

Focus topic: Medical–Surgical Nursing

Definition: Inflammation of the prostate gland caused by an infectious agent (bacteria, mycoplasma) or structure, hyperplasia.

Assessment
A. Assess for peritoneal discomfort, burning, urgency, or frequency.
B. Assess for generalized pain or pain associated with ejaculation or voiding.
C. If acute, client may have sudden onset of fever, chills, and pain.
D. Evaluate clients with chronic conditions, even with absence of pain.

Implementation
A. Monitor broad-spectrum antimicrobials (sensitive to causative agent) may be tetracycline (Panmycin, Sumycin), doxycycline (Oracea, Vibramycin, or others). Treatment is 10–14 days.
B. Maintain client on bed rest until symptoms are alleviated.
C. Promote comfort with analgesics, antispasmodics, sedatives, sitz baths, stool softeners.

Medical–Surgical Nursing: Benign Prostatic Hypertrophy

Focus topic: Medical–Surgical Nursing

Definition: Enlargement of prostate gland from normal tissue, usually in males over 50 years of age.

Assessment
A. Causes narrowing of urethra, which may result in obstruction.
B. Clinical manifestations.

  • Recurring infection and urinary stasis.
  • Nocturia, frequency, dysuria, urgency, dribbling, retention, and hematuria.
  • Hesitancy in starting urination, abdominal straining with urination.

Implementation
A. Treatment.

  • Drug—Proscar (finasteride) reduces hypertrophy through inhibition of enzyme that blocks uptake of androgens; has severe side effects (impotence).
  • Alpha-adrenergic receptor blockers (Hytrin [terazosin]) relax smooth muscles of bladder neck and prostate.
  • Herbs (saw palmetto) and nutrients: magnesium, calcium, and zinc reduce hypertrophy.
  • Monitor drug therapy if indicated.

B. Encourage fluids: 2000–3000 mL/day as long as not contraindicated by cardiac or renal function.
C. Suggest diet high in minerals: calcium, magnesium, zinc, manganese.
D. Avoid drugs that could cause urinary retention (anticholinergics).
E. Provide postoperative care for removal of the hypertrophied fibroadenomatous portion of the prostate. (See Prostatectomy.)

Medical–Surgical Nursing: Cancer of the Prostate

Focus topic: Medical–Surgical Nursing

Characteristics
A. Type: androgen-dependent adenocarcinoma.
B. Clinical manifestations.

  • Early symptoms similar to BPH.
  • Urinary obstruction late in disease.
  • Pain radiating from lumbosacral area down legs strongly indicative of cancer.

C. Many cancers so slow-growing the client will die of other diseases before the cancer spreads significantly.
D. Prostate-specific antigen (PSA) test shows concentration is proportional to total prostatic mass.

  • Does not necessarily indicate malignancy.
  • Used routinely to monitor client’s response to cancer therapy.
  • Only biopsy determines malignancy.

Medical–Surgical Nursing: Prostatectomy

Focus topic: Medical–Surgical Nursing

Definition: Removal of the prostate gland.

Assessment
A. Observe for signs of hemorrhage and shock.
B. Assess for fluid and electrolyte balance.

  • Observe for water intoxication (after transurethral resection of the prostate [TURP]).
  • Symptoms are confusion; warm, moist skin; nausea; vomiting.

C. Observe for complications.

  • Epididymitis (most frequent).
  • Gram-negative sepsis.
  • Overdistended bladder.

Implementation
A. Maintain adequate bladder drainage via catheter.

  • Suprapubic catheter used following suprapubic prostatectomy.
  • Continuous bladder irrigation (or triple-lumen catheter) is used following transurethral resection.
    a. One lumen is used for inflating balloon (usually 30 mL), one for outflow of urine, and one for instillation of irrigating solution.
    b. Function.
    (1) Continuous antibacterial irrigation of solution to prevent infection.
    (2) Continuous saline irrigation to rid the bladder of tissue and clots following surgery.
    c. Nursing management.
    (1) Run solution in rapidly if bright red drainage or clots are present; when drainage clears, decrease to about 40 drops/min. Urine should be red to light pink in 24 hours, amber in 3 days.
    (2) If clots cannot be rinsed out with irrigating solution, irrigate with syringe as ordered, usually 50 mL.
    (3) Maintain accurate I&O. Observe color and consistency of fluid.
  • After catheter removal, monitor for urinary retention and continence.
  • Instruct client in perineal exercises to regain urinary control.
    a. Tense perineal muscles by pressing buttocks together; hold for as long as possible.
    b. Repeat this process 10 times every hour.

