Download Nursing Interventions

CARE OF THE
GYNECOLOGICAL PATIENT
PART 2
EFREN N. AQUINO M.D.
OCT 13, 2009
1
Cancer: The second most common cause of
death in women, and malignant tumors of
the reproductive tract represent a
significant portion of the total number of
deaths from cancer
 Cervical cancer is the sixth most common
cancer of women
1)
2)
3)
4)
5)
breast
colon and rectum,
endometrium,
lung, and
ovary
2
Cancer of the Female Reproductive Tract
Cervical cancer often affects women in their
reproductive years. The cancer can be
detected in its early stages with a
diagnostic Pap test.

Cancer of the cervix: Pathophysiology
– Squamous cell carcinoma diagnosed in early
stage by Pap smear.
– Carcinoma in situ – Microscopic, preinvasive,
asymptomatic, 100% curable
– If untreated, invades the vagina, pelvic wall,
bladder, rectum, and regional lymph nodes
3

Cancer of the cervix: Etiology
– Closely linked to sexual behavior and STD
with HPV
– Increased risk
 Sexually active during teens
 Multiple sexual partners
 Multiple births
 DES during pregnancy
 Smokers, chronic infections and
erosions of the cervix
4
Cancer of the Cervix (cont)

Clinical manifestations/assessment
– Silent to few symptoms in early stages
 Leukorrhea
 Irregular vaginal bleeding; spotting between
menses
 Bleeding often occurs after coitus or after
menopause
 Vaginal exudate is watery at first then
becomes dark to bloody with offensive odor
– Advanced
 Pain in the back, upper thighs, and legs
5
Cancer of the Cervix (cont)

Diagnostic tests: The following tests are
performed to determine the presence of
cervical cancer:
(1) Pap test
(2) Schiller’s test
(3) Physical examination - internal
examination
(4) cervical biopsy and
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Cancer of the Cervix (cont)

Diagnostic tests:
other additional studies, such as a :
 computed tomography (CT) scan,
 chest radiographic evaluation,
 intravenous pyelogram,
 cystoscopy,
 sigmoidoscopy, or
 liver function studies to determine the
extent of invasion.
7
Cancer of the cervix (cont)

Medical management
– Carcinoma in situ
 Removal of the affected area (electrocautery,
cryosurgery, laser, conization)
– Early carcinoma
 Hysterectomy
 Intracavitary radiation
– Advanced carcinoma
 Radical hysterectomy with pelvic lymph node
dissection
 Radiation and chemotherapy
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Nursing Interventions and Patient
Teaching
Nursing interventions should include verbal
reassurance.
 In advanced cancer of the cervix, the nurse
should position the patient comfortably;
change her position slowly; maintain her
body alignment; provide pain relief
measures; change the patient’s dressing and
sanitary pads frequently; and assess color,
odor, and amount of drainage.
 The skin is assessed for impairment.

12
Prognosis
The prognosis is good if the cancer is treated in
the early stages. It usually takes 2 to 10 years for
squamous cell carcinoma to become invasive.
Therefore early diagnosis and treatment are vital
for survival.
 Survival for people with preinvasive lesions is
nearly 100%. Ninety percent of cervical cancer
patients survive 1 year after diagnosis, and 71%
survive 5 years. When detected at an early stage,
invasive cervical cancer is one of the most
successfully treated cancers with a 5-year survival
rate of 92% for localized cancers.

13
Cancer of the Endometrium

Etiology/pathophysiology
It is the most common malignancy of the
female genital tract. Those groups at
increased risk are:
 those with a history of irregular
menstruation, difficulties during
menopause, obesity, hypertension, or
diabetes mellitus;
 those who have not had children; and
 those with a family history of cancer of
the uterus.
14
Cancer of the Endometrium

Etiology/pathophysiology, CONT..2
 Women who have used estrogen
replacement therapy to treat
menopausal symptoms have a greater
likelihood of developing endometrial
cancer.
 Women on tamoxifen are also at
increased risk for developing uterine
cancer.
15
Cancer of the Endometrium

Clinical manifestations/assessment
– Postmenopausal bleeding (50% will have
cancer)
– Abdominal pressure; pelvic fullness

