Tumors of the Uterus
Benign Uterine Tumors
The fibroid tumor is the most common type of benign uterine tumor. Fibroid tumors range in size, usually growing slowly and arising from muscle cells. They are believed to result from hormonal influences. The first symptom is abnormal vaginal bleeding, associated with a feeling of heaviness and pressure in the pelvic region. A fibroid tumor, or myoma, may become so large that it presses on the urethra or bowel, causing urinary retention or constipation.
Treatment. Treatment for fibroids depends somewhat on the client’s age. Often it is possible to remove a nonmalignant tumor from the uterus without removing the uterus itself, an especially important consideration for a woman of childbearing years. Other treatments include medroxypro – gesterone (Depo-Provera) injections or oral contraceptives to suppress the uterine lining, thus shrinking the tumors. Leuprolide (Lupron) injection therapy is showing promise in shrinking fibroids as well.
Key Concept Most nonmalignant tumors shrink after menopause; thus, postmenopausal bleeding is seldom caused by a myoma.
Cancer of the Fundus or Endometrium
The fundus, which is the body of uterus, is not attacked as frequently by cancer as the cervix. However, malignant growths do occur in the endometrium and fundus. Cancers of the fundus and the endometrium are most likely to occur in postmenopausal women. Women who have previously taken estrogens also are at an increased risk. Therefore, hormone therapy is prescribed with caution.
Vaginal bleeding is the first sign of uterine cancer, possibly beginning as a watery, blood-tinged discharge. If it occurs before menopause, it may be mistaken for menstrual irregularity.
TABLE 91-1. Cancers of the Female Reproductive System
|
|
WARNING SIGNS |
RISK FACTORS |
EARLY DETECTION |
TREATMENT (DEPENDENT ON INVOLVEMENT) |
|
Breast Cancer |
Breast changes: Lump, pain, thickening, swelling, tenderness, distortion, retraction, dimpling, scaliness |
Age >40 (risk increases with age), history of breast cancer; early menarche, nulliparity, first birth at late age |
Monthly self-examination; mammogram by age 40, every 2 years between ages 40 and 49, and every year after age 50 in asymptomatic women |
Lumpectomy, mastectomy, radiation therapy, chemotherapy, hormone manipulation therapy |
|
Cervical Cancer |
Often asymptomatic; symptoms, if present, can include irregular bleeding or abnormal vaginal discharge |
Intercourse at an early age, multiple sex partners, cigarette smoking, history of certain sexually transmitted diseases, such as human papillomavirus |
Annual Pap test for women >18 or who are sexually active; after three consecutive normal tests, Pap tests may be done less often at the healthcare provider’s discretion |
Carcinoma in situ: Cryotherapy electrocoagulation, local excision Metastatic cancer: Surgery or radiation therapy or both |
|
Endometrial Cancer |
Irregular bleeding outside of menses, unusual vaginal discharge, excessive bleeding during menstruation, post-menopausal bleeding |
Obesity, early menarche, multiple sex partners, late menopause, history of infertility, anovulation (not ovulating), unopposed estrogen or tamoxifen therapy, family history of endometrial cancer |
Endometrial biopsy at menopause (for high-risk women) |
Precancerous changes: Progesterone therapy Diagnosed cancer: Surgery or radiation therapy or both |
|
Ovarian Cancer |
Often asymptomatic; symptoms, if present, can include abdominal enlargement, vague digestive disorders, discomfort, gas distention |
Risk increases with age (especially after age 60), nulliparity, history of breast cancer |
Periodic, complete pelvic examination; cancer-related checkup every year after age 40 |
Surgery, including oophorectomy (excision of an ovary), hysterosalpingo-oophorectomy, salpingo-oophorectomy, excision of all intra-abdominal disease; radiation therapy; chemotherapy |
A diagnostic curettage to obtain uterine scrapings is performed if the Pap test suggests cancer. If the results of the tests of the scrapings are positive, a hysterectomy is performed, followed by radium implantation, x-ray therapy, or both, to the pelvic cavity. This client may have postoperative chemotherapy, but usually not hormone therapy.
Cancer of the Cervix
Of the cancers affecting the female reproductive system, cancer of the cervix is common, being surpassed only by breast cancer. Cervical cancer occurs most commonly in women between the ages of 40 and 55 years. Box 91-1 lists factors that place women at a higher risk of developing cervical cancer.
Signs and Symptoms
Bleeding is the first sign of cervical cancer, but it does not occur in the early stages, when a positive Pap test would indicate the presence of cancer cells. The bleeding usually appears first as spotting between periods or after intercourse. Gynecologists should follow up carefully with women at risk. These women should have frequent Pap tests. The condition also can occur after menopause.
