Uterine Myoma-Final

I.
Introduction
e learn more by looking for the answer to a question and not finding it than we do from learning the answer itself. ~Lloyd Alexander, American Author, 1924
In the field of nursing, one encounters a wide-array of various diseases and conditions. In order to give adequate and holistic care to individuals, it is necessary that nurses be equipped with the proper knowledge and skills for dealing with different health states. It is only through continuous learning that nurses acquire the necessary skill. A case study is a means of continuing such learning. In doing a case study, the students delve into the question, what is this disease condition? Student nurses learn actively and will be able to handle patients and experience what it means to care for a patient with that particular condition. They learn, from continuous interaction with the patients along side with inquires into books and informative journals of the disease process, it symptoms, and corresponding treatments. Myomas are one of the conditions which student-nurses encounter during their exposure at the clinical setting. The disease comprises of complexities of the anatomical concepts that surveys a thorough description to understand its manifestations and formulate interventions. It is interesting on our part to learn its definition, causes, and proper management. The studentnurses chose the case to be able to have an insight about the condition. Brief Description Uterine myoma is the most common tumors of female genitalia tract. Myoma commonly called fibroid. It is the benign tumor of the smooth muscle in the wall of the uterus. The fibroids start off very small, actually from one cell, and generally grow slowly over years before they cause any problems. Most fibroids are benign; malignant fibroids are rare. The cause of fibroids is unknown, although it is known that fibroids have a tendency to run in
Uterine Mayoma-Case Report Page 1
families. It may grow as a single nodule or in clusters, and may range in size from 1 mm to more than 20 cm in diameter. Myomas are the most frequently diagnosed tumor of the female pelvis, and the most common reason for hysterectomy. Fibroids are very common, with an estimated 50% of women having them. Fibroids can be diagnosed by pelvic examination or by ultrasound. Fibroids do not have to be removed unless they are causing symptoms such as heavy periods, irregular bleeding, or severe cramps with periods. A hysterectomy is the surgical removal of the uterus or womb, which usually includes the cervix. One or both of the ovaries may he removed at the same time as the hysterectomy. The operation to remove an ovary and fallopian tube is called a salpingo-oophorectomy. The uterus may he removed through an abdominal incision or through the vagina Fibroids can be present and be apparent. However, they are clinically apparent in up to 25% of the women. Approximately 25 % of the myomas will cause symptoms and need medical treatment. Myomas that that do not produce symptoms, do not need to be treated. The said 25 % of women cause significant morbidity, including prolonged or heavy menstrual bleeding, pelvic pressure or pain, and in rare cases, reproductive dysfunction. In the Philippines, the estimated number of women is 86,241,697 squared, and the 4,312,084 had been affected of Myoma. Current Trends Radio Frequency Energy Used To Shrink Fibroids And Reduce Symptoms In New Minimally Invasive Procedure Biomedcentral.com- 06 Jan 2010 Montefiore Medical Center recently became the only hospital on the East Coast to conduct the Radio Frequency Ablation procedure to shrink uterine fibroids in women 30 years and older. This minimally invasive procedure, initially used to treat liver cancer, uses a tiny needle that is inserted into the fibroid, applying low energy radio frequency electrical current, which creates localized tumor destruction by heat.
Uterine Myoma-Case Report Page 2
"More than 30% of all women suffer from fibroids, which can cause excessive menstrual bleeding and pain," said Erika Banks, MD, Director of the Fibroid Center at Montefiore and lead investigator of the study. "This procedure is another option for these women who wish to preserve their uterus -- an important advantage of this minimally invasive procedure."
Treatment of 235 fibroid tumors in 70 women outside the U.S. resulted in significant reduction of symptoms and improvement in quality of life for about 90% of women, according to Dr. Banks. Montefiore Medical Center encompasses 126 years of outstanding patient care, innovative medical "firsts," pioneering clinical research, dedicated community service and ground-breaking social activism. A full-service, integrated delivery system caring for patients in the New York metropolitan region and beyond, Montefiore is a 1,491-bed medical center that includes: four hospitals -- the Henry and Lucy Moses Division, the Jack D. Weiler Division, the North Division and The Children's Hospital at Montefiore; a large home healthcare agency; the largest school health program in the US; a 23-site medical group practice integrated throughout the Bronx and Westchester; and a care management organization providing services to 179,000 health plan members.
In 2008, The Children's Hospital at Montefiore was ranked as one of "America's Best Children's Hospitals" in US News & World Report's prestigious annual listing and also received honors in the magazine's 2009 edition. The Leapfrog Group lists Montefiore among the top one percent of all U.S. hospitals based on its strategic investments in sophisticated and integrated healthcare technology.
Montefiore is committed to meeting the healthcare needs of the future through medical education and manages one of the largest residency programs in the country. Montefiore is The University Hospital and Academic Medical Center for Albert Einstein College of Medicine and has an affiliation with New York Medical College for residency programs at the North Division.
Distinguished centers of excellence at Montefiore include cardiology and cardiac surgery, cancer care, tissue and organ transplantation, children's health, women's health, surgery and the surgical subspecialties. Montefiore is a national leader in the research and treatment of diabetes, headaches, obesity, cough and sleep disorders, geriatrics and geriatric psychiatry, neurology and neurosurgery, adolescent and family medicine, HIV/AIDS and social and environmental medicine, among many other specialties.
Source: Montefiore Medical Center Myomas are one of the conditions which is present in a clinical setting. The disease comprises of complexities of the anatomical concepts that surveys a thorough description to understand its manifestations and formulate interventions. It is interesting on our part to learn its definition, causes, and proper management. As a nurse, knowledge about the disease condition is an advantage as they may render more care to their patient and think of possible interventions to help the patient.
II.
ANATOMY & PHYSIOLOGY
The female reproductive system consists of the ovaries, uterine tubes uterus, (or fallopian vagina, tubes), external
genitalia, and mammary glands. The internal reproductive
organs of the female are located within the pelvis, between the urinary bladder and the rectum. The uterus and the vagina are in the midline , with an ovary to each side of the organ. The internal reproductive organs are held in place within the pelvis with ligaments. The most conspicuous is the brad ligament, which spreads out on both sides of the uterus and to which the ovaries and the uterine tubes attach.
Ovaries The ovaries are for oogenesis-the production of eggs (female sex cells) and for hormone production (estrogen and progesterone). The two ovaries are small organs suspended in the pelvic cavity by ligaments. The suspensory ligament extends from each ovary to the lateral body wall, and the ovarian ligament attaches the ovary to the superior margin of the uterus. In addition, the ovaries are attached to the posterior surface of the broad ligament by folds of the peritoneum called the mesovarium. The ovarian arteries, veins, and nerves transverse the suspensory ligament and enter the ovary through the mesovarium.
A layer of visceral peritoneum covers the surface of the ovary. The outer part of the ovary is made up of dense connective tissue and contains the ovarian follicles. Each of the ovarian follicles contains an oocyte, the female sex cell. Loose connective tissue makes up the inner part of the ovary, where blood vessels, lymphatic vessels, and nerves are located. The ovaries are about the size and shape of almonds. They lie against the lateral walls of the pelvis, one on each side. They are enclosed and held in place by the broad ligament. There are compact like tissues on the ovaries, which are called ovarian follicles. The follicles are tiny sac-like structures that consist of an immature egg surrounded by one or more layers of follicle cells. As the developing egg begins to ripen or mature, follicle enlarges and develops a fluid filled central region. When the egg is matured, it is called a graafian follicle, and is ready to be ejected from the ovary. (3) Process of egg production--oogenesis (a) The total supply of eggs that a female can release has been determined by the time she is born. The eggs are referred to as "oogonia" in the developing fetus. At the time the female is born, oogonia have divided into primary oocytes, which contain 46 chromosomes and are surrounded by a layer of follicle cells. (b) Primary oocytes remain in the state of suspended animation through childhood until the female reaches puberty (ages 10 to 14 years). At puberty, the anterior pituitary gland secretes follicle-stimulating hormone (FSH), which stimulates a small number of primary follicles to mature each month.
Human ovary (c) As a primary oocyte begins dividing, two different cells are produced, each containing 23 unpaired chromosomes. One of the cells is called a secondary oocyte and the other is called the first polar body. The secondary oocyte is the larger cell and is capable of being fertilized. The first polar body is very small, is nonfunctional, and incapable of being fertilized. (d) By the time follicles have matured to the graafian follicle stage, they contain secondary oocytes and can be seen bulging from the surface of the ovary. Follicle development to this stage takes about 14 days. Ovulation (ejection of the mature egg from the ovary) occurs at this 14-day point in response to the luteinizing hormone (LH), which is released by the anterior pituitary gland. (e) The follicle at the proper stage of maturity when the LH is secreted will rupture and release its oocyte into the peritoneal cavity. The motion of the fimbriae draws the oocyte into the fallopian tube. The luteinizing hormone also causes the ruptured follicle to change into a granular structure called corpus luteum, which secretes estrogen and progesterone. (f) If the secondary oocyte is penetrated by a sperm, a secondary division occurs that produces another polar body and an ovum, which combines its 23 chromosomes with those of the sperm to form the fertilized egg, which contains 46 chromosomes.
(4) Process of hormone production by the ovaries. (a) Estrogen is produced by the follicle cells, which are responsible secondary sex characteristics and for the maintenance of these traits. These secondary sex characteristics include the enlargement of fallopian tubes, uterus, vagina, and external genitals; breast development; increased deposits of fat in hips and breasts; widening of the pelvis; and onset of menses or menstrual cycle. (b) Progesterone is produced by the corpus luteum in presence of in the blood. It works with estrogen to produce a normal menstrual cycle. Progesterone is important during pregnancy and in preparing the breasts for milk production. Uterine Tubes A uterine tube, fallopian tube, or oviduct (named after the italian anatomist, Gabriele Fallopio) is associated with each ovary. The uterine tubes extend from the area of the ovaries to the uterus. The open directly into the peritoneal cavity near each ovary and receive an oocyte. The opening of each uterine tube is surrounded by long, thin processes called fimbriae. The fallopian tubes transport ovum from the ovaries to the uterus. There is no contact of fallopian tubes with the ovaries. The distal end of each fallopian tube is expanded and has finger-like projections called fimbriae, which partially surround each ovary. When an oocyte is expelled from the ovary, fimbriae create fluid currents that act to carry the oocyte into the fallopian tube. Oocyte is carried toward the uterus by combination of tube peristalsis and cilia, which propel the oocyte forward. The most desirable place for fertilization is the fallopian tube
Uterus The uterus is a hollow organ about the size and shape of a pear. It serves two important functions: it is the organ of menstruation and during pregnancy it receives the fertilized ovum, retains and nourishes it until it expels the fetus during labor. The uterus is located between the urinary bladder and the rectum. It is suspended in the pelvis by broad ligaments. The uterus consists of the body or corpus, fundus, cervix, and the isthmus. The major portion of the uterus is called the body or corpus. The fundus is the superior, rounded region above the entrance of the fallopian tubes. The cervix is the narrow, inferior outlet that protrudes into the vagina. The isthmus is the slightly constricted portion that joins the corpus to the cervix. The walls are thick and are composed of three layers: the endometrium, the myometrium, and the perimetrium. The endometrium is the inner layer or mucosa. A fertilized egg burrows into the endometrium (implantation) and resides there for the rest of its development. When the female is not pregnant, the endometrial lining sloughs off about every 28 days in response to changes in levels of hormones in the blood. This process is called menses. The myometrium is the smooth muscle component of the wall. These smooth muscle fibers are arranged. In longitudinal, circular, and spiral patterns, and are interlaced with connective tissues. During the monthly female cycles and during pregnancy, these layers undergo extensive changes. The perimetrium is a strong, serous membrane that coats the entire uterine corpus except the lower one fourth and anterior surface where the bladder is attached. Vagina The vagina is the female organ of copulation and functions to receive the penis during intercourse. It also allows menstrual flow and childbirth. The vagina extends from the uterus to outside the body. The superior portion of the vagina is attached to the sides of the cervix so that a part of the cervix extends into the vagina.