B. Provide fluids to prevent dehydration (2–3 L).
C. Provide high-protein, high-vitamin diet.
D. Ambulate early (after urine has returned to nearly normal color)—avoid strenuous activity.
E. Administer analgesics; urinary antiseptics or antibiotics to prevent infection; antispasmodics (spasms decrease within 24–48 hours).
F. Provide wound care for suprapubic and retropubic prostatectomies (similar to that for abdominal surgery)—change dressing frequently.
G. Provide sitz bath and heat lamp treatments to promote healing.

Medical–Surgical Nursing

Medical–Surgical Nursing: Conditions of the Female Reproductive Tract

Focus topic: Medical–Surgical Nursing

Medical–Surgical Nursing: Menstruation

Focus topic: Medical–Surgical Nursing

Definition: The sloughing off of the endometrium, which occurs at regular monthly intervals if conception fails to take place. The discharge consists of blood, mucus, and cells, and it usually lasts for 4–5 days.

Characteristics
A. Menarche—onset of menstruation—usually occurs between the ages of 11 and 14.

B. Abnormalities of menstruation.

  • Dysmenorrhea (painful menstruation).
    a. May be caused by psychological factors: tension, anxiety, preconditioning.
    b. Physical examination is usually done to rule out organic causes.
    c. May subside after childbearing.
    d. Treatment.
    (1) Oral contraceptives: produce anovulatory cycle.
    (2) Mild analgesics such as aspirin.
    (3) Client urged to carry on normal activities.
  • Amenorrhea (absence of menstrual flow).
    a. Primary: Occurs over the age of 17 and menstruation has not begun.
    (1) Complete physical necessary to rule out abnormalities.
    (2) Treatment aimed at correction of underlying condition.
    b. Secondary: Occurs after menarche; does not include pregnancy and lactation.
    (1) Causes include psychological upsets or endocrine conditions.
    (2) Evaluation and treatment by physician is necessary.
  • Menorrhagia (excessive menstrual bleeding). May be due to endocrine disturbance, tumors or inflammatory conditions of the uterus.
  • Metrorrhagia (bleeding between periods). Symptom of disease process, benign tumors, or cancer.

Assessment
A. Assess characteristics of the menstrual cycle.
B. Evaluate cycle pattern.
C. Evaluate discomforts associated with menstruation.

  • Breast tenderness and feeling of fullness.
  • Temperament and mood changes because of hormonal influence. Levels of estrogen and progesterone drop sharply.
  • Discomfort in pelvic area, lower back, and legs.
  • Retained fluids and weight gain.

Implementation
A. Educate client about the physiology of normal menstruation. Answer questions about the myths and cultural beliefs associated with menstruation.
B. Educate client about abnormal conditions associated with menstruation: absence of bleeding, bleeding between periods, etc.
C. Educate client about normal hygiene during menstruation.

  • Importance of cleanliness.
  • Use of perineal pads and tampons.
  • Continuing normal activities.

Medical–Surgical Nursing: Menopause

Focus topic: Medical–Surgical Nursing

Definition: The cessation of menstruation caused by physiologic factors; ovulation no longer occurs. Menopause usually occurs between the ages of 45 and 52.

Characteristics
A. Ovaries lose the ability to respond to pituitary stimulation and normal ovarian function ceases.

  • Gradual change due to alteration in hormone production.
    a. Failure to ovulate.
    b. Monthly flow becomes smaller, irregular, and gradually ceases.
  • Menopause is accompanied by changes in reproductive organs: vagina gradually becomes smaller; uterus, bladder, rectum, and supporting structures lose tone, leading to uterine prolapse, rectocele, and cystocele.