Staging of Cervical Cancer
Cervical cancer can be staged differently depending on the professional agency providing the information.Pap tests are identified differently, but are commonly used as preliminary guides to identify cervical cancer. This cancer is commonly staged similarly to many other types of cancer, which will help to standardize treatments that depend on location and extent of spread of the cancerous growth:
• Stage 0: Carcinoma in situ (cancer limited to the epithelial layer with no signs of invasion of deeper tissue or of surrounding area)
• Stage I: Cancer is confined to cervix
• Stage II: Cancer extends beyond the cervix, but not into the pelvic wall, or involves vagina but not the lower one-third
• Stage III: Cancer extends to the pelvic wall and involves lower one-third of the vagina
• Stage IV: Cancer is widely spread throughout the pelvic region or throughout the body.
BOX 91-1. Risk Factors for Developing Cervical Cancer
• Infection with human papillomavirus (HPV)
• Sexual activity at a young age
• Frequent sexual activity
• Multiple sex partners
• Presence of genital warts (condyloma)
• Presence of herpes virus II
• Maternal history of cancer especially cervical cancer
• Maternal use of diethylstilbestrol (DES) during pregnancy with this daughter (especially if mother had toxicity to DES)
Treatment
Early cervical cancer (in situ and some types of stage I) is susceptible to radiation therapy (usually radon implantation). In addition, early cervical cancer is more easily localized and, therefore, more easily excised. In these early states, conization with cryosurgery or laser surgery is frequently used. If conization is performed, Pap tests should be done every 3 months for the first year and every 6 months after that time. These procedures may be done on an outpatient basis in selected cases. Hysterectomy also may be done for early cervical cancer if the woman does not wish to remain capable of child-bearing.
In the early and middle stages, conization or hysterectomy may be done. In the middle stages, hysterectomy is the treatment of choice. Many of these surgical procedures are combined with radiation or chemotherapy, particularly in stages other than cancer in situ.
Cervical Cancer in the Pregnant Woman
If a woman is pregnant and cervical cancer in situ is discovered, treatment is delayed until after delivery, which may be allowed to occur vaginally. If invasive cancer is discovered early in the pregnancy, the pregnancy is terminated, and the cancer is treated as in the nonpregnant woman. If invasive cancer is discovered late in pregnancy (third trimester), treatment is delayed until the fetus is viable, and cesarean delivery is done.
Nursing Alert The importance of the Pap test for women past puberty, particularly sexually active women, cannot be overstated. Cervical cancer is almost 100% curable if it is discovered early and treated before it spreads.
Caring for the Woman Undergoing a Hysterectomy
Hysterectomy is a term that describes the removal of portions or all of the female reproductive system. The type of hysterectomy depends on which organs are affected and the goal of surgery. If the entire uterus, including the cervix, is removed, it is called a total hysterectomy (panhysterectomy). Today, the cervix is rarely left in place. However, if it is, and the body and fundus of the uterus are removed, it is called a subtotal hysterectomy. Removal of the attached oviducts as well is called a salpingectomy; the total procedure is called a panhysterosalpingectomy. Removal of both ovaries combined with total removal of the uterus and both oviducts is known as a panhysterosalpingo-oophorectomy. If one ovary is removed, the operation is a unilateral oophorectomy; if both are removed, it is bilateral.
If cancer has metastasized to the entire abdomen, radiation therapy, with or without chemotherapy, may be used palliatively, and surgery may be unnecessary. In some cases, however, radical surgery is performed.
Preoperative Considerations. In addition to the usual preparation for abdominal or perineal surgery, the client may have a vaginal irrigation or douche. She will most likely have at least one enema to cleanse the colon of feces.
The client must receive instruction in the administration of the enema and other procedures to be done the evening before surgery. She will be allowed nothing by mouth (NPO) after midnight. This client will probably come into the healthcare facility on the morning of the surgery.
A Foley catheter is often inserted in the client surgical preparation room to lessen the danger of bladder perforation during removal of the uterus. The Foley catheter is usually removed on the first postoperative day and is not replaced unless the client is unable to void. If the bladder also is repaired, the surgeon may insert a suprapubic Cystocath during surgery to drain urine and rest the bladder. Antiembolism stockings usually are applied to the legs to prevent thrombophlebitis.
Be sure to answer all the client’s questions fully. Include the woman’s husband or partner in teaching. A hospital chaplain or the client’s spiritual leader can be a source of needed support and reassurance. Be sure to document all teaching.