The wall of the vagina consists of an outer muscular layer and an inner mucous layer. The muscular layer is smooth muscle and contains many elastic fibers. Thus the vagina can increase in size to accommodate the penis during intercourse, and it can stretch greatly during childbirth. The mucous membrane is moist stratified squamous epitheliam that forms a protective surface layer. Lubricating fluid passes through the vaginal epithelium into the vagina. In young females, the vaginal opening is covered by a thin mucous membrane known as the hymen. The hymen can completely close the vaginal oriface in which case it must be removed to allow menstrual flow. More commonly, the hymen is perforated by one or several holes. The openings of the hymen are usually greatly enlarged during the first sexual intercourse. The hymen can also be perforated during a variety of activities including strenuous exercise. The condition of the hymen is therefore not a reliable indicator of virginity. The External Genitalia The external organs of the female reproductive system include the mons pubis, labia majora, labia minora, vestibule, perineum, and the Bartholin's glands. As a group, these structures that surround the openings of the urethra and vagina compose the vulva, from the Latin word meaning covering. The external female genitalia, also called the vulva, or pudendum, consists of the vestibule and its surrounding structures. a. Mons Pubis. This is the fatty rounded area overlying the symphysis pubis and covered with thick coarse hair. b. Labia Majora. The labia majora run posteriorly from the mons pubis. They are the 2 elongated hair covered skin folds. They enclose and protect other external reproductive organs. c. Labia Minora. The labia minora are 2 smaller folds enclosed by the labia majora. They protect the opening of the vagina and urethra. d. Vestibule. The vestibule consists of the clitoris, urethral meatus, and the vaginal introitus.
(1) The clitoris is a short erectile organ at the top of the vaginal vestibule whose function is sexual excitation. (2) The urethral meatus is the mouth or opening of the urethra. The urethra is a small tubular structure that drains urine from the bladder. (3) The vaginal introitus is the vaginal entrance.
External female genitalia. e. Perineum. This is the skin covered muscular area between the vaginal opening (introitus) and the anus. It aids in constricting the urinary, vaginal, and anal opening. It also helps support the pelvic contents. f. Bartholin's Glands (Vulvovaginal or Vestibular Glands). The Bartholin's glands lie on either side of the vaginal opening. They produce a mucoid substance, which provides lubrication for intercourse.
BLOOD SUPPLY The blood supply is derived from the uterine and ovarian arteries that extend from the internal iliac arteries and the aorta. The increased demands of pregnancy necessitate a rich supply of blood to the uterus. New, larger blood vessels develop to accommodate the need of the growing uterus. The venous circulation is accomplished via the internal iliac and common iliac vein. Mammary Glands Mammary glands are located inside the breasts of sexually mature female body. They are in actuality modified sweat glands which are in fact comprised of secretory mammary alveoli and the appropriate ducts. Mammary glands are considered to be part of the integumentary system rather than the reproductive system. The glands are associated with the female reproductive system in part due to their assistance in attracting a mate as well as their role in nourishing a baby. Size and shape of the female breast are different for every human body and factors such as race, age, body fat, and pregnancy can make a large difference in these variations. The release of estrogen during puberty releases hormones that stimulate the growth of the breasts and the functions of the mammary glands. Pregnant women as well as nursing women experience hypotrophy of the breasts while it is not uncommon for atrophy of the breasts to occur after menopause. Breasts are situated over ribs 2 through 6 and overlap the pectoral muscle as well as some portions of the oblique muscles. The lateral margin of the sternum creates an unintentional margin for the edge of each breast. Each breast also follows the anterior margin of the respective axilla. Coming within very close proximity to the Axillary vessels, the breasts upward and laterally toward the axilla, which contributes to the high incidence of breast cancer due to the axillary process lymphatic drainage.
15 to 20 lobes compose the mammary gland, and each lobe is equipped with its own duct to the outside of the body. Adipose tissue in varying amounts segregates each lobe. While this tissue controls the size and shape that the breast takes, there is no determination by this tissue when it comes to the woman s ability to suckle her young. Lobules are subdivisions of each lobe. These subdivisions contain mammary alveoli. The milk of a lactating female are produced within the mammary alveoli. Suspensory ligaments support the breasts which are attached between the lobules and run deep into the fascia which overlap the pectoral muscles. Breast milk is secreted into a network of mammary ducts which receive the milk from the clusters of mammary alveoli. These mammary ducts converge to form lactiferous ducts. Near the nipple, each lactiferous duct expands into the lumen to allow for outward flow of milk. The lactiferous sinuses store the milk before the suckling action, or additional pressure, releases it from the body. The milk leaves the body from the tip of the nipple. The nipple contains some erectile tissue that protrudes into a cylindrical projection. The circular area around the nipple that contrasts in color is the areola. Sebaceous areola glands create a bumpy surface around the areola which reside just under the surface of the areola s skin. These glands secrete fluids during lactation as well as when a woman is not lactating, which keep the nipple supple. The complexion of the areola is based on the complexion of the skin that covers the rest of the body, varying in pigments and tints. During gestation most areola surfaces darken. It also becomes larger in most cases. This is thought to be more obvious for a nursing infant to find. Branches of the internal thoracic artery are responsible for supplying blood flow to the nipple as well as the rest of the breast and mammary glands. Between the second, third, and forth intercoastal spaces these braches of the thoracic artery enter the mammary glands. These spaces are positioned laterally to the sternum and offer entry to the mammary artery, which only supplies supportive blood. The return veins run alongside the initial arteries which supply the blood. During pregnancy and lactation, and sometimes during other periods, a superficial venous plexus can be seen through the surface of the skin.
The fourth, fifth, and sixth thoracic nerves innervate the breast principally through sensory somatic neurons. These neurons are derivative of the anterior and lateral branches of the thoracic nerves. The release of milk is dependant upon the sensory innervations as stimulus is the only natural release an infant can provide to be nourished. Menstrual Cycle Menstruation is the shedding of the lining of the uterus (endometrium) accompanied by bleeding. It occurs in approximately monthly cycles throughout a woman's reproductive life, except during pregnancy. Menstruation starts during puberty (at menarche) and stops permanently at menopause. Menstruation is the periodic discharge of blood, mucus, and epithelial cells from the uterus. It usually occurs at monthly intervals throughout the reproductive period, except during pregnancy and lactation, when it is usually suppressed. a. The menstrual cycle is controlled by the cyclic activity of follicle stimulating hormone (FSH) and LH from the anterior pituitary and progesterone and estrogen from the ovaries. In other words, FSH acts upon the ovary to stimulate the maturation of a follicle, and during this development, the follicular cells secrete increasing amounts of estrogen .
b. Hormonal interaction of the female cycle are as follows: (1) Days 1-5. This is known as the menses phase. A lack of signal from a fertilized egg influences the drop in estrogen and progesterone production. A drop in progesterone results in the sloughing off of the thick endometrial lining which is the menstrual flow. This occurs for 3 to 5 days. (2) Days 6-14. This is known as the proliferative phase. A drop in progesterone and estrogen stimulates the release of FSH from the anterior pituitary. FSH stimulates the maturation of an ovum with graafian follicle. Near the end of this phase, the release of LH increases causing a sudden burst like release of the ovum, which is known as ovulation. (3) Days 15-28. This is known as the secretory phase. High levels of LH cause the empty graafian follicle to develop into the corpus luteum. The corpus luteum releases progesterone, which increases the endometrial blood supply. Endometrial arrival of the fertilized egg. If the egg is fertilized, the embryo produces human chorionic gonadotropin (HCG). Thehuman chorionic gonadotropin signals the corpus luteum to continue to supply progesterone to maintain the uterine lining. Continuous levels of progesterone prevent the release of FSH and ovulation ceases. c. Additional Information. (1) The length of the menstrual cycle is highly variable. It may be as short as 21 days or as long as 39 days. (2) Only one interval is fairly constant in all females, the time from ovulation to the beginning of menses, which is almost always 14-15 days. (3) The menstrual cycle usually ends when or before a woman reaches her fifties. This is known as menopause.
By definition, the menstrual cycle begins with the first day of bleeding, which is counted as day 1. The cycle ends just before the next menstrual period. Menstrual cycles normally range from about 25 to 36 days. Only 10 to 15% of women have cycles that are exactly 28 days. Usually, the cycles vary the most and the intervals between periods are longest in the years immediately after menarche and before menopause. Menstrual bleeding lasts 3 to 7 days, averaging 5 days. Blood loss during a cycle usually ranges from to 2 ounces. A sanitary pad or tampon, depending on the type, can hold up to an ounce of blood. Menstrual blood, unlike blood resulting from an injury, usually does not clot unless the bleeding is very heavy. OVULATION Ovulation is the release of an egg cell from a mature ovarian follicle . Ovulation is stimulated by hormones from the anterior pituitary gland, which apparently causes the mature follicle to swell rapidly and eventually rupture. When this happens, the follicular fluid, accompanied by the egg cell, oozes outward from the surface of the ovary and enters the peritoneal cavity. After it is expelled from the ovary, the egg cell and one or two layers of follicular cells surrounding it are usually propelled to the opening of a nearby uterine tube. If the cell is not fertilized by union of a sperm cell within a relatively short time, it will degenerate. Menopause When a woman is 40-50 years old, the menstrual cycles become less regular and ovulation does not consistently occur during each cycle. Eventually, the cycles stop completely. The cessation of menstrual cycles is called menopause, and the whole time period from the onset of irregular cycles to their complete cessation is called the female climacteric. The major cause of menopause is age-related changes in the ovaries. The number of follicles remaining in the ovaries of menopausal women is small. In addition to this, the follicles that remain become less sensitive to the stimulation of FSH and LH. As the ovaries become less responsive to stimulation by FSH and LH, fewer mature follicles and copora lutea are produced.
Gradual changes occur in women in response to the reduced amount of estrogen and progesterone produced by ovaries. During the climacteric, some women experience hot flashes, irritability, fatigue, anxiety, temporary decrease in libido, and occasionally severe emotional disturbances. Many of these symptoms can be treated successfully with hormone replacement therapy, which usually consists of small amounts of estrogen or progesterone. A potential side effect of HRT is a slightly increased possibility of the development of breast cancer, uterine cancer, heart attacks, strokes, and blood clots. HRT does slow the decrease in bone density that can become sever in some women after menopause, and decreases the risk of developing colorectal cancer. HORMONES AND FEMALE CYCLES The ovarian cycle is
hormonally regulated in two phases. The follicle secretes estrogen before the ovulation; the corpus luteum secretes both estrogen after and
progesterone
ovulation.
Hormones from the hypothalamus and anterior pituitary control the ovarian cycle. The ovarian cycle covers events in the ovary; the menstrual cycle occurs in the uterus. Menstrual cycles vary from between 15 and 31 days. The first day of the cycle is the first day of blood flow (day 0) known as menstruation. During menstruation, the uterine lining is broken down and shed as menstrual flow. FSH and LH are secreted on day 0, beginning both the menstrual cycle and the ovarian cycle. Both FSH and LH stimulate the maturation of a single follicle in one of the ovaries and the secretion of estrogen. Rising levels of estrogen in the blood trigger secretion of LH, which
stimulates follicle maturation and ovulation (day 14, or mid cycle). LH stimulates the remaining follicle cells to form the corpus luteum, which produces both estrogen and progesterone. Estrogen and progesterone stimulate the development of the endometrium and preparation of the uterine lining for implantation of a zygote. If pregnancy does not occur, the drop in FSH and LH causes the corpus luteum to disintegrate. The drop in hormones also causes the sloughing off of the inner lining of the uterus by a series of muscle contractions of the uterus.
III.
Pathophysiology
O O K - B A S E D :
Y N T H E S I S
O F
T H E
D I S E A S E
a. Schematic Diagram
Precipitating Factors: -High fat diet -Obesity -Anxiety/Stress -Oral Contraceptives or -Hormone replacement therapy -Luteal Insufficiency -Coffee/ Caffeine intake
Predisposing Factors: -Age -Race -Heredity -Early Menarche -Nulliparity
Etiology: Unknown
Estrogen Dominance or increase in Estrogen production
* Classified according to area of growth: intramural, submucous, & subserous
Proliferation of cells in uterus*
Overstimulation
S/sx: -Swelling of breasts -Depression -Loss of sex Drive -Dysmenorrhea
increases the size of the uterine lining or Overgrowth the endometrial lining
Myoma: Development of uterine fibroid