Medical management/nursing interventions
– Surgery: total abdominal hysterectomy with
bilateral salpingo-oophorectomy (TAH-BSO)
– Radiation; chemotherapy
16
Prognosis
 Cancer of the endometrium is primarily a
slow-growing adenocarcinoma.
 Metastasis occurs late, and the sign of
irregular vaginal bleeding often appears
early enough to allow for cure of the
disease.
 Stage1 tumors have the highest 5-year
survival rate (about 94%).
17
Cancer of the ovary
– Etiology/pathophysiology
 Fourth most common cause of cancer
death in women
 Leading cause of gynecologic death in
the USA
 High risk: infertile; anovulatory;
nulliparous; habitual aborters; high-fat
diet; exposure to industrial chemicals
18

Cancer of the ovary (continued)
– Clinical manifestations/assessment
 Early
–Vague abdominal discomfort
–Flatulence; mild gastric disturbance
 Advanced
–Enlarged abdominal girth
–Flatulence; constipation
–Urinary frequency
–Nausea and vomiting
–Weight loss
19
20
Diagnostic Tests
 Ovarian cancer is diagnosed by palpation of
a pelvic mass and aspiration of ascitic fluid
and detection of cancer cells in the fluid. A
blood test to determine CA-125 and vaginal
ultrasonography are used to identify women
with ovarian cancer
21

Cancer of the ovary (continued)
– Medical management/nursing
interventions
 Surgery
–TAH-BSO and omentectomy
 Radiation and/or chemotherapy
22
Nursing Interventions
Because ovarian cancer is generally at an
advanced stage when diagnosed, despite
the woman’s feeling well, support and
encouragement to comply with the
treatment regimen are important nursing
interventions.
 As the disease progresses, the nurse will
become involved in activities to increase the
patient’s comfort.

23
Prognosis
 More than 60% of women with ovarian
cancer are diagnosed with advanced
disease.
 The 5-year survival rate
– stage 1 tumors is 60% to 70%;
– stage II tumors, the survival rate is 0% to
40%.
– stage III and IV it is extremely poor.
 By the time most cases are diagnosed,
the 5-year survival rate is below 20%.
24
Hysterectomy
Total hysterectomy
– Removal of the uterus including the cervix
 TAH-BSO
– Removal of the uterus, fallopian tubes,
and ovaries
– panhysterosalpingo-oophorectomy
 Radical hysterectomy
– TAH-BSO with removal of the pelvic lymph
nodes

25
A hysterectomy involves the removal of the
uterus, including the cervix.
 This procedure may be done for many
conditions, such as:
1. dysfunctional uterine bleeding,
2. endometriosis,
3. malignant and nonmalignant tumors of
the uterus and cervix, and
4. disorders of pelvic relaxation and
uterine prolapse.

26
Hysterectomy
Vaginal hysterectomy
– The uterus is removed through the vagina
 Abdominal hysterectomy
– Abdominal incision is made to perform
procedure

27

Vaginal hysterectomy: A vaginal
hysterectomy may be done for a prolapsed
uterus.
– It is not used nearly as often as the
abdominal approach.
– The vaginal approach is selected for the
patient who cannot tolerate abdominal
surgery or prolonged anesthesia.
– There is no abdominal incision.
– The patient is placed in lithotomy position,
and the uterus is removed through the
vagina.
28

Advantages of the vaginal entrance are
that:
(1) there is no wound dehiscence,
(2) there is less pain,
(3) complications are less likely,
(4) hospitalization is shorter, and
(5) there is no abdominal scar.
29
Vaginal Hysterectomy
The most important disadvantage is a
limited view of the operative field for
visualizing intrapelvic and intraabdominal
organs.
 Vaginal hysterectomy is not used in cases of
uterine fibroids or enlarged uterine size.
 Other disadvantages are risk of bleeding
and postoperative infection.

30
31
ABDOMINAL HYSTERECTOMY
 An abdominal hysterectomy is preferred
when there is a need to explore the pelvic
cavity and if the fallopian tubes and ovaries
are to be removed.
 There are three procedures for an abdominal
hysterectomy
1) Subtotal hysterectomy
2) Total hysterectomy
3) TAH-BSO
32