Postoperative Nursing Considerations. Plan nursing care according to the type of hysterectomy performed. Provide the same postoperative care for the woman who has had an abdominal hysterectomy as for any person who has had an abdominal incision. The client recovers more quickly from the vaginal procedure than from the abdominal procedure.
Give routine postoperative care to prevent complications. Antiembolism stockings are typically ordered and need to be removed and reapplied at least every 8 hours. Encourage early ambulation. The client often has a urethral catheter in place. After it is removed, report any difficulty in voiding. If the woman cannot void within 6 to 8 hours, the surgeon needs to be notified.
Perineal pads are worn after surgery. Teach the client to pull the underwear and pad straight down to avoid fecal contamination of the operative area. Check the amount, color, and odor of vaginal drainage. Some bloody drainage is normal. However, notify the surgeon of unusual bleeding. Give perineal care, if ordered. The use of the peri bottle can help to keep the perineum clean and the client more comfortable. Teach the client how to perform perineal self-care.
Vaginal packing may be inserted during surgery. This is usually removed on the first or second postoperative day. The client may complain of severe back pain while the pack is in place. Reassure her that removal of the packing will relieve much of the pain.
Before discharge from the healthcare facility, inform the client of complications that might occur and when to notify the healthcare provider. Carefully document all teaching (see In Practice: Nursing Care Plan 91-1).
Breast Neoplasms
Most breast lesions are benign. Benign lesions tend to be round or oval with a smooth border and usually show no secondary signs. Furthermore, benign lesions are likely to be movable. Malignant lesions are more likely to be irregularly shaped and hard, and often show secondary signs, such as enlarged lymph nodes in the axillary area, asymmetry of the breast, retraction of the nipple, bloody discharge, dimpling, or elevation of one breast. Additionally, malignant lesions are often attached to the surrounding skin, underlying structures, or breast tissue. Diagnosis, however, requires a laboratory analysis of tissue or biopsy study.
Benign Neoplasms
Chronic Cystic Mastitis. Cystic disease is the most common breast disorder in women between the ages of 30 and 50 years. It is believed to result from a hormonal imbalance and is related to the activity of the ovaries. Cyst formation decreases after menopause.
Breast tissue cells collect together and form a mass. This cell mass shuts off the ducts and forms cysts. These masses may form fibrous tumors (fibromas) or breast lumps. A biopsy may be performed to rule out cancer. Most lumps removed from the breast are benign. A cyst may be excised or drained without removal of any of the surrounding tissue. On rare occasions, particularly if the woman is extremely anxious, the surgeon may perform a simple mastectomy, in which only the breast is removed as a preventive measure. Caffeine aggravates cyst formation. Women with a cystic condition are therefore advised to avoid coffee, tea, chocolate, and cola drinks. Encourage the client to perform breast self-examinations. Researchers suggest that these women have a yearly mammogram or ultrasound or both.
Breast Cancer
Cancer of the breast is the most common type of cancer in women and the second most common cause of cancer death in women. (Lung cancer is the most common cause.). Research shows that if breast cancer is treated within 3 months of its discovery, 5-year survival rates are much higher. Breast cancer in men occurs, but it is rare. Factors predisposing to breast cancer are presented in Box 91-2. Note that breast cancer can occur in women with no known risk factors.
BOX 91-2. Risk Factors for Developing Breast Cancer
The following categories of women have an increased risk for developing breast cancer; however; breast cancer can occur in women with no known risk factors.
• Menarche prior to age 12
• Late menopause (after age 50)
• Long or irregular menstrual cycles
• Women older than 40 (approximately 25% are between the ages of 40 and 49; approximately 70% are older than 50)
• Family history of breast cancer especially in mother, maternal grandmother maternal aunt, sister, or daughter
• History of fibrocystic breast disease
• History of cancer of the other breast
• History of endometrial or ovarian cancer
• Women who have never had a baby
• Women who had their first baby after age 30
• Women who have not breast-fed
• Women on antihypertensive therapy
• Radiation exposure before age 30
• Diet high in fat
• Obesity
• Alcohol and tobacco use
• Previous breast surgery (biopsies, implants, cosmetic mammoplasty)
• Estrogen replacement therapy >8 years
IN PRACTICE: NURSING CARE PLAN 91-1
THE CLIENT WHO IS AT RISK FOR COMPLICATIONS FOLLOWING A HYSTERECTOMY
Medical History: J.WB., a 41-year-old Native American, was admitted with severe vaginal bleeding due to uterine fibroids. Her hemoglobin and hematocrit were 8.7 g/dL and 36.6%, respectively An abdominal hysterectomy was performed. Indwelling urinary catheter was inserted during surgery Intravenous (IV) infusing at 125 mL/hour Vital signs within acceptable parameters following surgery Client has a history of varicose veins and of deep vein thrombosis after the delivery of both of her children. Antiembolism stockings in place.