B. Atherosclerosis and osteoporosis are more likely to develop at this time.

Assessment
A. Clinical manifestations vary from mild to severe.
B. May be accompanied by psychological symptoms (e.g., feelings of loss, children grown, aging process occurring).
C. May be accompanied by hot flashes and nervous symptoms, such as headache, depression, insomnia, weakness, and dizziness.

Implementation
A. Instruct client in use of hormone replacement therapy (HRT) as alternative way to cope with menopause.

  • Postmenopausal estrogen/progestin intervention (PEPI) appears to improve lipoproteins and lowers fibrinogen levels.
  • Estrogen alone is not recommended for women who have not had a hysterectomy. It is associated with endometrial hyperplasia.
  • HRT is contraindicated for women who have a history of breast cancer, vascular thrombosis, active liver disease.
  • Methods of treatment vary from daily doses of both estrogen and progestin (now very controversial and not recommended) to 25 days of estrogen and natural progesterone taken 10–14 days during the cycle.
  • Estrogen patches must have accompanying oral progestin or natural progesterone.

B. Answer questions, clarify and/or counsel client on menopausal issues and alternatives to HRT.

C. Alternatives to HRT.

  • Selective estrogen receptor modulators (SERMs) such as Evista (raloxifene).
    a. Acts like estrogen in some tissues but not in others.
    b. Significantly reduces risk of breast cancer.
    c. Used in treatment of osteoporosis.
  • Studies indicate HRT (especially estrogen– progesterone combination) may present major cancer risk to women.
  • Herbal combination used to decrease symptoms of menopause.
  • Other alternative is to use natural estrogen (estriol) and natural progesterone.

Medical–Surgical Nursing: Vulvitis/Vaginal Infections

Focus topic: Medical–Surgical Nursing

Definition: An inflammation of the vulva or vagina, which usually occurs in conjunction with other conditions such as vaginal infections and venereal disease.

Characteristics
A. Vagina normally protected from infection by acidic environment.
B. Leukorrhea (whitish vaginal discharge) normal in small amounts at ovulation and prior to menstruation.

Assessment
A. Evaluate burning pain during urination.
B. Assess for itching.
C. Observe for red and inflamed genitalia.
D. Observe for discharge and odor.
E. Trichomonas vaginalis (overgrowth of protozoan normally present in vaginal tract)—normal pH altered and overgrowth occurs.
F. Candida albicans—fungal infection caused by yeast, also called monilia.

  • More than 500,000 Americans get this infection annually—majority are women.
  • Widespread use of antibiotics increasing epidemic—these destroy protective organisms normally present.
  • Candida thrives in sugar–carbohydrate-rich environment.
  • Symptoms: itching; swelling; white, cheesy discharge from vagina or thrush in mouth; may have systemic symptoms of fatigue, allergies, depression, flatus.

G. Evaluate for related conditions, psychological factors, endocrine disorders, and reactions to chemical substances that the client may be using.

Implementation
A. Give soothing compresses, colloidal baths.
B. Apply medicated creams.
C. Nystatin and Monistat (miconazole nitrate) are drugs of choice systemically; vaginal inserts and ointment.
D. Gyne-Lotrimin (clotrimazole) and Terazol (terconazole) creams (vaginal) are inserted at night.
E. Diflucan (fluconazole) (oral agent) is given one time. Results appear in 3 days.

Medical–Surgical Nursing: Endometriosis

Focus topic: Medical–Surgical Nursing

Definition: The abnormal growth of endometrial tissue outside the uterine cavity. A common cause of infertility.

Characteristics
A. Embryonic tissue that remains dormant until ovarian stimulation after menarche.
B. Endometrial tissue transported from the uterine cavity through the fallopian tubes during menstruation.
C. Endometrial tissue transported by lymphatic tissue during menstruation.
D. Accidental transfer of endometrial tissue to pelvic cavity during surgery.

Assessment
A. Evaluate lower abdominal and pelvic pain during menstruation due to distention of involved tissue and surrounding area by blood; symptoms are acute during menstruation.
B. Assess for dysmenorrhea: usually steady and severe.
C. Assess for abnormal uterine bleeding.
D. Ask about pain during intercourse.
E. Assess for back and rectal pain.