Three procedures for an abdominal
hysterectomy, explained
1) Subtotal hysterectomy refers to the removal
of the corpus (the midsection or body) of the
uterus and leaves the cervical stump in
place.
2) Total hysterectomy is the removal of the
entire uterus, including the cervix, but leaves
the fallopian tubes and ovaries in place.
3) TAH-BSO involves the removal of the entire
uterus, the fallopian tubes, and the ovaries.
33
34
Nursing Interventions
Preoperative interventions.
1) The nurse reinforce the explanation of
operative procedure and answer any
questions the patient might have.
2) The nurse should encourage verbalization
of fears.
3) The nurse should instruct the patient how
to turn, cough, and deep breathe.
35
Nursing Interventions
Preoperative interventions.
4) the colon is emptied to prevent
postoperative distention.
5) The patient is placed on a low-residue diet
for several days preoperatively.
6) Enemas maybe given the evening before
surgery.
36
Nursing Interventions
Preoperative interventions.
7) The bladder may be decompressed to
prevent trauma during surgery. The
indwelling catheter will generally remain in
place for 1 to 2 days after surgery.
8) An antiseptic vaginal douche may be
ordered to decrease microbial invasion of
the surgical site.
9) If the surgeon anticipates excessive manipulation
of the intestines, a nasogastric tube may be
inserted to prevent abdominal distention.
37
Nursing Interventions
Preoperative interventions.
10) Surgical preparation of the skin includes
the surgical prepping of the abdomen,
pelvis, and perineum.
11) The patient will sign a consent form, and
oral intake after midnight will be restricted.
38
Nursing Interventions
Postoperative interventions
1) Monitor vital signs
2) Catheter care to prevent bladder infection
3) Prevent urinary retention
4) Prevent intestinal distention
5) Prevent venous thrombosis
6) Early ambulation to return the bowel to
normal function
39
Nursing Interventions
Postoperative interventions
7) The patient should avoid bending her
knees. This could cause pooling of blood
in the pelvic cavity, resulting in stasis in the
lower extremities.
8) The patient at risk for thromboembolic
disease may receive low-dose heparin to
prevent thrombus formation.
9) The nurse will observe the abdominal
dressing on the patient with an abdominal
hysterectomy for evidence of hemorrhage.
40
Nursing Interventions
Postoperative interventions
Surgical asepsis is carried out for the
dressing change.
10) The patient usually receives intravenous
feedings for several days postoperatively.
41


Patient Teaching
Before the patient’s discharge, the
physician will explain to the woman and
her partner that there should be no sexual
intercourse for 4 to 6 weeks after surgery.
If with an abdominal incision, there may be
further restrictions on heavy lifting
(nothing greater than 10 pounds), walking
up and down stairs, and prolonged riding
in the car. Riding in the car may cause
pelvic pooling and development of a
thrombus in the legs.
42


Patient Teaching, cont…2
The patient should know that vaginal
drainage is normal for about 2 to 4 weeks
after an abdominal hysterectomy.
The patient should avoid wearing any tight
clothing such as a girdle or knee-high
hose, which might constrict circulation to
the surgical site and cause venous stasis.
43

Patient Teaching, cont..3
There are several signs and symptoms of
infection that should be reported to the
physician if they occur:
(1) erythema, edema, exudates, or increased
tenderness along the surgical incision;
(2) increased malodorous vaginal exudates;
(3) a temperature of 101oF (38.3oC) or more; and
(4) any problems with urinating, such as difficulty
in starting to void, voiding too often, voiding
small amounts, or a burning sensation while
urinating (indicative of a bladder infection).
44
DISORDERS OF THE FEMALE BREAST
B. Lymphatic
drainage of the
breast.
(From Seidel, H.M., Ball, J.W., Dains, J.E., Benedict, G.W. [2003]. Mosby’s guide to physical
examination. [5th ed.]. St. Louis: Mosby.)
45
46
Disorders of the Female Breast

Fibrocystic breast condition
– Etiology/pathophysiology
 Hyperplasia and cystic formation in mammary
ducts
– Clinical manifestations/assessment
 Cysts are soft, well-differentiated, tender, and
freely moveable; often bilateral and multiple
– Diagnostic Tests
 The disorder is diagnosed by mammography
or ultrasound and confirmed by biopsy.
47
Fibrocystic Breast Disorders
Symptoms follow a periodic trend tied
closely to the menstrual cycle.
 Symptoms tend to peak immediately
before each period and decrease
afterwards. At peak, breasts may feel full
and swollen.
 No complications related to breastfeeding
have been found.

