Download This is chapter 73

This is chapter 73
Care of Patients with
Breast Disorders
Benign Breast Disorders
• Fibroadenoma, most common cause of
breast masses during adolescence; may
occur in patients in their 30s
• Solid, slowly enlarging, benign mass;
round, firm, easily movable, nontender, and
clearly delineated from the surrounding
tissue
• Usually located in the upper outer quadrant
of the breast
Fibrocystic Breast Condition
• Fibrocystic changes of the breast that
include a range of changes involving the
lobules, ducts, and stromal tissues of the
breast
• Most often occurs in premenopausal women
between 20 and 50 years of age
• Thought to be caused by an imbalance in
normal estrogen-to-progesterone ratio
Collaborative Management
• Symptomatic management
• Hormonal manipulation
• Drug therapy—vitamins C, E, and B
complex
• Diuretics
• Avoidance of caffeine
• Reduction of dietary fat
• Mild analgesics
Collaborative Management
(Cont’d)
• Limited salt intake before menses
• Well-padded supportive bra
• Local application of heat or ice for pain
relief
Ductal Ectasia
• Benign breast problem of women
approaching menopause; caused by dilation
and thickening of the collecting ducts in the
subareolar area
• Mass that is hard with irregular borders,
tender
• Greenish brown nipple discharge, enlarged
axillary nodes, and edema over the site of
the mass
Intraductal Papilloma
• Occurs most often in women 40 to 55 years
of age
• Benign process in the epithelial lining of the
duct, forming an outgrowth of tissue
Intraductal Papilloma (Cont’d)
• Trauma and erosion within the duct,
resulting in bloody or serous nipple
discharge
• Diagnosis aimed first at ruling out breast
cancer
Gynecomastia
• Benign condition of breast enlargement in
men
• Can be a result of primary cancer such as
lung cancer
• Causes include:
– Drugs
– Aging
– Obesity
Gynecomastia (Cont’d)
– Underlying disease causing estrogen excess
– Androgen deficiency
– Breast cancer
Breast Cancer
• Types of breast cancer
• Complications include:
– Invasion of lymph channels causing skin edema
– Metastasis to lymph nodes
– Bone, lungs, brain, and liver—sites of
metastatic disease from breast cancer
– Ulceration of overlying skin
Nipple Retraction
Peau d’orange
Breast Cancer in Men
• Of all breast cancers, only 1% occur in men.
• Breast cancer in men usually presents as a
hard, painless, subareolar mass.
• Breast cancer in men is often a widely
spread disease because it is usually detected
at a later stage than in women.
Mammography
• Baseline screening mammography yearly
beginning at age 40 years is recommended.
• Barriers to mammography.
Breast Self-Examination
• The goal of screening for breast cancer is
early detection because breast selfexamination cannot prevent breast cancer.
• Early detection reduces mortality rate.
• Teach breast self-examination.
BSE
Breast Care
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Clinical breast examination
Cancer surveillance
Prophylactic mastectomy
Chemoprevention
Anxiety
• Interventions:
– Anxiety for the woman with breast cancer
begins the moment the lump is discovered.
– Level of anxiety may be related to past
experiences and personal associations with the
disease.
– Allow the patient to ventilate feelings.
– Flexibility is the key to nursing care.
Potential for Metastasis
• For patients with late-stage breast cancer,
nonsurgical treatment may be the only
alternative; tumor may be removed with
local anesthetic, follow-up treatment with
hormonal therapy, chemotherapy, and
sometimes radiation.
Potential for Metastasis (Cont’d)
• For breast cancer at a stage for which
surgery is the main treatment, follow-up
with adjuvant radiation, chemotherapy,
hormone therapy, or targeted therapy is
commonly prescribed.
Surgical Management
Surgical Management (Cont’d)
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Removal of the mass
Neoadjuvant therapy
Axillary node dissection
Sentinel lymph node biopsy
Breast-conserving surgery
Modified radical mastectomy
Postoperative Care
• Avoidance of using the affected arm for
blood pressure measurement, giving
injections, or drawing blood
• Monitoring of vital signs
• Care of drainage tubes
• Comfort measures
• Mobility and diet
• Breast reconstruction
Adjuvant Therapy
• To decrease the risk of recurrence, adjuvant
therapy consists of:
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Radiation therapy
Chemotherapy
Hormonal therapy
Stem cell transplantation
Targeted therapy
This is chapter 74
Care of Patients with
Gynecologic Problems
Primary Dysmenorrhea
• One of the most common gynecologic
problems, occurring most often in women in
their teens and early 20s.