Implementation
A. Explain to client that pregnancy may delay growth of lesions. Symptoms usually recur after pregnancy.
B. Instruct that hormone therapy with oral contraceptives usually eliminates menstrual pain and controls endometrial growth.
C. Discuss use of in vitro fertilization in cases where pregnancy is desired.
D. Prepare client for surgical intervention; total hysterectomy may be indicated.

Medical–Surgical Nursing: Pelvic Inflammatory Disease

Focus topic: Medical–Surgical Nursing

Definition: An inflammatory condition of the pelvic cavity that may involve ovaries, fallopian tubes, vascular system, or pelvic peritoneum.

Assessment
A. Assess for cause of disease.

  • Gonorrheal and chlamydial organisms most common causes.
  • Caused by sexual transmission.

B. Assess for elevated temperature, general malaise, headache.
C. Evaluate for nausea and vomiting.
D. Assess for lower pelvic pain and tenderness following menses.
E. Pain increases during voiding and defecation.
F. Observe for purulent, foul-smelling vaginal discharge.
G. Evaluate for leukocytosis.

Implementation
A. Instruct client on controlling spread of infection.
B. Place in semi-Fowler’s position: dependent drainage.
C. Apply heat to abdomen for comfort.
D. Take and record vital signs every 4 hours.
E. Administer antibiotics as ordered.
F. Note nature and amount of vaginal discharge.
G. Instruct to avoid use of tampons and urinary catheterization to prevent spread of infection.
H. Instruct on good nutrition and fluid intake.

Medical–Surgical Nursing: Toxic Shock Syndrome

Focus topic: Medical–Surgical Nursing

Definition: An uncommon but serious illness reported by menstruating women, usually under age of 30, who use tampons. Toxic shock syndrome (TSS) may also occur in women using sanitary napkins.

Assessment
A. Assess for two primary symptoms: sudden high fever (may be as high as 103–105°F or 39.4–40.5°C) and rash that looks like a sunburn.
B. Other symptoms commonly observed: hypotension; vomiting and diarrhea; dizziness, fainting or near fainting when standing up, headache; copious vaginal discharge; and sore throat.
C. Red macular rash occurs in many women first on torso.

Implementation
A. When toxic shock is suspected, client is hospitalized—the development of severe circulatory compromise cannot be predicted.
B. Blood, urine, and vaginal cultures determine sites of focal Staphylococcus aureus infection; a beta-lactamase– resistant antibiotic with bactericidal activity is administered when there is no focal infection site.
C. Monitor blood pressure and administer IV colloids and vasopressor agents as ordered.
D. Administer sodium bicarbonate for acidosis.
E. Monitor for signs of respiratory distress.

Medical–Surgical Nursing: Conditions of the Uterus

Focus topic: Medical–Surgical Nursing

Definition: May include displacement of the uterus, prolapse of the uterus, or fibroid tumors of the uterus.

Assessment
A. Assess for displacement.

  • Retroversion and retroflexion: backward displacement of the uterus.
  • May cause difficulty in becoming pregnant.

B. Assess for prolapse.

  • Weakening of uterine supports causes the uterus to slip down into the vaginal canal; the uterus may even appear outside the vaginal orifice.
  • Prolapse may cause urinary incontinence or retention.

Implementation
A. Instruct in good perineal hygiene if pessary is used.
B. Follow nursing care for hysterectomy clients.

Medical–Surgical Nursing: Fibroid Tumors

Focus topic: Medical–Surgical Nursing

A. Fibroid tumors are benign.
B. Occur in 20–30% of all women between the ages of 25 and 40.
C. Symptoms include menorrhagia, back pain, urinary difficulty, and constipation.
D. Fibroid tumors may cause sterility.
E. Treatment.

  • Removal of tumors, if they are small.
  • Hysterectomy, if tumors are large.