48
Medical Management
 Needle aspiration
 Danazol (danocrine) – inhibits FSH and
LH production thus decreasing
estrogen production by the ovaries
 Eliminate methylxanthines
 Vitamin E
Nursing Interventions and Patient Teaching
– The nurse should instruct the patient to
perform BSE 1 week after menses and
be able to recognize the presence of
cysts and note any changes.
49
Fibroadenoma of the breast
A benign fibroepithelial tumor characterized
by proliferation of both glandular and
stromal elements of the breast.
Etiology and epidemiology


They are the most common breast tumor in
adolescent women.
Their incidence declines with increasing age,
and they generally appear before the age of
thirty years, probably partly as a result of
normal estrogenic hormonal fluctuation.
50
Fibroadenoma, CONT..2
Signs and symptoms
The typical case is the presence of a painless,
firm, solitary, mobile, slowly growing lump in
the breast of a woman of childbearing years.
Diagnosis
A fibroadenoma is usually diagnosed through
clinical examination, ultrasound or
mammography, and often a needle biopsy
sample of the lump.
Management:
 Surgery or cryoablation
51

Acute Mastitis
– Etiology/pathophysiology
 Acute bacterial infection of the breast
– Clinical manifestations/assessment
 Breasts are tender, inflamed, and engorged
– Medical management/nursing interventions
 Keep breasts clean
 Application of warm packs
 Support: well-fitting bra
 Systemic antibiotics
52

Chronic Mastitis
– Etiology/pathophysiology
 Fibrosis and cysts in the breast
– Clinical manifestations/assessment
 Tender, painful, and palpable cysts
 Usually unilateral
– Medical management/nursing
interventions
 Same as for acute mastitis
53
Breast Cancer
 The most common malignancy affecting
women in the United States.
Approximately 1 of every 8 women will
develop breast cancer during her lifetime.
 Breast cancer ranks second among cancer
deaths in women (after lung cancer).
54
Breast Cancer, cont..2
 Women consider this disease their most
serious health problem.
 Vital to the process of detection are monthly
BSE, breast imaging with mammography and
other diagnostic studies to detect small
tumors before they can be palpated, and
periodic breast examinations by a physician.
55
Predisposing Factors for Women at High
Risk for Breast Cancer
1. Gender: being a female introduces a high risk.
2. Age: higher incidence occurs with women older
than 40 years of age and in the postmenopausal
phase of life.
3. Race: white, in the middle or upper
socioeconomic class.
4. Genetics: the inherited susceptibility genes BRCA1
and BRCA2, account for approximately 5% of all
cases and confer a lifetime risk in these women,
ranging from 35% to 85%.
56
Predisposing Factors for Women at High
Risk for Breast Cancer, cont..2
5. Parity (total number of pregnancies): decreased
for women if birth is before 18 years; increased for
women who are not sexually active, infertile
women, and women who become pregnant after
35 years of age.
6. Menopause: menopause after 55 years of age.
7. Other cancer: had another cancer such as
endometrial, ovarian, and colon; if cancer has
appeared in one breast, it is more likely to occur in
the other breast.
57
Breast Cancer, cont.. 3
 Etiology/pathophysiology
 Unknown cause; usually adenocarcinoma
 Other risk factors include:
– early menarche,
– a first pregnancy after age 30,
– natural menopause after age 55, and
– having one or more breast cancer genes.
 The most common sites for metastasis are, in
order: bones, lungs, pleura, breast site,
central nervous system, and liver.
58

Breast Cancer, cont.. 4
 Clinical
manifestations/assessment
 Occurs most often in the upper outer
quadrants of the breasts of women who have
not given birth or breastfed a child.
 Small, solitary, irregular-shaped, firm, nontender, and non-mobile tumor
 Change in skin color
 Puckering or dimpling of tissue
 Nipple discharge; retraction of nipple
 Axillary tenderness
59
Diagnostic Tests

The essential factors in the early detection of
breast cancer are the regular performance of BSE,
regular clinical breast examination (CBE), and
routine mammography.
Current guidelines accepted by the
American Cancer Society.
Monthly BSE starting at 20 years of age.
 Physical examinations of the breast by a trained
health professional; CBE every 3 years between 20
and 40 years of age and every year thereafter.
 Screening mammography annually beginning at 40
years of age.