S/sx: - prolonged and/or excessive menstrual bleedings
excessively thickened endometrium
(B)
Uterine Cavity begins to stretch or increase in size
S/sx: -Pain -Increased pelvic Pressure - An abnormally enlarged abdomen
Interference in the vascular supply
Deterioration of the surrounding tissues
replace smooth muscle cells by fibrous connective tissue
Degeneration of the interior part of fibroid
S/sx: -hypermenorrhea -Abnormal bleeding
S/sx: - Pressure on the bladder frequent urination, urinary incontinence or urine retention. -Pressure on the bowel constipation and/or bloating
fibroid continually grows and its size
pressure on the adjacent organs (bladder and rectosigmoid)
b. Definition of the Disease Uterine Leiomyomas
are the most common pelvic tumors of reproductive-age
women (Ling & Duff, 2009). They occur in up to 50 % of patients in autopsy series, and are more common in AfricanAmerican women. They are composed of smooth muscle cells within a fibrous tissue matrix and are unicellular in origin. The growth of these benign tumor tends to be promoted by estrogen and other growth factors. Uterine fibroids are leiomyomata of the uterine smooth muscle. They may vary in size and location. Leiomyomas may be submucous, subserous, intraligamentous, peduncultated or parasitic (Ling & Duff, 2009) As other leiomyomata, they are benign, but may lead to excessive menstrual bleeding (menorrhagia), often cause anemia and may lead to infertility. Enucleation is removal of fibroids without removing the uterus (hysterectomy), which is also commonly performed. Laser surgery (called myolysis) is increasingly used, and provides a viable alternative to traditional surgeries. Oral contraceptive pills can be used to decrease excessive menstrual bleeding and pain associated with uterine fibroids. Uterine leiomyomas originate in the myometrium and are classified by location: y y y Submucosal lie just beneath the endometrium. Intramural lie within the uterine wall. Subserosal lie at the serosal surface of the uterus or may bulge out from the myometrium and can become pedunculated.
The tumors become malignant in less that 0.1 % of patients, which should serve as comfort to women concerned with the possibility of uterine malignancy in association with a fibroid. (McCann & Holmes, 2003) The actual cause of uterine myomas/ leiomyomas are unknown, however, they are seen to be increased with the presence of the following factors. c. Synthesis of the disease The incidence is higher on women during the reproductive years where estrogens and other hormones are actively produced by the body. Many women opt to use oral contraceptives as a birth control method. Oral contraceptives promote estrogen dominance and eventually influence the growth of the cells in the uterus. High-fat diet is also considered a source of estrogen where as diets rich in fiber and low in fat decreases estrogen reabsorption. Leimyoma formation is also possible because of hyperestrogenism due to progesterone deficiency that is caused by luteal insufficiency. Apart from estrogen stimulation, heredity is a factor in the occurrence of leimyomas. Fibroids formation is 4.2 times more common in first-degree relatives than with fibroids without genetic influence. Estrogen is vital in the regulation the menstrual cycle. Presence of this hormone during the first phase influences the proliferation of smooth muscle cells in the uterine walls. Overstimulation increases the size of the uterine lining and further develops into a fibroid. During menstruation, the excessively thickened endometrium does not desquamate (shed its lining) easily (or even completely) at the end of the cycle, resulting in prolonged and/or excessive menstrual bleedings. Following the degeneration of the interior part of the fibroid, are the degenerative changes that eventually replace smooth muscle cells by fibrous connective tissue. The fibroid continually grows and its size puts pressure on the adjacent organs, the bladder and rectosigmoid. Urinary frequency and constipation, respectively, are the results of the compression of these organs.
Predisposing Factors 1. Age is a risk factor in the disease process of uterine leiomyoma. This is due to the differences of estrogen and progesterone levels in females as they get older and undergo the processes of menopause. 2. Race Although an actual connection between the disease process and race have yet to been validated and affirmed, many studies have shown that particular races such as American and African Americans are more susceptible to tumor growth in the endometrial lining among premenopausal women (Marshall, 1997). 3. Heredity Women whos mothers have had myoma themselves are more susceptible to getting the disease than those who have no family history of the disease. (Faerstein, 1997) 4. Early Menarche and Nulliparity Studies have suggested that an early start of menarche (less than the average age of 13) and nulliparity contribute to the development of a uterine leiomyoma, however, how this connection or relationship between the risk factor and the disease processes are still unknown (Faerstein, 2001). It is believed that these factors are precipitated because of the estrogen and progesterone levels in the body. Precipitating Factors 1. High Fat Diet & Obesity is also considered a source of estrogen where as diets rich in fiber and low in fat decreases estrogen reabsorption. Fat has an enzyme that converts adrenal steroids to estrogen. The higher the fat intake, the higher the conversion of fat to estrogen. Overeating is the norm in developed countries. A population from such countries, especially in the Western hemisphere where a large part of the dietary calorie is derived from fat, has a much higher incidence of menopausal symptoms. Studies have shown that estrogen and progesterone levels fell in women who switched from a typical high-fat, refined-carbohydrate diet to a low-fat, high-fiber and plant-based diet even though they did not adjust their total calorie intake. Plants contain over 5,000 known sterols that have progestogenic effects. 2. Anxiety/ Stress The stress levels of the individuals can influence the production of estrogen and progesterone in the body. Stress causes adrenal gland exhaustion as well as reduced progesterone levels. This tilts the estrogen to progesterone ratios in favor of estrogen. Excessive estrogen in turn causes insomnia and anxiety, which further taxes the adrenal
glands. This leads to a further reduction in progesterone output and even more estrogen dominance. After a few years in this type of vicious cycle, the adrenal glands become exhausted. This dysfunction leads to blood sugar imbalance, hormonal imbalances, and chronic fatigue. 3. Oral Contraceptives or HRT - Oral contraceptives promote estrogen dominance and eventually influence the growth of the cells in the uterus. This increases the level of estrogen in the body. Premarin, an estrogen-only drug commonly used in the past 40 years, is the mainstay of estrogen replacement therapy (ERT). It is a patented, chemicalized hormonal substitute that is different than the natural estrogen in your body. It contains 48% estrone and only a small amount of progesterone, which is insufficient to have an opposing effect. The indiscriminate and over-prescription of Premarin to many who may not need it is the problem. Symptoms include water retention, breast swelling, and fibrocysts in the breast, depression, headache, gallbladder problems, and heavy periods. The excessive estrogen from ERT also lead to increased chances of DNA damage, setting a stage for endometrial and breast cancer 4. Luteal Insufficiency - Leimyoma formation is also possible because of hyperestrogenism due to progesterone deficiency that is caused by luteal insufficiency 5. Caffeine or Coffee intake - Increase in coffee consumption. Caffeine intake from all sources is linked with higher estrogen levels regardless of age, body mass index (BMI), caloric intake, smoking, alcohol, and cholesterol intake. Studies have shown that women who consumed at least 500 milligrams of caffeine daily, the equivalent of four or five cups of coffee, had nearly 70% more estrogen during the early follicular phase than women who consume no more than 100 mg of caffeine daily, or less than one cup of coffee. Tea is not much better as it contains about half the amount of caffeine compared to coffee. The exception is herbal tea like chamomile, which contains no caffeine. Signs & Symptoms with Rationale 1. Swelling of breasts Enlargement of the breast and tenderness results from a fluctuation of the hormones progesterone and estrogen.
2. Pain in the back of legs This uterine myoma (fibroid) symptom appears as the fibroids press on nerves that extend to the pelvis and legs. 3. An abnormally enlarged abdomen-- Uterine Cavity begins to stretch or increase in size, this may be mistaken for weight gain or pregnancy.
4. Depression Due to imbalanced levels of estrogen in the body. 5. Loss of Sex Drive Due to imbalanced levels of estrogen in the body. 6. Dysmenorrhea Due to imbalanced levels of estrogen in the body. 7. Pain This symptom may appear as a result of the bulk or weight of the myoma (fibroids) pressing
on other structures in the pelvic area. Due to the stretching of the uterus and the proliferation
of cells which damages the endometrial wall. 8. Increased pelvic pressure Due to the growth of the tumor. 9. Hypremenorrhea and Abnormal Bleeding Due to the growth of the tumor as well as the deterioration of the surrounding tissues which may come from the ischemia due to the tumors growth. IV. Clinical Intervention Total Abdominal Hysterectomy 1.1 Description of prescribed surgical treatment performed Total abdominal hysterectomy is utilized for benign and malignant disease where removal of the internal genitalia is indicated. The operation can be performed with the preservation or removal of the ovaries on one or both sides. In benign disease, the possibility of bilateral and unilateral oophorectomy should be thoroughly discussed with the patient. Frequently, in malignant disease, no choice exists but to remove the tubes and ovaries, since they are frequent sites of micrometastases. The purpose of the operation is to remove the uterus through the abdomen, with or without removing the tube and ovaries.
Procedure:
The patient is placed in the dorsal lithotomy position, and an adequate pelvic examination is performed with the patient under general anesthesia. This is extremely important Self-retaining retractors are placed in the abdominal incision. A 0 synthetic absorbable suture is placed in the fundus of the uterus and used for uterine traction. The uterus is deviated to the patient's right. The left round ligament is placed on stretch and incised between clamps.
because it allows the surgeon to become acquainted with the anatomy of the internal genitalia. The patient is then put in
approximately a 15 Trendelenburg position. A Foley catheter is left in the bladder and connected to straight drainage. In general, midline incisions are preferred for malignant disease, since they allow accurate staging and exposure to the upper abdomen and aortic lymph nodes. If investigation of the upper abdomen and aortic lymph nodes is needed,
the midline incision should be extended around and above the umbilicus for
appropriate exposure.
The distal stump of the round ligament is ligated with 0 synthetic absorbable suture. The proximal stump is held with a straight Ochsner clamp. At this point the leaves of the broad ligament are opened both anteriorly and posteriorly. This is performed by delicate dissection with the Metzenbaum scissors. While retracting the uterus, the surgeon opens the anterior leaf of the broad ligament to the vesicouterine fold. Steps 2-4 are carried out on the opposite side.
The vesicoperitoneal fold is elevated, and the fine filmy attachments of the bladder to the pubovesical cervical fascia are visible. The bladder can be dissected off the lower uterine segment of the uterus and cervix by either blunt or sharp dissection. If there has been extensive lower segment disease, previous cesarean sections, or pelvic irradiation, blunt dissection of the bladder off the cervix is dangerous, and a sharp dissection technique should be performed.
If the ovaries are to be preserved, the uterus is retracted toward the pubic symphysis and deviated to one side with the
infundibulopelvic ligament, tube, and ovary on tension. A finger should be inserted through the peritoneum of the posterior leaf of the broad ligament under the suspensory ligament of the ovary and Fallopian tube. The tube and suspensory ligament are doubly clamped, incised, and tied with 0 synthetic absorbable suture. The distal stump of this structure is best doubly tied, first with a single tie of 0 synthetic absorbable suture and then with a ligature of 0 synthetic absorbable suture. The same procedure is carried out on the opposite side.
The uterus is then retracted and deviated to one side of the pelvis with the lower broad ligament on stretch. The filmy tissue The uterus is held in traction in position, and the handle of the knife is used to dissect the pubovesical cervical fascia inferiorly. This step mobilizes the ureter laterally and caudally.
surrounding the uterine vessels is skeletonized by elevating the round ligament and dissecting the tissue away from the uterine vessels. Three curved Ochsner clamps are placed at the junction of the lower uterine segment on the uterine vessels. This is best performed by placing the tips of the curved Ochsner clamps onto the uterus and allowing them to slide off the body of the uterus, thus ensuring complete clamping of the uterine vessels. An incision is made between the upper Ochsner clamp and the two lower Ochsner clamps. This is sutureligated with two 0 synthetic absorbable sutures, placing the first suture at the tip of the
lower Ochsner clamp and tying the suture behind the base of the clamp. The middle Ochsner clamp is left in place and is similarly suture-ligated by a second ligature placed at the tip of the Ochsner clamp and tied behind the base of the clamp. No attempt is made to place a suture in the middle of the pedicle, since it contains blood vessels and a pedicle hematoma can be created. The same procedure is carried out on the opposite side. A delicate, transverse, curved incision is made in the pubovesical cervical fascia overlying the lower uterine segment.
The posterior leaf of the broad ligament is Two straight Ochsner clamps are applied to the cardinal ligament for a distance of across the posterior lower uterine segment approximately 2 cm. The cardinal ligament is between the rectum and cervix. incised between the two clamps, and the distal stump is ligated with 0 synthetic absorbable suture. The suture is tied at the base of the clamp; no attempt is made to place this suture within the body of the pedicle because vessels can be torn and hematomas created. The same procedure is carried out on the opposite cardinal ligament. incised down to the uterosacral ligaments and
The uterosacral ligaments on both sides are The uterus is placed on traction cephalad, and clamped between straight Ochsner clamps, the lower uterine segment and upper vagina incised, and ligated with 0 synthetic absorbable suture. are palpated between the thumb and first finger of the surgeon's hand to ensure that the ligaments have been completely incised. The vagina is entered by a stab wound with a scalpel and is cut across with either a scalpel or scissors. The uterus is removed. The edges of the vagina are picked up with straight Ochsner clamps in a north, south, east, and west direction.
a. The vaginal cuff is never closed in our clinic. This alone has accounted for a radical decrease in postoperative febrile morbidity and abscess formation. The edges of the vaginal mucosa are sutured with a running locking 0 synthetic absorbable suture starting at the midpoint of the vagina underneath the bladder and carried around to the stumps of the cardinal and uterosacral ligaments, which are sutured into the angle of the vagina. b. The running locking suture is carried around the posterior wall of the vagina ensuring that the rectovaginal space is obliterated. c. The cardinal and uterosacral ligaments of the opposite side have been included in the
The pelvis is reperitonealized with running 2-0 synthetic absorbable suture from the anterior to the posterior leaf of the broad ligament. The stumps of the tubo-ovarian round, suspensory ligament of the ovary, and the cardinal and uterosacral ligaments are buried retroperitoneally.
running locking 0 synthetic absorbable suture, and the reefing process has been completed to the midpoint of the anterior vaginal wall. At this point, meticulous care should be taken to ensure that the lateral angle of the vagina is adequately secured and that hemostasis is complete between the lateral angle of the vagina and the stumps of the cardinal and uterosacral ligaments. This can be a site of hemorrhage. At this point, the pelvis is thoroughly washed with sterile saline solution. Meticulous care is taken to ensure that hemostasis is present throughout the dissected area.
Drains are rarely needed. If they are indicated, they are placed through the open vaginal cuff and carried along the lateral pelvic wall
retroperitoneally.
If the tube and ovary are to be removed, they are removed at Step 6 in the operation. Instead of placing a finger underneath the tube and suspensory ligament of the ovary, a finger is placed under the infundilbulopelvic ligament on that side. Care is taken to ensure that the ureter is not included. In various forms of pelvic disease (endometriosis, pelvic inflammatory disease, etc.), the ureter can be deviated ligament. The infundibulopelvic ligament is doubly clamped and incised, and the distal stump of the ligament is doubly ligated with a tie of 0 synthetic absorbable suture plus a ligature of 0 synthetic absorbable suture. For a bilateral salpingo-oophorectomy, the same procedure is carried out on the opposite infundibulopelvic ligament. close to the infundibulopelvic