• Treatment:
– NSAIDs, acetaminophen, anti-prostaglandins,
oral contraceptives
– Complementary and alternative therapies
Premenstrual Syndrome
• A collection of symptoms that are cyclic in
nature
• Nutrition therapy
• Drug therapy—hormonal therapy. Oral
contraceptives, gonadotropin-releasing
hormone, serotonin-reuptake inhibitors
• Complementary and alternative therapies
Endometriosis
• Endometriosis is endometrial tissue
implantation outside the uterine cavity.
Interventions
• Drug therapy
• Complementary and alternative therapy
• Surgical management
Dysfunctional Uterine Bleeding
• Bleeding that is excessive or abnormal in
amount or frequency
Dysfunctional Uterine Bleeding
(Cont’d)
• Associated with:
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Endocrine disturbances
Polycystic ovary disease
Stress
Obesity or underweight
Long-term drug use
Anatomic abnormalities
Collaborative Management
• Nonsurgical management includes hormone
manipulation.
• Surgical management includes:
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Dilation and curettage procedure
Laser or balloon endometrial ablation
Myomectomy
Hysterectomy
Menopause
• Normal biologic event marked for most
women by the end of menstrual periods (12
months of amenorrhea)
• Role of hormone replacement therapy in the
management of symptoms
• Perimenopause indicated by changes in
ovarian function
• Management
Vulvovaginitis
• Vaginal discharge and itching
• Inflammation of the lower genital tract
resulting from a disturbance of the balance
of hormones and flora in the vagina and
vulva
• Characterized by itching, change in vaginal
discharge, odor, or lesions
Toxic Shock Syndrome (TSS)
• First recognized in 1980 when it was found
to be related to menstruation and tampon
use
• Staphylococcus aureus
• Abrupt onset of high temperature, headache,
sore throat, vomiting, diarrhea, generalized
rash, hypotension
• Management
Uterine Prolapse
• Stages of uterine prolapse are described by
the degree of descent of the uterus
• Dyspareunia, backache, pressure in the
pelvis, bowel or bladder problems
• Pessaries
• Surgery
Uterine Prolapse (Cont’d)
Cystocele and Rectocele
Fistulas
• Abnormal opening between two adjacent
organs or structures
• Urethrovaginal fistula
• Vesicovaginal fistula
• Rectovaginal fistula
• Management
Benign Neoplasms
• Ovarian cyst
• Uterine leiomyoma:
– Nonsurgical management
– Surgical management
Uterine Leiomyomas
Cervical Polyps
• Pedunculated tumors (on stalks) arising
from the mucosa and extending to the
opening of the cervical os
• Polyp removal—a simple office procedure
Endometrial (Uterine) Cancer
• Endometrial cancer is a reproductive cancer,
of which adenocarcinoma is the most
common type.
• The main symptom is postmenopausal
bleeding.
• Diagnostic assessment includes these tests:
– CA-125 tumor marker
– Chest x-ray
Endometrial (Uterine) Cancer
(Cont’d)
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Possible testing for gene causing HNPCC
IV pyelography
Barium enema
CT of the pelvis
Liver and bone scans
Hysteroscopic examination of the uterus
Proctosigmoidoscopy
Surgical Management
• Total hysterectomy and bilateral
salpingectomy/oophorectomy
Surgical Management (Cont’d)
• Total abdominal hysterectomy and bilateral
salpingo-oophorectomy
• Radical hysterectomy with bilateral pelvic
lymph node dissection for stage II cancer
Nonsurgical Management
• Radiation therapy:
– Intracavitary radiation (brachytherapy)
– External radiation
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Drug therapy
Chemotherapy
Hormone therapy
Complementary and alternative therapies
Cervical Cancer
• Disorder is a progression—from totally
normal cervical cells, to premalignant
changes in appearance of cervical cells
(dysplasia), to changes in function, and
ultimately to transformation to cancer
• Carcinoma in situ
• Preinvasive or invasive
Health Promotion and
Maintenance
• HPV vaccine (Gardasil)
Clinical Manifestations
• Patient often asymptomatic
• Classic symptom—painless vaginal
bleeding
• Watery, blood-tinged vaginal discharge that
may become dark and foul-smelling as the
disease progresses
Clinical Manifestations (Cont’d)
• Leg pain
• Flank pain
• Unexplained weight loss, pelvic pain,
dysuria, hematuria, rectal bleeding, chest
pain, and cough
Diagnostic Assessment
• Pap smear
• Squamous atypia, inflammatory atypia, or
minor atypia abnormalities
• Bethesda system
• Colposcopic examination
• Endocervical curettage
Early Surgical Procedures
• Loop electrosurgical excision procedure
• Laser therapy
• Cryotherapy
Surgical Procedures
• Hysterectomy
• Pelvic exenteration
Ovarian Cancer
• Most common type—serous
adenocarcinoma
• Vague abdominal discomfort, dyspepsia,
indigestion, gas, and distention
• Ovarian antibody CA-125, ultrasound, IV
pyelography, barium enema, upper GI
radiographic series to rule out tumors
Nonsurgical Management
• Chemotherapy with agents such as cisplatin,
carboplatin, and paclitaxel
• Radiation therapy
Surgical Management
• Total abdominal hysterectomy and bilateral
salpingo-oophorectomy
• Staging
Vulvar Cancer
• Most are squamous cell carcinomas.