60
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Breast Self-Examination
1. The majority of breast lumps are not cancer.
2. Cancerous breast lesions are treatable.
3. Breasts should be examined by
premenopausal women each month, 7 to 8
days after conclusion of the menstrual period
when they are least congested, and on the
same day of each month for postmenopausal women.
4. Visual inspection and palpation should be
done.
63
Breast Self-Examination, cont..2
5. Visual inspection should be done when the
woman is stripped to the waist and looking
in a mirror, using the following arm
positions:
(a) arms at rest at sides,
(b) hands on hips and pressed into hips,
(c) contracting chest muscles,
(d) hands over the head (torso in upright
position),
(e) hands over head (torso leaning
forward).
64
Breast Self-Examination, cont..3
6. Palpation may be done in the shower when the
soap and water assist the hands to glide over the
skin. However, the examination of large breasts
and axillae is better done in a supine position rather
than a standing position.
7. The entire breast should be examined in a
systematic way, moving clockwise, with a circular
motion. Always include the axillae in the
examination.
8. Specific examination of the nipple, through
compression for discharge, and the areola, through
palpation, should not be forgotten.
9. Any changes should be reported to the physician,
particularly if there’s a discharge.
65

Several techniques can be used to
screen for breast disease or provide a
diagnosis of a suspicious physical
finding.
– Mammography: In younger women,
mammography is less sensitive because
of the greater density of breast tissue,
resulting in more false-negative results.
– Tissue biopsy: most definitive
66

Several techniques can be used to
screen for breast disease, cont..2
– Ultrasound (echogram, sonogram) is
another diagnostic procedure that can be
used to differentiate a benign cyst (fluidfilled) from a malignant mass (solid).
– Other methods that are used to help
diagnose and stage breast cancer include
magnetic resonance imaging (MRI) and
positron emission tomography (PE).
67
Sentinel lymph node mapping Diagnostic tool used prior to therapeutic
surgery which identifies the first lymph node
most likely to drain the cancerous cells.
 Estrogen and Progesterone receptor
status – Hormone receptor: Another
diagnostic test useful both for treatment
decisions and prediction of prognosis