Medical–Surgical Nursing: Surgical Interventions

Focus topic: Medical–Surgical Nursing

Medical–Surgical Nursing: Tumors of the Breast

Focus topic: Medical–Surgical Nursing

Definition: Tumors or neoplasms are composed of new and actively growing tissue. They are classified in many ways, the most common according to origin and whether they are malignant or benign. The second highest cause of death in females is malignant tumors of the reproductive system.

Assessment
A. Assess for lump in upper outer quadrant of breast, usually nontender, but may be tender.
B. Observe for dimpling of breast tissue surrounding nipple or bleeding from nipple.
C. Check for presence of asymmetry with affected breast being higher.

D. Check for prominent venous pattern—can signal increased blood supply to tumor.
E. Erythema can indicate benign local infection or superficial lymphatic invasion by a neoplasm.
F. Evaluate staging from Stage I to Stage IV.
G. Evaluate types of surgery to be done.

  • Breast-conserving therapy.
    a. Surgical procedures: lumpectomy, wide excision, partial mastectomy, segmental mastectomy, quadrantectomy.
    b. Removal of involved breast tissue and some surrounding tissue and axillary lymph nodes.
  • Total mastectomy.
    a. Removal of breast tissue only.
    b. Performed for carcinoma in situ, typically ductal.
  • Modified radical mastectomy.
    a. Removal of breast tissue and axillary lymph nodes.
    b. Pectoralis major and minor muscles remain intact.
  • Radical mastectomy.
    a. Removal of breast tissue and pectoralis major and minor.
    b. Axillary lymph node dissection.

Implementation: Mastectomy
A. Begin emotional support preoperatively and continue in postoperative period.

  • Client may have altered body image.
  • Client may be extremely depressed.

B. Place in semi-Fowler’s position with affected arm elevated to prevent edema.
C. Turn, cough, and deep-breathe to prevent respiratory complications.
D. Turn only to back and unaffected side.
E. Jackson–Pratt drain or Hemovac may be placed postoperatively.
F. Prevent complications of contractures and lymphedema by encouraging range-of-motion exercises early in postoperative period.
G. Provide IV fluids. Should not be administered in affected arm.
H. Monitor vital signs for prevention of complications such as infection and hemorrhage. Take blood pressure on unaffected arm only.
I. Reinforce pressure dressings. Observe for signs of restriction from dressing.

  • Impaired sensation.
  • Color changes of skin.

J. If skin grafts were applied, provide nursing care as for any other graft.
K. Encourage visit from Reach for Recovery Group.
L. Instruct to perform self-breast exam monthly at a regular time, 7 days after start of menstruation.
M. Teach importance of mammography.

Breast Reconstruction
A. Emotional and psychological implications of loss of a breast are severe.

  • Loss has impact on body image, self-esteem, sense of being sexually attractive, and intimate relationships.
  • Reconstructive surgery following a mastectomy may positively affect the woman’s adjustment to loss of a breast.

B. Reconstruction may be immediate (following surgery) or delayed.
C. Mastectomy without reconstruction—client uses a breast prosthesis.

D. Types of procedures.

  • Implants are soft sacs or a tissue-expander prosthesis filled with silicone gel.
    a. Expander sac is gradually expanded via a needle until breast matches remaining breast; takes several months to complete process.
    b. Following expansion, prosthesis may be removed and replaced by silicone implant.
  • Silicone implants may result in complications.
    a. Fibrous capsular contractions around implant.
    b. Infection is usually a rare complication.
    c. Debate about use of silicone led, in 1992, to the FDA’s limiting use of silicone to breast reconstruction.
  • Autogenous tissue flaps—second type of breast reconstruction.
    a. Tissue flaps eliminate need for implant—unless there is insufficient skin available (TRAM [transverse rectus abdomins myocutaneous] flap, latissimus dorsi).
    b. Involves use of tissue from upper portions of back or lower abdomen.

E. Performing immediate breast reconstruction— eliminates need for second hospitalization and surgery.

Medical–Surgical Nursing: Cancer in the Reproductive System

Focus topic: Medical–Surgical Nursing

Characteristics
A. Cancer of the cervix.