• Women often report irritation or itching in
their perineal area or a sore that will not
heal.
• Toluidine blue test identifies abnormal cells.
• Keyes dermal punch is used for tissue
biopsy.
Management
• Laser therapy
• Radiation therapy
• Surgical management—vulvectomy or
skinning vulvectomy or radical vulvectomy
Vulvectomy
Postoperative Care
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Providing wound care
Promoting urinary and bowel elimination
Managing pain
Addressing sexuality
Vaginal Cancer
• Rare
• Treatment with any of these:
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Laser therapy
Wide excision
Partial or total vaginectomy
Topical chemotherapy
Radiation therapy
Fallopian Tube Cancer
• Rarest of all gynecologic cancers
• Most common symptoms—postmenopausal
bleeding, increased abdominal pain, watery
vaginal discharge, leukorrhea
• Treatment—total abdominal hysterectomy
and bilateral salpingo-oophorectomy with
omentectomy
This is chapter 75
Care of Male Patients with
Reproductive Problems
Benign Prostatic Hyperplasia
• Glandular units in the prostate that undergo
an increase in the number of cells, resulting
in enlargement of the prostate gland
• Hyperirritable bladder, urgency and
frequency, hypertrophied bladder wall
muscles, cellules and diverticula,
hydroureter, hydronephrosis, and overflow
urinary incontinence
BPH
Potential Complications of BPH
Assessment
• Urinary pattern, frequency, nocturia, and
other symptoms of bladder neck
obstruction
• Lower urinary tract symptoms
• Hesitancy, intermittency, reduced force and
size of urinary stream, a sensation of
incomplete bladder emptying, and postvoid dribbling
• Hematuria
Laboratory Assessment
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Complete blood count
Blood urea nitrogen and creatinine levels
Prostate-specific antigen
Other diagnostic studies
Drug Therapy
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5-alpha reductase inhibitor (5-ARI)
Alpha-blocking agents
Alpha blockers
Estrogens and androgens
Antimuscarinic agent
Other Nonsurgical Measures
• Thermotherapy
Surgical Procedures
• Transurethral resection of the prostate
(TURP)
• Suprapubic prostatectomy
• Retropubic prostatectomy
• Perineal prostatectomy
Prostatectomy Procedures
Continuous Bladder Irrigation
• Three-way urinary catheter with a 30- to
45-mL retention balloon through the
urethra into the bladder
• Traction via taping to patient’s abdomen or
thigh
• Uncomfortable urge to void continuously
• Antispasmodic medications
CBI
Postcatheterization Care
• Patient feels burning on urination as well as
some urinary frequency, dribbling, and
leakage.
• Symptoms are normal and will subside.
• Monitor fluid intake.
Prostate Cancer
• Most common invasive cancer among men
in the United States
• One of the slowest growing malignancies;
metastasizes in a predictable pattern
• First symptoms related to bladder neck
obstruction
Prostate Cancer (Cont’d)
• Digital rectal examination
• Prostate-specific antigen
• Biopsy necessary to confirm suspected
prostatic cancer
Prostate Cancer (Cont’d)
Surgical Management
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Minimally invasive surgery
Open surgical technique
Prostatectomy
TURP
Bilateral orchiectomy
Preoperative care
Postoperative Care of Radical
Prostatectomy
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Hydration with IV therapy
Caring for wound drains
Preventing emboli
Preventing pulmonary complications
Antibiotics
Analgesics
Postoperative Care of Radical
Prostatectomy (Cont’d)
• Laxative and stool softener
• Indwelling urinary catheter
• Antispasmodic
Complications
• Urinary incontinence
• Erectile dysfunction
Nonsurgical Management
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Radiation therapy
Hormonal therapy
Chemotherapy
Cryotherapy
Complementary and alternative therapies
Targeted therapy
Erectile Dysfunction
• Inability to achieve or maintain an erection
for sexual intercourse
• Organic erectile dysfunction
• Functional erectile dysfunction
• Assessment:
– Medical, social, sexual history
– Complete physical examination
– Duplex Doppler ultrasonography test
Interventions
• Drug therapy includes sildenafil (Viagra),
vardenafil (Levitra), and tadalafil (Cialis).
• Avoid alcohol before sexual intercourse.
• Common side effects include headaches,
facial flushing, and stuffy nose.
• Men who take nitrates should not take these
drugs; profound hypotension and reduced
blood flow to vital organs can result.