68
Hormone Receptor-positive tumors
(1) show evidence of being well
differentiated
(2) frequently have a more normal DNA
content and low proliferation;
(3) have a lower chance for recurrence,
(4) are frequently hormone dependent and
responsive to hormonal therapy.
69
Hormone Receptor-negative tumors
(1)poorly differentiated,
(2)have a high incidence of abnormal DNA
content and high proliferation,
(3)frequently recur, and
(4)are usually unresponsive to hormonal
therapy (Lewis et al, 2004).
70
HOW BREAST CANCER IS STAGED
 Breast cancer is staged using the TNM
(tumor, node, metastasis) system
 Tumor.
– A number from 0 to 4 indicates the tumor’s size
and whether it has spread to nearby tissue.
– (Tis indicates a carcinoma in situ.) Higher
numbers indicate a larger tumor or wider
spread.
 For example, a tumor labeled t1 is 2 cm or
smaller, T4 indicates a tumor of any size that
has spread to the chest wall or the skin.
71
HOW BREAST CANCER IS STAGED, cont..2
 Nodes. A number from 0 to 3 indicates
whether the cancer has spread to
surrounding lymph nodes and, if so, the
number of nodes that are affected.
– For example, N1 indicates a spread to 1,2
or 3 lymph nodes under the arm on the
same side as the breast cancer.
 Metastasis. MO means the cancer has not
spread to distant organs; M1 means the
cancer has metastasized to other organs.
72
All of the above information is combined to
determine an overall stage of 0 to IV.
Stage 0; Refers to carcinoma in situ, in which the
tumor is confined to the milk duct or the lobule, no
nodes have been affected, and no metastasis has
occurred.
Stage 1: The tumor is 2 cm or smaller. Lymph nodes
are negative. There is no distant cancer spread.
Stage IIA: The tumor is 5 cm or smaller. It may have
spread to 1,2,or 3 axillary nodes. There is no distant
cancer spread.
Stage IIB: The tumor can be larger than 5 cm. Up to
three lymph nodes may be involved, but there is no
metastasis to other organs.
73
All of the above information is combined to
determine an overall stage of 0 to IV,
cont..2
Stage IIIA: The tumor can be larger than 5 cm and
has spread to more than 3 but fewer than 10
lymph nodes. No distant organs are involved.
Stage IIIB: The tumor, regardless of size, has spread
to the chest wall or the skin. There is lymph node
involvement but no distant metastasis.
Stage IIIC: Refers to any size tumor, including one
that has spread to the chest wall or the skin.
There is involvement of 10 or more lymph nodes,
but no distant metastasis.
Stage IV: The tumor can be any size. There is nodal
involvement and metastasis to distant organs.
74
Several surgical approaches may be
selected for the removal of the breast
carcinoma.
1) Breast conservation surgery (termed
lumpectomy), which conserves the breast,
is the removal of a circumscribed area
along with the tumor. (excision-biopsy)
2) A partial mastectomy is another form of
segmental mastectomy in which the
quadrant of the breast where the tumor is
located, is removed.
75
Several surgical approaches may be
selected for the removal of the breast
carcinoma.
3) A simple mastectomy is the removal of the
entire breast.
4) A modified radical mastectomy may be
performed when the tumor is 4 cm or
larger.
** Statistics show that Lumpectomy with
radiation has about the same 10-year
survival rate as the modified radical
mastectomy.
76
Adjuvant therapies
Radiation therapy.
 The three situations in which radiation
therapy may be used for breast cancer are
(1) as the primary therapy to destroy the
tumor or as a companion to surgery to
prevent local recurrence;
(2) to shrink a large tumor to operable size;
and
(3) as the palliative treatment for pain
caused by local recurrence and metastasis.
77
Adjuvant therapies
 External beam radiation
 Internal radiation, also known as implant
radiation or brachytherapy, is now used
78
Chemotherapy. Regimens for node-negative
disease (i.e., cancer that has not spread to
the lymph nodes) include:
1. cyclophosphamide (Cytoxan, Neosar),
methotrexate, and 5-fluorouracil (Adrucil,
Efudex), referred to as CMF;
2. cyclophosphamide, doxorubicin
(Adriamycin), and 5-fluorouracil, or CAF;
3. and doxorubicin and cyclophosphamide,
commonly called AC.
79
Chemotherapy, cont..2
For those with node-positive disease, the
regimens include CAF, AC followed by
paclitaxel (Taxol), doxorubicin (Adriamycin),
followed by CMF
The most common adverse effects of
traditional antineoplastic drugs are bone
marrow suppression (which causes anemia,
thrombocytopenia, and leukopenia), nausea
and vomting, alopecia, weight gain,
mucositis, and fatigue
80
Hormonal therapy.
– Hormonal therapy removes or blocks the
source of estrogen, thus promoting tumor
regressions.
– Tamoxifen (also known as Nolvadex) is a
synthetic compound similar to estrogen.
It mimics the action of estrogen on the
bones and uterus, but blocks the effects
of estrogen on breast tissue.
 Tamoxifen is the hormonal agent of
choice in postmenopausal, estrogen
receptor-positive women with or
without lymph node involvement.
81
Hormonal therapy.. cont 2
– Toremifene (Fareston), an antiestrogen
agent similar to tamoxifen, is indicted as
first-line treatment for metastatic breast
cancer in postmenopausal women with
estrogen receptor-positive or estrogen
receptor-unknown tumors.
– Fulvestrant (Faslodex) may be given to
women with advanced breast cancer who no
longer respond to tamoxifen. This drug slows
cancer progression by destroying estrogen
receptors in the breast cancer cells.
82
Hormonal therapy.. cont 3
– Aromatase inhibitor drugs, which interfere
with the enzyme that synthesizes
endogenous estrogen, are used to treat
advanced breast cancer in
postmenopausal women with disease
progression.
 These drugs include anastrozole
(Arimidex), letrozole (Femara), vorozole
(Rizivor), exemestane (Aromasin), and
aminogluthethimide (Cytadren).
83
Hormonal therapy.. cont 4
– Raloxifen (Evista), used to prevent bone
loss, may also reduce the risk of breast
cancer without stimulating endometrial
growth. Raloxifen acts as an estrogen
antagonist at the hormone-sensitive
tissues of breast cancer and bone.
– Additional drugs that may be used to
suppress hormone-dependent tumors
include megestrol (Megace),
diethylstilbestrol (DES), and
fluoxymesterone (Halotestin) (Lewis et al,
2004).
84
Monoclonal antibody therapy - A recent
drug treatment for breast cancer is the
monoclonal antibody trastuzumab
(Herceptin). It is used to treat metastatic
breast cancer.
 Ovarian ablation. Another promising
treatment option is ovarian ablation by
means of a bilateral oophorectomy, which is
used in combination with tamoxifen for
metastatic disease.