  • Most common type of cancer in the reproductive system.
  • Usually appears in females between the ages of 30 and 50.
  • Signs and symptoms include bleeding between periods—may be noted especially after intercourse or douching; leukorrhea.
  • May become invasive and include tissue outside the cervix, fundus of the uterus, and the lymph glands.
  • Treatment—depends on extent of the disease.
    a. Hysterectomy.
    b. Radiation.
    c. Radical pelvic surgery in advanced cases.

B. Cancer of the endometrium, fundus, or corpus of uterus.

  • Usually not diagnosed until symptoms appear—Pap smear inadequate for diagnosis.
  • Progresses slowly—metastasis occurs late.
  • Treatment.
    a. Early—hysterectomy.
    b. Late—radium and x-ray therapy.

C. Cancer of the vulva.

  • Long-standing pruritus (itching) and local discomfort—itching occurs in half of women.
  • Foul-smelling and slightly bloody discharge.
  • Early lesions. May appear as chronic vulval dermatitis (cancerous lesions grow slowly).
  • Surgical interventions.
    a. Vulvectomy is the preferred treatment.
    b. Radiation therapy is used in the inoperable lesions.

D. Cancer of the ovary.

  • Malignancy may occur at all ages—risk increases after age 40.
  • The most deadly form of reproductive cancer; lack of warning symptoms; etiology not understood.
  • Early diagnosis and surgical removal important (survival rate is 93%).
    a. Usually detection is by chance, no screening.
    b. Tumor marker, CA-125, may be useful, but many false negatives occur.
  • Cancer is staged according to the involvement of tissue and may involve one or both ovaries.
    a. Stage I—limited to the ovaries.
    b. Stage II—pelvic extension.
    c. Stage III—metastasis outside pelvis or positive retroperitoneal lymph nodes.
    d. Stage IV—distant metastasis.
  • Laparotomy is used for diagnosis and treatment—surgery is primary treatment.
  • Chemotherapy may be used for Stage I; radioactive instillation for Stage II.
    a. Chemotherapeutic drugs include Cytoxan (cyclophosphamide), Platinol (cisplatin), Paraplatin (carboplatin), and Taxol (paclitaxel).
    b. Platinol and Taxol most commonly used because of clinical benefits and manageable toxicity.
    c. Leukopenia, neurotoxicity, and fever may occur with treatment.
    d. Taxol can cause cardiac effects.
  • Bone marrow transplantation or stem cell transplantation may be used.
  • Nursing care is the same as for any major abdominal surgery with the exception of psychosocial implications of cancer.

Implementation
A. Provide immediate postoperative care.

  • Observe dressings for signs of hemorrhage.
  • Check vital signs until stable.
  • Assist client to turn, cough, and deep-breathe every 2 hours.
  • Give pain medications as ordered.
  • Observe drainage and empty Hemovac as necessary.
  • Record intake and output.
  • Maintain IV.
  • Maintain catheter care to reduce incidence of infection.
  • Position for comfort.

B. Provide convalescent care.

  • Encourage verbalization regarding change in body image.
  • Irrigate wound as ordered, using solution as prescribed (usual solution is either sterile saline or hydrogen peroxide), which cleans area and improves circulation.
  • Prevent wound infection.

C. Instruct client on discharge teaching.

  • Signs of infection—foul-smelling discharge, elevated temperature, swelling.
  • Nutritious diet and planned rest periods.
  • Wound irrigation and dressing change.
  • Importance of follow-up care by physician.

Medical–Surgical Nursing: Hysterectomy

Focus topic: Medical–Surgical Nursing

Characteristics
A. Total hysterectomy—removal of the uterus including the cervix; fallopian tubes and ovaries are not removed.
B. Total abdominal hysterectomy and bilateral salpingo-oophorectomy—involves removal of the entire uterus, ovaries, and fallopian tubes.

C. Radical hysterectomy—partial vaginectomy with dissection of lymph nodes in the pelvis.

Assessment
A. Observe for hemorrhage—vaginal and at the incision site.
B. Observe for signs of infection—elevated temperature, foul-smelling vaginal discharge, and pelvic congestion.
C. Assess for changes in body image—feelings of loss.
D. Evaluate for pneumonia.
E. Auscultate for paralytic ileus.
F. Observe for thrombophlebitis.