The tube and ovary have been mobilized medially with the uterine specimens. The remainder of the operation is carried out as described in Steps 7-13.
The peritoneum of the pelvis has been reestablished with the tube and ovary removed. The stump of the infundibulopelvic ligament is buried retroperitoneally. Postoperatively, no vaginal packing is left in the vagina, and no Foley catheter drainage of the bladder is indicated. The open vaginal cuff closes without difficulty. Rarely, a small bit of granulation tissue is noted in the upper vagina and is adequately treated by application of silver nitrate 4 weeks postoperatively in the clinic or office. The patient is allowed to resume sexual intercourse 4 weeks after examination in the clinic and is allowed to resume work 5 weeks postoperatively.
Total Vaginal Hysterectomy Total vaginal hysterectomy is an excellent operation when removal of the uterus is indicated in cases of either benign disease or carcinoma in situ of the cervix. The technique described here is simple and easy and can be accomplished with a minimum of operative time. Procedure:
After appropriate general anesthesia, the patient is placed in the dorsal lithotomy position with the buttocks well off the end of the table. A thorough bimanual examination is necessary prior to performing a hysterectomy. The vulva and vagina are fully prepped with a surgical soap solution. The cervix is exposed by placing a weighted posterior vaginal retractor into the vagina. A small right-angle retractor is
After the injection of Pitressin into the vaginal mucosa, the mucosa is incised with a scalpel around the entire cervix. The incision should stay above the pubovesical cervical fascia anteriorly and the perirectal fascia posteriorly.
used to elevate the anterior vaginal wall; a second right-angle retractor displaces one lateral vaginal wall and exposes the cervix. Two Jacobs tenacula are used to grasp the anterior and posterior lips of the cervix and pull them into the vaginal introitus. The vaginal mucosa at its junction to the cervix is being injected with a dilute solution of Pitressin. Ten international units of Pitressin are diluted with 25 mL of sterile saline solution, and 10 mL of this mixture are injected into the vaginal mucosa to aid hemostasis. This solution should not be used on patients with
hypertension or cardiac arrhythmias but is most useful in healthy premenopausal patients.
While downward traction is applied on the Jacobs tenacula, the handle of the knife is used to dissect the bladder off the anterior lower uterine segment.
sponge-covered
finger
dissects
the
bladder all the way up to the peritoneal vesicouterine fold. This step is frequently insufficiently performed for fear of entering the bladder. If dissection is not carried up to the peritoneal vesicouterine fold, entry into the anterior cul-de-sac is most difficult.
A right-angle retractor is placed under the vaginal mucosa and bladder. It is used to elevate the bladder. This maneuver aids in identifying the peritoneal vesicouterine fold. The peritoneal fold appears as a white transverse line across the lower uterine segment. Strong downward traction is applied to the Jacobs tenacula on the cervix, and the peritoneal vesicouterine fold is grasped with
By elevating the peritoneal vesicouterine fold with the pickup forceps, a definite hole can be seen. It is advisable to insert a finger in this hole and explore the area (1) to be sure one is in the peritoneal cavity and not the bladder and (2) to uncover any unsuspected pathologic condition that was not identified during the examination. With the finger remaining in the hole, an anterior
pickup forceps and incised with sharp curved Mayo scissors.
Heaney right-angle retractor is placed into the defect underneath the finger.
The Jacobs tenacula are brought acutely up toward the pubic symphysis, exposing the culde-sac. Pickup forceps are used to retract the posterior vaginal cuff, thereby placing the peritoneum of the cul-de-sac on tension. The peritoneum of the cul-de-sac is incised with curved Mayo scissors.
A finger is immediately placed in the cul-desac, and the area is explored as in the exploration of the anterior cul-de-sac. Approximately 75-100 mL of peritoneal fluid may be seen upon opening the cul-de-sac. A second right-angle Heaney retractor is placed into the posterior cul-de-sac.
The weighted posterior vaginal retractor is removed. With the two Heaney retractors the broad ligament is exposed from the uetrosacral ligament to the tubo-ovarian round ligament. A finger placed in the posterior cul-de-sac and moved laterally reveals the uterosacral
With the cervix on upward and lateral retraction via the Jacobs tenacula, a curved Heaney clamp is placed in the posterior culde-sac with one blade underneath the uterosacral ligament and the opposite blade over the uterosacral ligament. The clamp is placed immediately next to the uterine cervix so that some tissue of the cervix is included in this clamp. This is done to prevent possible ureteral damage from clamping the uterosacral ligament in the lateral position.
ligament as it attaches to the lower uterine segment.
The uterosacral ligament is cut with curved Mayo scissors.
A Heaney fixation 0 synthetic absorbable suture is used to suture-ligate the
uterosacral ligament. In addition, the first of four steps is initiated for vaginal cuff suspension. In A, the suture has been placed from the inside of the uterosacral ligament at the tip of the Heaney clamp through the uterosacral ligament and brought out through the vaginal mucosa. In B, the suture is brought back through the vaginal mucosa and through the midportion of the the
uterosacral
ligament
underneath
Heaney clamp. This plicates the uterosacral ligaments to the angle of the vagina and aids hemostasis as well as vaginal cuff suspension.
When tied, the suture is held with a Kelly clamp for traction. This suture not only ligates the uterosacral ligament but plicates that pedicle to the vaginal cuff.
With the uterus on upward and lateral retraction via the Jacobs tenacula on the cervix, the cardinal ligament is clamped adjacent to the lower uterine segment and incised.
The cardinal ligament is suture-ligated with 0 synthetic absorbable suture. No fixation suture is used here for fear of producing a hematoma in the vascular cardinal ligament. Before proceeding farther up the broad ligament, the lateral retractor and cervix are moved to the opposite side, exposing the opposite
When
the
uterosacral
and
cardinal
ligaments on each side have been clamped, incised, and suture-ligated, the remaining portion of the broad ligament attached to the lower uterine segment containing the uterine artery is clamped adjacent to the cervix. Use of a single clamp in the vaginal hysterectomy reduces the chance of
uterosacral and cardinal ligaments, and they are likewise clamped and suture-ligated.
damage to the ureter, whereas using two clamps will allow this portion of the broad ligament to be clamped in its lateral position, thus increasing the chance of ureteral injury.
With the uterosacral ligament, the cardinal ligament, and the uterine artery pedicle on both sides now clamped, incised, and sutureligated, the cervix is retracted upward in the midline via the Jacobs tenacula. Thyroid clamps are used to grasp the posterior uterine wall, and with a hand-over-hand "walking out" technique the fundus is delivered posteriorly.
The Jacobs tenacula and the thyroid clamp are held in one hand, and the finger of the opposite hand is inserted under the tuboovarian round ligament, exposing the ligated portion of the lower broad ligament.
Two Heaney clamps are applied to the tuboovarian round ligament, and it is incised close to the fundus.
The tubo-ovarian round ligament is tied twice. In A, a tie of 0 synthetic absorbable suture is placed behind the second clamp. The tubo-ovarian round ligament is tied with a simple 0 synthetic absorbable suture. After the clamp at the rear of the pedicle is removed, the forward clamp is "flashed" (i.e., slightly opened and immediately closed), to allow the suture to securely ligate all the structures in this pedicle. In B, a second suture ligature is tied in a fixation stitch, placing the suture in the midportion of its pedicle. In C, the suture is tied in front of and behind the pedicle prior to removing the first clamp. In D, the pedicle is tied, and the second suture is held in a
straight clamp for traction.
The anterior and posterior Heaney right-angle The reperitonealization of the pelvis, carried retractors are removed, and the weighted out with pursestring sutures, provides the posterior vaginal retractor is placed in the second of four steps in suspension of the vagina. The anterior vaginal wall is elevated vaginal cuff. The suture is started on the with a short-angle retractor. This allows better vaginal cuff exposure. The entire broad ligament and its respective pedicles are round ligament. After the stump of the exposed from the tubo-ovarian round ligament tubo-ovarian round ligament is sutured, the anteriorly to the uetrosacral ligament suture ligature held for retraction can be posteriorly. A free sponge is pushed into the cut. The pursestring is continued down peritoneal cavity to displace the ovaries, tubes, through one or more of the pedicles and is and bowel and give better exposure to the finally brought through the uterosacral broad ligament structures. The tail of the cardinal ligament pedicles and the vaginal sponge is used to wipe the pedicles of each of these ligaments to check for hemostasis. If mucosa, plicating these pedicles to the vaginal mucosa to provide additional anterior peritoneal edge and brought through the stump of the tubo-ovarian
there is bleeding from any pedicle or portion thereof, the bleeding points can be clamped with a curved Heaney clamp and suture-ligated. It is preferable that the suture be brought through the tip of the Heaney clamp and out through the vaginal mucosa. If the surgeon encounters a wide area of bleeding, the entire broad ligament can be suture-ligated by a running 0 synthetic absorbable suture plicating the pedicles of the broad ligament to the lateral vaginal mucosa. Care should be taken not to go deeper than the original ties on the broad ligament pedicles to prevent damage to the ureter. The vesical peritoneal edge can be identified by grasping the anterior vaginal wall with tissue forceps. By using a hand-over-hand technique, the surgeon can progressively pull the bladder wall down into the vagina and easily identify the peritoneal edge.
suspension of the upper vagina. The suture is continued posteriorly across the
peritoneum of the cul-de-sac with one or two stitches. The traction sutures in the uterosacral ligaments should not be cut, as they are needed in a later step. The suture is brought from the inside of the opposite uterosacral ligament out through the vaginal mucosa and carried up the pedicles of the opposite side until the tubo-ovarian round ligament on the opposite side has been sutured. The traction suture on this pedicle can be cut. The suture is passed through the anterior vesicoperitoneal edge. When this suture is tied, the pelvis is reperitonealized, and the stumps of the broad ligament are retroperitonealized.
The final step is to observe the upper The vaginal cuff is never closed and is left open for drainage to prevent postoperative pelvic abscesses. A running locking 0 synthetic absorbable suture is started at the 12 o'clock position on the anterior vaginal cuff and is carried around the entire edge of the vagina until the cardinal and uterosacral ligaments are reached. At that point, the suture is brought through the cardinal and uterosacral, and the surgeon again plicates these ligaments to the vaginal cuff, completing the third of four steps in vaginal suspension. The same is done for the uterosacral and cardinal ligaments on the opposite side. The running locking suture is continued until the entire cuff has been sutured. The two retraction sutures held by Under certain conditions the Fallopian tubes VAGINAL BILATERAL SALPINGOvaginal area for hemorrhage. We prefer to catheterize the bladder at the end rather than at the beginning of the procedure because there may be less chance of injuring a bladder that is partially filled with urine than one that is empty. No vaginal pack is left in the vagina, and no Foley catheter is placed in the bladder. All patients undergoing vaginal hysterectomy are given antibiotics preoperatively.
OOPHORECTOMY DURING TOTAL VAGINAL HYSTERECTOMY
Kelly clamps on the uterosacral ligaments are tied in the midline. This aids in obliterating the cul-de-sac and reduces the incidence of enterocele.
and ovaries may be removed at the time of vaginal hysterectomy. Salpingo-
oophorectomy can be performed during the hysterectomy, although it is easier to perform immediately after the uterine specimen has been removed. If the tubes and ovaries are to be removed with the specimen, the uterus is delivered into the vagina as in Figure 18.
Exposure is facilitated by clamping and cutting the round ligament on each side. The thyroid clamp on the fundus, which has been placed on traction (Fig. 18), is removed to expose the anatomy.
After the round ligament has been cut and tied on each side, additional traction on the uterine fundus delivers the fundus into the vagina and places tension on the infundibulopelvic ligament. A finger can be inserted up and under this ligament. Two Heaney clamps are placed across the ligament. It is cut and doubly tied with 0 synthetic absorbable suture as demonstrated in Figure 20. The second suture on this pedicle is held in a straight clamp as seen in Figure 21 (on the tubo-ovarian round ligament). Reestablishing the peritoneum and vaginal cuff suturing are performed as in Figure 22 and 23. The infundibulopelvic ligament pedicle is used for establishing the peritoneal lining, as was the tubo-ovarian round ligament pedicle in Figure 22. The vaginal cuff is sutured with a running locking stitch and left open.
1.2 Indication of prescribed surgical treatment A hysterectomy can end symptoms of pain and bleeding and in some cases act as a life saver. As a result many women find that a hysterectomy improves their health and well-being arid ensures that they can continue to lead an active life. It is important to understand exactly what a hysterectomy can mean to you and what benefits it will bring. Make sure that you understand from your doctor how the operation will affect the particular symptoms you have.
Hysterectomy is a relatively safe operation, although like all major surgery it carries risks. These include unanticipated reaction to anesthesia, internal bleeding, blood clots, damage to other organs such as the bladder, and post-surgery infection. Other complications sometimes reported after a hysterectomy includes changes in sex drive, weight gain, constipation, and pelvic pain. Hot flashes and other symptoms of menopause can occur if the ovaries are removed. Women who have both ovaries removed and who do not take estrogen replacement therapy run an increased risk for heart disease and osteoporosis (a condition that causes bones to be brittle). Women with a history of psychological and emotional problems before the hysterectomy are likely to experience psychological difficulties after the operation. As in all major surgery, the health of the patient affects the risk of the operation. Women who have chronic heart or lung diseases, diabetes, or iron-deficiency anemia may not be good candidates for this operation. Heavy smoking, obesity, use of steroid drugs, and use of illicit drugs add to the surgical risk. 1.3 Required instruments, devices, supplies, equipment and facilities Abdominal Hysterectomy The predominant point of caution in performing abdominal hysterectomy is to ensure that there is no damage to the bladder, ureters, or rectosigmoid colon. y Mobilization of the bladder with a combination of sharp and blunt dissection frees the bladder from the lower uterine segment and upper vagina. This reduces the incidence of damage to the bladder. y By exercising extreme care in management of the uterine artery pedicle, the surgeon may minimize the risk of injury to the ureter. The same is true of the management of the cardinal and uetrosacral ligament pedicles. y If the vaginal cuff is left open with the edges sutured, the incidence of postoperative pelvic abscess is dramatically reduced
Vaginal Hysterectomy y Care must be taken to ensure that entry into the anterior cul-de-sac is made before the uterus is totally removed to avoid accidental entry into the bladder. y If the anterior and posterior cul-de-sacs can be entered, there is a significant reduction in bleeding from the pedicles of the clamped broad ligament. y The pedicles of the broad ligament should be retroperitonealized before reefing the vaginal mucosa. y The vaginal mucosa should not be closed. the edges of the vaginal mucosa should be reefed with a running locking 0 synthetic absorbable suture and left open for drainage. C. Required Instruments, Devices, Supplies, Equipment, and Facilities 12 Curve Clamps y Occludes the bleeding point y Clamp blood vessels
3 Allis y Scissor action. Each jaw curves slightly inward with a row of teeth at the end. y It holds tissue gently but securely.
2 Bobcocks y End of each jaw is rounded to fit around a structure or to grasp tissue without injury.
2 Mixters
2 Needle Holders y Used to grasp and hold curved surgical needles.
1 Blade Holder y Use to hold blades.
1 Thumb Forceps y Used to hold delicate tissues.
1 Tissue forceps y Used to hold tough tissues.
1 Long Thumb / Russian y To hold tissues that will not injure delicate structures.
1 Self Retaining Retractor y To spread the edges and hold them apart.
1 army navy
1 Deaver y Used in retracting and exposing the skin
1 Ochsnerse y Used for clamping and holding tissues.
Scissors Metz y Cut smooth tissues and muscles.
Mayo y Cut rough tissue/fascia
Straight y To cut sutures.
Needles
OR Table
Mayo Table
D. Perioperative tasks and responsibilities of the Nurse Circulating Nurse Preoperative:

y The circulating nurse will function as an observer of the room during the procedure to
maintain sterility.
y She assists the entire tam and the patient. y She also sends for the patient at the appropriate time. y She receives, greets and identifies the patient upon admission and checks for the
completeness of the chart.

y Upon admission to the operating room, she will assist the patient in moving safely to the
operating room table. Intraoperative:

y She is also the one who assist the anesthesiologist, when requested, stays with the patient
during the induction of anesthesia.

y Being a circulating nurse, included in the unsterile team, she will also tie the scrubbed
members gowns and checks operating room lights on at appropriate time and adjusts when needed.
y After positioning the patient, the circulating nurse will prepare the operative site using an
antiseptic in a circular motion from inner to outer part.

y A dependent nursing function like inserting a Foley catheter is also done if ordered by the
surgeon.
y The circulating nurse and the scrub nurse do the sponge count. y As an overseer, it is her responsibility to provide foot stools of needed by the surgical team
and watches the forehead for perspiration.

y Intraoperatively, she will fill out required operative records completely and legibly. y She remains in the room as much as possible to be constantly available.
y Watches progress of the surgery, anticipates needs and reacts quickly to emergency. y She is also responsible for using equipment and supplies economically and conservatively like
the use of the suction machine, the need for extra cherry, abdominal packs, OS (gauze) and sterile water.
y Working on a sterile field, the circulating nurse should watch out for the sterility at all times
and remind those who break any technique. Postoperative:

y At the conclusion or termination of the operation, the circulating nurse also directs cleaning
of the room and preparation for the next operation.

y Gathers supplies for case and opens sterile supplies for the scrub nurse. y She is also responsible for sending all tissues or specimen removed from the patient to the
laboratory with proper label and necessary request for the kind of laboratory work to be done as soon as the case is terminated. Scrub Nurse Preoperative:
y Reads the schedule, noting the type of case, estimated length and type of anesthesia to be
used.
y Review basic anatomy, physiology and operative technique if she is not thoroughly familiar
with the type of case to be performed.

y Check all types of instruments to be needed and discuss these with the surgeon to obtain idea
of preference which are not written in his own preference card and for visiting surgeons.
y Discusses any question she has about the nature of the case with the surgeon. y Makes available all types of sutures in each surgeon s preference card that will be used in the
case.
Intraoperative:
y Aids the surgeon in gowning and gloving. y She also aids in draping the patient. y Intraoperative, the scrub will set up sterile supplies and instruments assist the surgeon as
needed throughout the surgery like pulling the retractors manageable in order to visualize the part to be manipulated.
y He/she will also be responsible for draping the patient and the field. Instruments, sutures and
sponges are handed to the surgeon in an efficient manner.