85

Bone marrow and stem cell
transplantation.
Autologous (i.e., originating within self)
bone marrow or stem cell transplantation
combined with high-dose chemotherapy has
been used to treat patients with advanced
metastatic breast cancer.
86
Nursing Interventions
 The nurse plays an active role as listener
and reinforcer of information provided by
the physician and as a provider of responses
that can encourage and assist the patient to
verbalize her concerns and recognize her
feelings about the surgery.
 Need for the patients support system which
will openly discuss the patient’s fears
 Reach to Recovery is a source of
information, encouragement, and support
for women with breast cancer.
87
Nursing interventions for patients who
undergo modified radical mastectomy
include monitoring vital signs and observing
for symptoms of shock or hemorrhage.
 Drains such as Jackson-Pratt, Davol, or
Hemovac may be placed in the axilla to
facilitate drainage and prevent formation of
a hematoma.

88
Postoperatively, when the vital signs are
stable, the patient is placed in a 45-degree
Fowler’s position to promote drainage.
 Deep breathing and coughing are
encouraged.
 Pain management and wound care will be
priorities.

89
Patient Teaching
 It is important for the patient to deep
breathe and cough to prevent postoperative
atelectasis.
 Patients should be taught not to have any
procedures involving the arm on the affected
side – BP readings, injections, intravenous
infusion of fluids, or the drawing of blood,
which may cause edema or infection-and to
guard against infections from burns, needle
pricks (sewing), and gardening injuries.
90
Patient Teaching, cont..2
 An exercise regimen, built up gradually, can
help decrease lymphedema among other
things.
 Instruct the patient to avoid lifting heavy
objects with the affected arm for 6 to 8
weeks
 Clothing on the affected arm should be
nonconstricting.
 The patient should b instructed to avoid
sleeping on the involved arm.
91
Exercises:
1. Regain and increase muscle strength
2. Improve circulation
3. Prevent muscular contractures
Postoperative
1. Body image acceptance
 Prosthesis
 Breast Reconstruction
 Breast implant
92
Prognosis and Nodal Involvement
in Breast Cancer
LYMPH NODES
INVOLVED
1 to 3 nodes
4 to 10 nodes
10 nodes
METASTATIC
RECURRENCE
 50% to 60% metastasis
 75% to 85% metastasis
 Even worse prognosis

93
Prognosis
 The 5-year survival rate for localized breast
cancer is 85% for white women and 79%
for African-American women. After the
disease spreads beyond the breast, the
survival rate drops dramatically.
 Breast cancer is the leading cause of cancer
deaths among women 15 to 54 years of
age. The most important prognostic factor
is the stage of the disease
94
Sexually Transmitted Diseases
STDs, previously called venereal diseases,
are infections that are usually transmitted
during intimate sexual contact.
 Other routes of transmission (e.g., an
infected mother to her newborn), occur with
or without symptoms, and have long periods
of asymptomatic infectivity.

95
Sexually Transmitted Diseases..2
Any sexually active person may be at risk for
an STD.
 People who have frequent sexual contact
with multiple partners are at increased risk.
 Common characteristics of these individuals
are young, single, urban, poor, male, and
homosexual.

96
Sexually Transmitted Diseases..3
STDs continue to be among the world’s most
common communicable diseases.
Four main factors are responsible:
(1) unprotected sex,
(2) antibiotic resistance,
(3) treatment delay, and
(4) sexual behavior patterns and
permissiveness
97
Genital herpes: herpes simplex virus
type II - HSV
 Etiology/pathophysiology
– Infectious viral disease; usually acquired
sexually

Clinical manifestations/assessment
– Fluid-filled vesicles
– Eventually rupture and develop shallow,
painful ulcers
– Fever; malaise
– Dysuria
– Leukorrhea (female)
98
Herpes simplex virus type II in a male and
female patient.
99
Genital herpes (herpes simplex virus
type II) HSV,Cont…