Vacuum Devices
• Cylinder fits over the penis and sits firmly
against the body.
• Vacuum is created to draw blood into the
penis to maintain an erection.
• Rubber ring (tension band) is placed around
the base of the penis to maintain the
erection; cylinder is removed.
Injecting the Penis
• Vasodilating drugs can make the penis erect
by engorging it with blood
• Caverject
• Paverine
• Regitine
• Combination of any or all of these drugs
Intraurethral Applications
• Alprostadil is a self-administered
suppository that is placed in the urethra
with an applicator.
• Erection occurs in about 10 minutes and
lasts 30 to 60 minutes.
• Burning of the urethra can occur after
application, as well as syncope.
Prosthesis
• Penile implants are used when other
modalities fail.
• Implants are semirigid, malleable, or
hydraulic inflatable and multicomponent or
one-piece instruments.
• Reservoir is placed in the scrotum.
• Major disadvantages are device failure and
infection.
Testicular Cancer
• Although uncommon, this cancer is the most
common malignancy in men 15 to 34 years of
age.
• With early detection by testicular selfexamination and treatment with combination
chemotherapy, testicular cancer can be cured.
• Germ cell tumors arise from sperm-producing
cells.
• Non–germ cell tumors
Laboratory Assessment
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Alpha-fetoprotein (AFP)
Beta human chorionic gonadotropin (hCG)
Lactate dehydrogenase (LDH)
Ultrasound
Computed tomography
Magnetic resonance imaging
Interventions
• Surgery is the main treatment for testicular
cancer
• Preoperative care
• Operative procedure
• Postoperative care
Nonsurgical Management
• Chemotherapy
• Radiation therapy
Risk for Sexual Dysfunction
• Interventions include:
– Oligospermia, azoospermia
– Health teaching about reproduction, fertility,
and sexuality
– Sperm storage
– Other reproductive options
Potential for Metastasis
• Interventions include:
– Surgical management
– Preoperative care
– Operative procedures—radical retroperitoneal
lymph node dissection, orchiectomy
Potential for Metastasis (Cont’d)
• Postoperative care; expected problems
include:
– Pain from surgical incisions
– Immobility
– Injuries related to invasive catheters or tubes
Hydrocele
• Cystic mass is usually filled with strawcolored fluid that forms around the testis
resulting from impaired lymphatic drainage
of the scrotum, causing a swelling of the
tissue surrounding the testes.
• Hydrocele may be drained via needle and
syringe, or it may be removed surgically.
Spermatocele
• A sperm-containing cyst develops on the
epididymis alongside the testicle.
• Normally, spermatoceles are small and
asymptomatic and require no interventions.
• If they become large enough to cause
discomfort, a spermatocelectomy is
performed.
Varicocele
• A cluster of dilated veins occur behind and
above the testis.
• Varicoceles can also cause infertility.
• Varicocelectomy is performed through an
inguinal incision in which the spermatic
veins are ligated in the cord.
Common Problems
Cancer of the Penis
• Epidermoid (squamous) carcinomas
developing from squamous cells
• Circumcision in infancy—almost always
eliminates the possibility of penile cancer
• Painless, wartlike growth or ulcer
• Excisional biopsy
• Radiation therapy
• Penectomy
Phimosis and Paraphimosis
• Constricted prepuce that cannot be
retracted over the glans; prepuce remains
down around the tip of the penis
• Emergency requiring immediate treatment
• Circumcision
• Warm bath to allow dressing to loosen
• Barbiturate sleeping medications
Priapism
• Uncontrolled and long-maintained erection
without sexual desire; causes the penis to
become large and painful
• Can occur from:
– Thrombosis of veins of corpora cavernosa
– Leukemia
– Sickle cell disease
Priapism (Cont’d)
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Diabetes mellitus
Malignancies
Abnormal reflex
Some drug effects
Recreational drugs
Prolonged sexual activity
Collaborative Management
• Urologic emergency
• Goal of intervention—to improve the
venous drainage of the corpora cavernosa
• Meperidine
• Warm enemas
• Urethral or suprapubic catheterization
• Large-bore needle or surgical intervention
Prostatitis
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Inflammation of the prostate gland
Acute bacterial prostatitis
Chronic bacterial prostatitis
Nonbacterial/chronic pelvic pain syndrome
Asymptomatic inflammatory prostatitis
Epididymitis
• Inflammation of the epididymis resulting
from an infection or noninfectious source
such as trauma
• Treatment—bedrest with scrotum elevated
on a towel, scrotal support when
ambulating
• Comfort measures
• Epididymectomy
Orchitis
• Acute testicular inflammation resulting
from trauma or infection
• Treatment—bedrest with scrotal elevation,
application of ice, and administration of
analgesics and antibiotics
• Mumps orchitis