y As a scrub nurse, it is also his/her responsibility to keep operative tidy during the operation. y As much as possible, the scrub nurse must wipe blood from instruments and keep close watch
on needles, instruments and sponges so that none will be misplaced or lost during the operation.
y The instrument nurse and the suture nurse will keep an accurate account of needles and
instruments.
y Makes sure that supplies are sterile and if in doubt, they should be discarded immediately. An
important nursing responsibility is to count the instruments at all times. The scrub nurse and the circulating nurse should establish an accurate count on the things that are present before, during and after the operation.
y Observe the skin incision from the viewpoint of how much bleeding is occurring so as to
anticipate the need for hemostatic clamps and ligatures to control bleeding.
y Observe the progress of dissection to be able to anticipate the need for special instruments,
sponges and free suture ends. Thus maintaining the orderliness and neatness of the field, this is the major factor in safe and efficient surgery.
y Anticipate special problems so as to advise the circulating nurse accordingly for the possible
need for special instruments and equipments.
Postoperative:
y At the termination or conclusion of the procedure, the scrub nurse will clean the instruments
and supplies used during the operation so that the instruments will ready for sterilization.
y Accountable for any loss of such instruments, wash and return the instruments properly.
E. Expected Outcome of Surgical Treatment Performed As with much operation, there is risk associated with having a major abdominal surgery. It is the bruising or infection in the wound. Internal bruising and infection may also occur. A blood transfusion is often needed to replace blood loss during the operation. Very occasionally, there may be internal bleeding after the operation, making a second operation necessary. Patients occasionally suffer from blood clots in the legs or pelvis. This can lead to a clot in the lungs. Moving around as soon as possible after the operation can help prevent this. One of the aggravations the patient may face in the first few weeks of surgical recovery is a crampy bladder. This may feel like having an infection, it may seem like cramps after we urinate, she may have trouble telling when we need to go or she may feel as though she need to go very frequently. All of these are fairly normal things and are results of the trauma to our bladders during surgery. After the operation, the bladder and the bowels may take some time to begin working properly. Some women have loss of feeling in the bladder that may take some months to get better. During this time, the health care team needs to take special care to empty the bladder regularly. Rectal dysfunction manifested by abnormal internal sphincter relaxation, decreased rectal sensation, and increased abdominal pressure required to produce a bowel movement are rarely reported, although these conditions may be the result of disruption of autonomic sensory nerves. The risk for bowel complications is markedly increased with the addition of preoperative medications which in relaxation of smooth muscle. The patient may have trouble
opening their bowels or have some discomfort for the first few days after the operation. The physician usually orders laxative and painkillers for them. The skin around is usually numb for several months until small nerve damaged by the incision grow back. Sometimes the numbness may affect the top of the legs or the inside of the thighs. This nearly gets better in 6-12 months. Postoperative complications include wound complications that lead to wound skin separation, wound abscess and wound dehiscence. Poor healing due to obesity, steroid dependence, COPD and poor preoperative nutritional status, can significantly contribute to an increased risk for wound complications. During this time, it may feel important for the patient and her partner to maintain intimacy despite refraining from sexual intercourse. The patient should understand that she won t get back to the usual self at least 4-6 weeks. If the patient haven t experienced menopause before surgery, she may discuss with the doctor about ways to handle menopausal symptoms. About six weeks after the surgery, the patient and her partner can resume sexual activity. If the patient s sex life was good before a hysterectomy, it will probably continue to be. Some women even experience an increase in sexual pleasure. This may be associated with relief from chronic pain or heavy bleeding that was caused by uterine problems. Pre-menopausal women will undergo surgical menopause. Unlike the gradual changes usually experienced by women in natural menopause, these changes are more sudden and can be quite distressing. HRT is one treatment option often recommended by doctors as a way of alleviating menopausal symptoms like hot flushes and vaginal dryness. As one woman put it, I think the best thing we can all do for ourselves is to ride the wave of change and passage . Rather than dwell on what the patient feel she has lost after an operation, spend that energy nourishing their future goals and celebrating the blessings in their life. One of the most important things to learn is that it s not all so bad. Take advantage of some wonderful quiet moments than just sit and do nothing at all. Also, advice the patient to
take some wonderful quiet moments with God. Notice how amazing the human body is and what is capable of. F. Medical Management of Physiologic Outcomes One thing that can be beneficial in dealing with pain in the first hours after surgery is the use, from the Recovery Room on, of a relatively new anti-inflammatory called Toradol. It is given IV, regularly, and it seems to keep the level of pain down such that narcotics may not be required or may be required only in lesser amounts than when they are used alone. It also seems to ease the transition to oral meds, particularly of the long-acting NSAID family (such as the 12-hour dose of naproxen), and does not carry the effects of the opiates (in either allergy or constipation). Two fairly common pain management setups are the patient-administered IV and the epidural block. The former is a pump, connected to your IV, that contains morphine or demerol, a very potent narcotics. The pump is set for a maximum dose per hour, but you may trigger it to deliver a dose whenever you need it, up to that maximum. This allows you to pre-medicate before doing something that you feel might cause pain (like getting up) and allows you to control the amount of medication you get. This pump is typically used for one to two days, and is gradually replaced by oral medication While it is obvious that the PCA is not a psychological treatment for postoperative pain, there are important psychological advantages to this method of managing pain most importantly, it provides control to the patient, to take what is needed when it is needed, as he or she is the best judge of their pain. While PCA is a safe and effective means of managing postoperative pain, not all patients feel comfortable being placed in charge of their pain medication. They may be afraid of taking too much or too little of the PCA system malfunctioning, or of becoming addicted. Once these fears and concerns are addressed and the safeguards are explained to them, most patients do very well with the PCA pump system and report a high level of satisfaction with their pain control.
Psychologists help patients cope with postoperative pain through a variety of means. The process usually begins before there is any pain, and even before the surgery itself. Providing accurate information ahead of time about the surgery and recovery gives the individual a realistic idea of what to expect during the hospital stay (for example, how much pain one is likely to experience) and can help to relieve anxiety and fear, both of which are known to make pain worse. Understanding the factors that are associated with intense pain after surgery can be helpful in preventing or pre-empting post surgical pain. Research studies have shown that providing information and education about pain and its management to patients can help reduce post surgical pain intensity. Psychological interventions that are specifically aimed at reducing pre-surgical anxiety have also been found to reduce post surgical pain. Other tools that psychologists use that have been shown to be effective in reducing postoperative pain intensity include hypnosis and self-hypnosis, relaxation training, and cognitive behavioral therapy. Psychologists are exploring new ways to improve post surgical pain management. For example, some recent studies found that playing a tape-recorded message during surgery while the patient was under the effects of anesthetic led to lower pain levels after surgery. The message contained positive suggestions for a pain-free recovery. While this type of approach is still in an experimental stage, it illustrates that new techniques can also make an impact. Many people that have undergone surgery have many reactions to the procedures that have been made. Some people may feel happy with the results because the operation causes alleviation of pain they previously felt, or in cosmetic or anesthetic purpose a successful operation boost self esteem. Some people are still worried after the surgery because they fear further complications may compromise their health once more. Some will have a low self esteem because of the scar that has been made. Some people are still worried after the surgery because they fear further complications may compromise their health once more.
1. IVF
Medical Management
General Description
Indication or Purpose
Client s response to the treatment
5% Dextrose in Lactated Ringer s Solution
Hypertonic Solution A solution containing sodium chloride, potassium chloride, calcium chloride and sodium lactated in distilled water, referred to Lactated Ringer s solution calories from dextrose
y y
To replace fluids and electrolytes loss To increase vascular/ plasma volume necessary during bleeding or blood loss To replenish fluid loss of the body, maintain nutritional intake when patient is unable to tolerate feedings, also serves as medium for administration of medications.
No adverse reactions or IV complications will be noted
NURSING RESPONSIBILITIES Before the Procedure y y y y Check the doctor s order regarding to what type of IVF to be used and also its volume and rate. Explain the procedure to the patient. Gather all materials needed for the insertion of IVF to save time and not to waste time for looking for other materials. Wash hands before and after the procedure to prevent contamination from insertion site.
During the Procedure y y y Place patient in a comfortable position to facilitate easy insertion of IV line an d to decrease patient s fear about the procedure. Make sure that we give the proper IV fluid and drop rate accurately because patient may experience fluid overload or dehydrat ion. Check for its patency by observing the backflow of blood upon insertion.
After the Procedure y y y y Press the site where the needle was inserted and secure it with micropore. Check the site of hand where the needle is inserted if bulging is not visible. If so, reinsertion is to be undertaken. Advice patient to avoid scratching the site less movement of the hand where the needle was inserted to keep it in place. Instruct patient and significant others to inform the nurse on duty if bulging of the site is visible, if there is back flow of blood of if IVF is not infusing well. y y Observe the IV site at least every hour for signs of infiltration or other complications fluid or electrolyte overload and air embolism. IVF regulation should be checked and monitored upon receiving patient.
y y y y y y y
Always check the doctor s order for new orders regarding th e IVF supplement of the patient. Always check if the IVF is infusing well and intact. Monitor the patient s skin integrity. Provide comfort for the patient. Remove and dispose used items. Report and record as appropriate. Place IV tag
2. Drugs
NAME OF DRUGS -GENERIC NAME -BRAND NAME
-ROUTE OF ADMINISTRATION -DOSAGE & FREQ. OF ADMINISTRATION
Indication or Purposes
Clients Response to Treatment
Brand Name: Nubain
10 mg / amp PRN
An Opioid analgesic that binds with opiates Receptors in the CNS, altering perception of and emotional response to
The patient will verbalize relief from pain.
Generic Name: Nalbuphine Hydrochloride
pain.
Nursing Responsibilities Before the administration of drug: y Verify Doctor s order y Remember the 10R s of Drug administration During the administration of drug: y Verify patient s identification y Inform the patient with regards to drug administration y Clean the IV port prior to administration of the drug After the administration of drug: y Monitor patient for adverse effects y Inform patient that easy bruising may occur y Caution patient not to stop taking drug abruptly without first consulting prescriber
Brand Name: Ancef Generic Name: Cefazolin Sodium
1g/IV q 8 ANST x 1 more dose
First generation cephalosporin
The patient will verbalize
anti-infective drug that inhibits understanding of taking this cell-wall synthesis, promoting osmotic instability; usually bactericidal. medication
Brand Name: Amlodipine Besylate Generic Name: Norvasc
5 mg / tab OD