Medical Management/nursing
interventions
 No cure; treat symptoms
 Acyclovir (Zovirax), Valacyclovir (Valtrex),
Famciclovir (Famvir)
 Sitz baths
 Local anesthetic; analgesics
 Keep lesions clean and dry
 GOOD handwashing
 No sexual contact while lesions are present
100
 Encourage use of condoms
 Syphilis
– Etiology/pathophysiology
 Treponema pallidum organism
 Transmission occurs primarily with sexual
contact
– Clinical manifestations/assessment
 Incubation period
–No symptoms
 Primary stage
–Chancre; headaches; enlarged lymph
nodes
101
Syphilis (cont)
Clinical manifestations/assessment
 Secondary stage
– Rash on palms of hands and soles of feet
– Generalized enlargement of lymph nodes

Latent stage
– No symptoms

Tertiary or late stage
– Lesions may affect many different systems;
– Cardiovascular, destruction of the aorta
– Dementia, tabes dorsalis (locomotor ataxia)
– Can be fatal
102
Syphilis (cont)

Medical management/nursing
interventions
– Penicillin
– Tetracycline or erythromycin, if allergic to
penicillin
– May be treated in any stage; damage will
not be reversed
– Treat all sexual contacts
103
Gonorrhea

Etiology/pathophysiology
– N. gonorrhoeae
– Transmitted by sexual contact

Clinical manifestations/assessment
– Vaginal (female)
– Urinary frequency and pain
– Yellowish discharge
– Nausea and vomiting
104
Gonorrhea (cont)
Clinical manifestations/assessment (continued)
 Urethra
– Urethral discomfort; dysuria
– Yellowish discharge containing pus
– Red and swollen meatus

Rectal (male and female)
– Perineal discomfort; purulent rectal discharge

Pharyngitis (male and female)
– Tonsillitis and pharyngitis
– Sore throat and swallowing discomfort
– Edema of the throat
105
Gonorrhea (cont)

Medical management/nursing
interventions
– Penicillin
– Rocephin
– Doxycycline or tetracycline

TREAT ALL SEXUAL CONTACTS
106
Trichomoniasis

Etiology/pathophysiology
– Protozoan T. vaginalis
– Usually sexually transmitted
– Can be caused by frequent douching, oral
contraceptives which raises vaginal pH

Clinical manifestations/assessment
– Most are asymptomatic
– Male: urethritis, dysuria, urinary frequency,
pruritus, and purulent exudate
107
Trichomoniasis
Clinical manifestations/assessment
(cont)

Female
– Frothy, gray, green, or yellow malodorous
discharge
– Pruritus
– Edema
– Tenderness of vagina
– Dysuria and urinary frequency
– Spotting; menorrhagia; dysmenorrhea
108
Trichomoniasis (cont)

Medical management/nursing
interventions
– Metronidazole (Flagyl): can turn urine
into dark orange or brown
– TREAT ALL SEXUAL CONTACTS
109
Candidiasis

Etiology/pathophysiology
– Fungal infections with C. albicans and C.
tropicalis

Clinical manifestations/assessment
– Mouth: edema; white patches
– Nails: edematous, darkened, erythematous nail
base; purulent exudate
– Vaginal: cheesy, tenacious white discharge;
pruritus; inflammation of the vagina
– Penis: purulent exudate
– Systemic: chills; fever; general malaise
110
Candidiasis (cont)

Medical management/nursing interventions
– Treat underlying condition
– Nystatin (Mycostatin)
– Topical amphotericin B
111
Chlamydia
Etiology/pathophysiology
– Chlamydia trachomatis: Caused by Gram
negative bacteria, the most common
sexually transmitted disorder in the US.
 Clinical manifestations/assessment
– Usually asymptomatic
– Male
 Scanty white or clear exudate
 Burning or pruritus
 Urinary frequency; mild dysuria

112
Chlamydia (cont..2)
Clinical manifestations/assessment
– Female
 Vaginal pruritus or burning
 Dull pelvic pain
 Low-grade fever
 Vaginal discharge; irregular bleeding
 Medical management/nursing interventions
– Tetracycline; doxycycline; Zithromax
 TREAT ALL SEXUAL CONTACTS

113
Nursing Process

Nursing diagnoses
– Anxiety
– Body image, disturbed
– Coping, ineffective
– Fear
– Fluid volume, deficient
– Health maintenance,
ineffective
– Infection, risk for
 Knowledge, deficient
 Pain, acute and
chronic
 Self-esteem,
situational low
 Sexual dysfunction
 Skin integrity,
impaired
 Tissue perfusion,
ineffective
 Urinary elimination,
impaired
114
DONE !!
115