Implementation
A. Immediate postoperative care.

  • Observe incision site for bleeding and reinforce dressings as needed.
  • Monitor vital signs frequently.
  • Administer pain medications as ordered (assist with patient-controlled analgesia [PCA] use).
  • Administer IV fluids as ordered.
  • Observe for signs of thromboembolism—administer heparin if ordered.
  • Provide for hygienic care.
  • Give catheter care to prevent infection—observe amount and color of drainage.
  • Assist client to cough, turn, and deep-breathe.
  • Promote methods to decrease pelvic congestion.
    a. Apply antiembolic stockings.
    b. Avoid high-Fowler’s position.
    c. Promote range of motion.

B. Provide convalescent care.

  • Increase activity as tolerated.
  • Ambulate with assistance.
  • Auscultate chest for breath sounds.
  • Auscultate abdomen for bowel sounds.
  • Allow client to verbalize feelings of loss of femininity, childbearing ability, disfigurement, fear of cancer.
  • Provide for emotional support.
  • Increase diet as tolerated—fluids to 3000 mL/day provided no cardiac or renal problems.
  • Administer laxatives and stool softeners as ordered, and rectal tubes or Harris flush for flatus—diet modification to prevent constipation.

C. Prepare client for discharge.

  • Encourage expression of feelings with significant other.
  • Explain that menstruation will no longer occur.
  • Explain that estrogen therapy may be ordered by the physician, if the ovaries were removed, to control menopausal symptoms.
  • Instruct the client to observe for signs of complications.
    a. Elevation of temperature.
    b. Foul-smelling vaginal discharge.
    c. Redness, swelling, or drainage from the incision site.
    d. Abdominal cramping.
  • Explain the importance of follow-up visits with the physician.
  • Explain the importance of taking medications as ordered.
  • Douching and coitus are usually avoided for 6 weeks.
  • Remind client to avoid both lifting heavy objects and prolonged sitting for several weeks as instructed by physician.

Medical–Surgical Nursing: Anterior and Posterior Colporrhaphy

Focus topic: Medical–Surgical Nursing

Characteristics
A. Repair of cystocele—downward displacement of the bladder toward the vaginal entrance, caused by tissue weakness, injuries in childbirth, and atrophy associated with aging.
B. Repair of rectocele—anterior sagging of rectum and posterior vaginal wall caused by injuries to the muscles and tissue of the pelvic floor during childbirth.

Assessment
A. Observe for foul-smelling discharge from vaginal area or operative site.
B. Observe for urinary retention and catheterize as necessary.

Implementation
A. Provide postoperative care to decrease discomfort.
B. Provide care of perineal sutures—two methods:

  • Sutures left alone until healing begins; thereafter, daily vaginal irrigations with sterile saline.
  • Sterile saline douches twice daily, beginning with the first postoperative day.

C. Preparation of client for discharge. Client should be instructed in perineal hygiene (no douching or coitus until advised by physician), and to watch for signs of infection.

Medical–Surgical Nursing: Pelvic Exenteration

Focus topic: Medical–Surgical Nursing

Definition: A surgical procedure that is performed when cancer is widespread and cannot be controlled by other means—life-saving in certain malignancies.

Characteristics
A. Total pelvic exenteration—removal of the reproductive organs, pelvic floor, pelvic lymph nodes, perineum, bladder, rectum, and distal portion of sigmoid colon.
B. A substitute bladder is made from a segment of the ileum. Client will have a permanent colostomy.
C. When cancer has spread beyond the pelvis, this procedure will not be done.

Implementation
A. Provide general postoperative procedures; in addition, give care for abdominal–perineal resection of the bowel and an ileal conduit.
B. Observe surgical site for drainage and reinforce dressings as necessary; client may have drainage tubes connected to suction from incision area.
C. Observe for complications (occur in 25–50%), usually involving urinary and GI systems.
D. Encourage client to express feelings—especially important considering the diagnosis.
E. Refer client to cancer support group, which studies have shown improve life expectancy.

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