Antianginals. Inhibits calcium ion influx acriss cardiac and smooth- muscle cells, dilates coronary arteries and arterioles, and decreases blood pressure and myocardial oxygen demand.
The patient will verbalize understanding of taking this medication
Brand Name: Voltaren Generic Name: Diclofenac Sodium
75 mg/deep IM ANST needed
Nonsteroidal anti-
The patient will verbalize
inflammatory drug, may inhibit understanding of taking this prostaglandin synthesis, to produce anti-inflmmatory, analgesic and anti-pyretic effects. medication
G. Nursing management of physiologic, physical and psychosocial outcomes Problem # 1: Ineffective breathing pattern Assessment Nursing Diagnosis Ineffective breathing pattern r/t abdominal incision pain Scientific Explanation Full expansion of the lungs and diaphragm puts pressure on the abdomen causing irritation of the nerve endings resulting to pain. The patient fears pain and so she copes by breathing in a rapid shallow manner. Desired Outcome Short Term: After 4 of Nursing interventions, verbalize awareness of causative factors and initiate needed lifestyle changes Long Term: After 2 days of nursing interventions, the patient will establish a normal/ Interventions Rationale Expected Outcome
S: O: Patient may manifest: shallow breathing splinting breathing poor coughing effort increased anteriorposterior diameter
Establish rapport
Monitor and record vital signs, especially rate and depth or respirations
-to obtain trust and cooperation of the patient -to obtain baseline data for assessing condition
Short term: After 4 of nursing interventions, the patient shall have established a normal/ effective respiratory pattern Long term: After 2 days of nursing interventions, the patient shall have verbalized awareness of causative factors and initiate needed lifestyle changes
Auscultate lung sounds at least every 4 hours for -to assess if 48 hours there is postopratively diminished lung sounds Observe for splinting. - assess degree to which pain is contributing to
effective respiratory pattern
Assess for abdominal distention
splinting -to indicate presence of ineffective breathing pattern -to treat underlying cause resulting to correction of the problem
Manage pain using whatever plan for pain management has been prescribed
Help patient splint abdominal incision by using hands or a pillow
Encourage ambulation as tolerated
-to ease the discomfort of coughing and taking deep breaths -to enhance breathing and mobilization of secretions
Problem # 2: Constipation Assessment Nursing Diagnosis Constipation r/t physical factors: Abdominal surgery, with manipulation of bowel and weakening of abdominal musculature Scientific Explanation Too little fluid, too little fiber, inactivity or immobility and disruption of daily routines as brought about by surgery can result to constipation. Use of medications particularly analgesics and iron supplements ca cause constipation. Another factor that causes constipation is psychological Desired Outcomes Short Term: After 4 of nursing interventions, the patient will verbalize measures that will prevent recurrence of constipation Long Term: After 2 days of nursing interventions, the patient will pass soft, formed stool of a frequency perceived as normal by the Interventions Rationale Expected Outcome Short term: After 4 of nursing interventions, the patient shall have verbalized measures that will prevent recurrence of constipation Long Term: After 2 days of nursing interventions, the patient shall have passed soft, formed stool of a frequency perceived as normal by the
S: O: patient may manifest: (-) bowel movement tender abdomen upon palpation nausea and vomiting abdominal distention
Establish rapport
Monitor and record vital signs
- to obtain trust and cooperation of the patient -to obtain baseline data
Auscultate bowel sounds. Note abdominal distention and presence of nausea and vomiting Assess activity level
-indicators of presence/resolution of ileus, affecting choice of intervention
-prolonged bed rest, lack of exercise, and inactivity contribute to constipation Evaluate current -drugs that can
disorder such as stress and depression
patient
medication usage that may contribute to constipation
cause constipation are antidepressants and iron supplements -ignoring the defecation urge eventually leads to chronic constipation, because the rectum no longer senses or responds to stools. The longer stool remains in the rectum, the drier and harder (and more difficult to pass) it becomes -to help stimulate intestinal function and rectum peristalsis
patients
Assess degree to which patient s procrastination contributes to constipation
Assist patient with sitting on edge of bed and walking
Encourage
-to promote softer stool and to aid in
adequate fluid intake, including fruit juices, when oral intake is resumed
stimulating peristalsis
Problem # 3: Anxiety (Moderate) Assessment Nursing Diagnosis Anxiety (moderate) r/t intrusive surgical management and perceived threat to physical and chemical integrity Scientific Explanation Anxiety is a vague uneasy feeling of discomfort by autonomic responses. It is feeling of apprehension caused by anticipation of danger and is an alerting signal that warns of impending danger to enable the individual to take measures to deal with the Desired Outcome Short Term: After 4 of nursing interventions, the patient will verbalize awareness of feelings of anxiety and healthy ways to deal with them. Long Term: After 2 days of nursing interventions, the patient appear relaxed and report Determine how patient copes with anxiety Interventions Rationale Expected Outcome
S: O: Patient may manifest: restlessness diaphoresis dry mouth fatigue and weakness palpitations faintness/ dizziness anorexia crying
Establish rapport
-to obtain trust and cooperation of the patient -to obtain baseline data that will determine level of anxiety -to determine appropriate nursing intervention -to help determine the effectiveness of coping strategies currently used by the patient
Short Term: After 4 of nursing interventions, the patient shall have appeared relaxed and shall have reported anxiety was reduced to a manageable level Long Term: After 2 days of nursing interventions, the patient shall have verbalized awareness of feelings of anxiety and healthy ways to deal with them
Assess patient s level of anxiety
threat
anxiety is reduced to manageable level.
Acknowledge awareness of patient s anxiety
-to validate the feelings and communicates acceptance of those feelings -to help patient anticipate and prepare for difficult treatment/ movements, as well as look forward to pleasant occurrences -to reduce anxiety -to reinforce feeling of security for the patient -to enhance patient s sense of personal
Provide as much order and predictability as possible in scheduling activities, care, and visitors
Reduce sensory stimuli by maintaining quiet environment and keeping threatening equipment out of sight Encourage patient
to seek assistance from an understanding significant other or from health care provider when anxious feelings become difficult Assist the patient in developing anxiety- reducing skills
mastery and confidence
-to promote release of endorphins and to aid in developing internal focus of control
Encourage/ instruct patient in guided imagery/ relaxation techniques (e.g. imaging a pleasant place, deep breathing, and mindfulness).
-to aid in meeting basic human need, to decrease sense of isolation, and to assist patient to feel less anxious
Provide tough, therapeutic touch, massage, and other adjunctive therapies as indicated
-to enable the patient intervene more quickly in managing anxiety
Problem # 4: Risk for fluid volume deficit Assessment Nursing Diagnosis Risk for fluid volume deficit r/t blood loss during surgery Scientific Explanation In every surgery, there is a possibility for hemorrhage. This exists until all blood vessels cut and ligated during surgery have been thrombosed, sclerosed, and permanently closed. Desired Outcome Short Term: After 4 of nursing interventions, the patient will report understanding of causative factors for fluid volume deficit Long Term: After 2 days of nursing interventions, the patient will demonstrate behaviors to correct deficit as indicated Interventions Rationale Evaluation
S: O: Patient may manifest: postural hypotension decreased skin turgor dry mucous membranes decreased urine output
Establish rapport
-to obtain trust and cooperation of the patient -to obtain baseline data for assessing condition -to prevent hypovolemic shock
Short Term: After 4 of nursing interventions, the patient shall have reported understanding of causative factors for fluid volume deficit Long Term: After 2 days of nursing interventions, the patient shall have demonstrate behaviors to correct deficit as indicated
Monitor and report any postoperative bleeding
Weigh patient daily at the same -to time, using the indicate changes same scale in fluid balance Encourage frequent intake as tolerated
-to replace what
is being lost Administer IV fluid as ordered; prepare to increase fluid if signs of fluid volume deficit appear
-to correct fluid volume deficit
Provide oral hygiene every 4 hours Discuss factors related to dehydration Restrict caffeine and alcohol intake
-to prevent dry mouth -to build patient s awareness regarding the problem -to prevent diuresis
Problem # 5: Risk for Altered patterns of urinary elimination Assessment Nursing Diagnosis Risk for altered patterns or urinary elimination r/t mechanical trauma from bladder manipulation during surgery Scientific Explanation During surgery, the bladder was handled and displaced so its tone and ability to sense filling may be inadequate to initiate voiding after surgery Desired Outcome Short Term: After 4 of nursing interventions, the patient will verbalize understanding of the condition Long Term: After 2 days of nursing interventions, the patient will demonstrate behaviors/ techniques to prevent urinary infection Interventions Rationale Expected Outcome
S: O: Patient may manifest: incontinence/ retention bladder distention
Establish rapport
-to obtain trust and cooperation of the patient -to obtain baseline data -to indicate possible retention
Short Term: After 4 of nursing interventions, the patient shall have verbalized understanding of the condition Long Term; After 2 days of nursing interventions, the patient shall have demonstrated behaviors/ techniques to prevent urinary infection.
Monitor and record vital signs Note voiding pattern and monitor urinary output. Assess status of indwelling catheter
Assess amount of urine for three voids after catheter is removed.
-to assess if there is an incomplete bladder emptying -to assess signs of infection
Assess for continued signs of decreased bladder tone (e.g. dribbling, incomplete emptying, and sensations of fullness after voiding) Keep bladder deflated by inserting indwelling catheter as ordered Provide perineal care regularly
-to maintain normal renal function and to prevent UTI
-to prevent urinary retention
-to promote comfort and cleanliness, reducing risk of ascending urinary tract infection
V. Conclusion As a member of the healthcare team, the group should be involved in the promotion, preventive, curative and rehabilitative stages of their patient s condition. Uterine abnormalities and of the other parts of female reproductive system can be prevented at the primary, secondary and tertiary level. The group should inculcate to the perception and mind of the client about better care for vital organs or care for the whole body in general. A gift to continue replication is an important gift given by God so the group should not take it for granted and they should take good care of it in order to have a continuity of reproduction. The group has a big role in the maintenance and care for their patients. A major life-changing event like uterine myoma removal brings about a way for the patient to deal with her life. A major surgery like this brings about number of lessons. The group must take part on how the patients will have a smooth surgery and recovery. Presenting this kind of case report is something that the group did in order to understand the role of nurses not just in the operating room setting but also in the outside of their field. As nurses, the group should be able to impart knowledge about something that the group had been learned and be able to provide health teachings about preventing such diseases that may affect the female reproductive system. To finalize it, this is just one of the man y cases in the Operating room that the group should have to know as a student nurses and doing such case made the group prepared if in the near future , they will encounter this kind of surgery.
VI. Reference
Black, J.M., Hawks, J. H. (2009). Medical-surgical nursing: clinical management for positive outcomes. Vol.2. New York. Saunders. Gutierrez, K. J., Peterson, P.G. (2007). Saunders sursing survival guide pathophysiology. 2nd Edition. New Orleans Louisiana. Saunders & Elsevier. Hole, J.W. (1993). Human anatomy and physiology. 6th edition. Dubuque, IA. Wm C. Brown Publishers, inc Huether, S.E., McCance, K.L. (2000). Understanding pathophysiology. 2nd edition. Singapore: Elsevier Science. Karch, A. M. (2000). Lippincott s nursing drug guide 2000 . University of Michigan. Lippincott, Williams, & Wilkins. Porth, Carol M., (2005). Pathophysiology: Concepts of altered health states. 7th Edition. Boston: Lippincott, Williams, & Wilkins Lubin, et al. Medical Management of Surgical Patient, Third Edition p.684-685