Medical Diagnosis: Abdominal hysterectomy postoperative day 1.
DATA COLLECTION/NURSING OBSERVATION
Client alert and oriented to person, place, and time. Client is complaining of moderate abdominal pain, rating it a 6 on a scale of 1 to 10. Meperidine (75 mg) given intramuscularly (IM), as ordered, with relief. Vital signs are within acceptable parameters. Abdominal incision with dressing is clean, dry and intact. Mucous membranes are pale pink. IV infusing at ordered rate into left wrist. IV site is clean, dry, and intact. Catheter draining clear yellow urine, 420 mL in the past 8 hours. Antiembolism stockings in place. Pedal pulses present and equal bilaterally. Toes are pink and warm; capillary refill 2 seconds. (Although other nursing diagnoses may be appropriate, a priority nursing diagnosis is addressed below.)
NURSING DIAGNOSIS
Risk for ineffective peripheral tissue perfusion related to presence of risk factors, as noted by history and client positioning during surgery
PLANNING
Short-term Goals
1. Client will demonstrate methods to enhance venous return while in bed.
2. By the end of the day, client will ambulate 5 feet in the hallway.
3. Client will exhibit no signs and symptoms of deep vein thrombosis.
Long-term Goals
4. By discharge, the client will demonstrate measures to prevent deep vein thrombosis while in and out of bed.
IMPLEMENTATION
Nursing Action
Observe lower extremities for changes; note color, temperature, pulses, sensations, and capillary refill. Check for positive Homans’ sign. Document and report any suspicious findings. Rationale: Changes in the status of the lower extremities may indicate early development of thrombosis, allowing for prompt initiation of treatment.
Nursing Action
Inspect lower extremities for swelling; if noted, measure calf circumference and compare measurements bilaterally Rationale: Swelling is an early sign of deep vein thrombosis. Comparing measurements bilaterally quantifies the swelling, if present, and aids in determining its severity.
Nursing Action
Remove and then reapply antiembolism stockings during bathing. Rationale: Removing the stockings during bathing allows for close inspection of the skin.
Nursing Action
Encourage the client to change position while in bed at least every 2 hours. Teach and encourage client to do leg exercises while in bed.
Rationale: Changing positions in bed frequently and performing leg exercises help to promote venous return from the lower extremities.
EVALUATION
Lower extremities pale pink; no redness, swelling, or warmth noted; pedal pulses present bilaterally; quick capillary refill. Negative Homans’ sign. Antiembolism stockings reapplied after bath. Client observed doing range-of-motion exercises to feet after bath. Progress to meeting Goals 1 and 3.
Nursing Action
Gradually increase client’s activity beginning with sitting at the edge of the bed, sitting in a chair, and then ambulating, as ordered. Administer analgesic, as ordered, before getting the client out of bed. Rationale: These activities help promote venous return from lower extremities. Premedicating the client helps to minimize the amount of pain that the client may experience when getting out of bed.
Nursing Action
Elevate the client’s lower extremities on a stool when out of bed in the chair. Rationale: Elevating the extremities helps to prevent venous pooling due to gravity.
EVALUATION
Client assisted out of bed to chair for 15 minutes with legs on stool; antiembolism stockings in place; complained of becoming lightheaded; assisted back to bed. Progress to meeting Goal 1.
Nursing Action
Reinforce the need for client to avoid placing any pressure under knees, and not to rub the calves of her legs. Rationale: Putting pressure under the knees increases the risk for thrombus formation; rubbing the calves could lead to an embolus if a thrombus is present.
Nursing Action
Teach client measures to prevent venous pooling, such as avoiding constricting clothing, elevating legs when sitting, and avoiding crossing the legs and standing for long periods of time. Rationale:These activities lead to venous pooling, increasing the client’s risk for thrombus formation.
EVALUATION
Client assisted out of bed; ambulated from bed to doorway, approximately 10 feet. Assisted back to bed; observed exercising lower extremities. No signs and symptoms of deep vein thrombus evident. Goal 1 met; Goal 2 met; progress to meeting Goal 3.
Nursing Action
Review measures to increase activity level as tolerated, with emphasis on measures to promote venous return. Encourage the use of antiembolism stockings even after discharge. Rationale: Adequate venous return, including activity and use of antiembolism stockings, helps to prevent deep vein thrombosis.
Nursing Action
Teach client the signs and symptoms of deep vein thrombosis to report immediately Rationale: Client teaching is important to reduce the client’s risk of potential complications postoperatively, including after discharge.