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I.

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ANATOMY & PHYSIOLOGY

genitalia, and mammary glands. The internal reproductive

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Predisposing Factors: -Age -Race -Heredity -Early Menarche -Nulliparity

Estrogen Dominance or increase in Estrogen production

* Classified according to area of growth: intramural, submucous, & subserous

Proliferation of cells in uterus*

S/sx: -Swelling of breasts -Depression -Loss of sex Drive -Dysmenorrhea

Myoma: Development of uterine fibroid

excessively thickened endometrium

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S/sx: -Pain -Increased pelvic Pressure - An abnormally enlarged abdomen

Interference in the vascular supply

Deterioration of the surrounding tissues

replace smooth muscle cells by fibrous connective tissue

Degeneration of the interior part of fibroid

S/sx: -hypermenorrhea -Abnormal bleeding

fibroid continually grows and its size

pressure on the adjacent organs (bladder and rectosigmoid)

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b. Definition of the Disease Uterine Leiomyomas

are the most common pelvic tumors of reproductive-age

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hypertension or cardiac arrhythmias but is most useful in healthy premenopausal patients.

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pickup forceps and incised with sharp curved Mayo scissors.

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ligament as it attaches to the lower uterine segment.

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The uterosacral ligament is cut with curved Mayo scissors.

A Heaney fixation 0 synthetic absorbable suture is used to suture-ligate the

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