HYSTERECTOMY
Hysterectomy is the surgical removal of the uterus, most commonly performed for malignancies and certain nonmalignant conditions (e.g., endometriosis/tumors), to control life-threatening bleeding/hemorrhage, and in the event of intractable pelvic infection or irreparable rupture of the uterus. A less radical procedure (myomectomy) is sometimes performed for removing fibroids while sparing the uterus.
Abdominal hysterectomy types include the following:
Subtotal (partial): Body of the uterus is removed; cervical stump remains.
Total: Removal of the uterus and cervix.
Total with bilateral salpingo-oophorectomy: Removal of uterus, cervix, fallopian tubes, and ovaries is the treatment of choice for invasive cancer (11% of hysterectomies), fibroid tumors that are rapidly growing or produce severe abnormal bleeding (about one-third of all hysterectomies), and endometriosis invading other pelvic organs.
Vaginal hysterectomy or laparoscopically assisted vaginal hysterectomy (LAVH) may be done in certain conditions, such as uterine prolapse, cystocele/rectocele, carcinoma in situ, and high-risk obesity. These procedures offer the advantages of less pain, no visible (or much smaller) scars, and a shorter hospital stay and about half the recovery time, but are contraindicated if the diagnosis is obscure.
A very complex and aggressive surgical procedure may be required to treat invasive cervical cancer. Total pelvis exenteration (TPE) involves radical hysterectomy with dissection of pelvic lymph nodes and bilateral salpingo-oophorectomy, total cystectomy, and abdominoperineal resection of the rectum. A colostomy and/or a urinary conduit are created, and vaginal reconstruction may or may not be performed. These patients require intensive care during the initial postoperative period. (Refer to additional plans of care regarding fecal or urinary diversion as appropriate.)
CARE SETTING
Inpatient acute surgical unit or short-stay unit, depending on type of procedure.
RELATED CONCERNS
Cancer
Psychosocial aspects of care
Surgical intervention (for general considerations and interventions)
Thrombophlebitis: deep vein thrombosis
Patient Assessment Database
Data depend on the underlying disease process/need for surgical intervention (e.g., cancer, prolapse, dysfunctional uterine bleeding, severe endometriosis, or pelvic infections unresponsive to medical management) and associated complications (e.g., anemia).
TEACHING/LEARNING
Discharge plan DRG projected mean length of inpatient stay: 2.9–5.9 days
considerations: May need temporary help with transportation; homemaker/maintenance tasks
Refer to section at end of plan for postdischarge considerations.
DIAGNOSTIC STUDIES
Pelvic examination: May reveal uterine/other pelvic organ irregularities, such as masses, tender nodules, visual changes of cervix, requiring further diagnostic evaluation.
Pap smear: Cellular dysplasia reflects possibility of/presence of cancer.
Ultrasound or computed tomography (CT) scan: Aids in identifying size/location of pelvic mass.
Laparoscopy: Done to visualize tumors, bleeding, known or suspected endometriosis. Biopsy may be performed or laser treatment for endometriosis. Rarely, exploratory laparotomy may be done for staging cancer or to assess effects of chemotherapy.
Dilation and curettage (D&C) with biopsy (endometrial/cervical): Permits histopathological study of cells to determine presence/ location of cancer.
Schiller’s test (staining of cervix with iodine): Useful in identifying abnormal cells.
Complete blood count (CBC): Decreased hemoglobin (Hb) may reflect chronic anemia, whereas decreased hematocrit (Hct) suggests active blood loss. Elevated white blood cell (WBC) count may indicate inflammation/infectious process.
Sexually transmitted disease (STD) screen: Human papillomavirus (HPV) is present in 80% of patients with cervical cancer.
NURSING PRIORITIES
1. Support adaptation to change.
2. Prevent complications.
3. Provide information about procedure/prognosis and treatment needs.
DISCHARGE GOALS
1. Dealing realistically with situation.
2. Complications prevented/minimized.
3. Procedure/prognosis and therapeutic regimen understood.
4. Plan in place to meet needs after discharge.
Hysterectomy is the surgical removal of the uterus, most commonly performed for malignancies and certain nonmalignant conditions (e.g., endometriosis/tumors), to control life-threatening bleeding/hemorrhage, and in the event of intractable pelvic infection or irreparable rupture of the uterus. A less radical procedure (myomectomy) is sometimes performed for removing fibroids while sparing the uterus.
Abdominal hysterectomy types include the following:
Subtotal (partial): Body of the uterus is removed; cervical stump remains.
Total: Removal of the uterus and cervix.
Total with bilateral salpingo-oophorectomy: Removal of uterus, cervix, fallopian tubes, and ovaries is the treatment of choice for invasive cancer (11% of hysterectomies), fibroid tumors that are rapidly growing or produce severe abnormal bleeding (about one-third of all hysterectomies), and endometriosis invading other pelvic organs.
Vaginal hysterectomy or laparoscopically assisted vaginal hysterectomy (LAVH) may be done in certain conditions, such as uterine prolapse, cystocele/rectocele, carcinoma in situ, and high-risk obesity. These procedures offer the advantages of less pain, no visible (or much smaller) scars, and a shorter hospital stay and about half the recovery time, but are contraindicated if the diagnosis is obscure.
A very complex and aggressive surgical procedure may be required to treat invasive cervical cancer. Total pelvis exenteration (TPE) involves radical hysterectomy with dissection of pelvic lymph nodes and bilateral salpingo-oophorectomy, total cystectomy, and abdominoperineal resection of the rectum. A colostomy and/or a urinary conduit are created, and vaginal reconstruction may or may not be performed. These patients require intensive care during the initial postoperative period. (Refer to additional plans of care regarding fecal or urinary diversion as appropriate.)
CARE SETTING
Inpatient acute surgical unit or short-stay unit, depending on type of procedure.
RELATED CONCERNS
Cancer
Psychosocial aspects of care
Surgical intervention (for general considerations and interventions)
Thrombophlebitis: deep vein thrombosis
Patient Assessment Database
Data depend on the underlying disease process/need for surgical intervention (e.g., cancer, prolapse, dysfunctional uterine bleeding, severe endometriosis, or pelvic infections unresponsive to medical management) and associated complications (e.g., anemia).
TEACHING/LEARNING
Discharge plan DRG projected mean length of inpatient stay: 2.9–5.9 days
considerations: May need temporary help with transportation; homemaker/maintenance tasks
Refer to section at end of plan for postdischarge considerations.
DIAGNOSTIC STUDIES
Pelvic examination: May reveal uterine/other pelvic organ irregularities, such as masses, tender nodules, visual changes of cervix, requiring further diagnostic evaluation.
Pap smear: Cellular dysplasia reflects possibility of/presence of cancer.
Ultrasound or computed tomography (CT) scan: Aids in identifying size/location of pelvic mass.
Laparoscopy: Done to visualize tumors, bleeding, known or suspected endometriosis. Biopsy may be performed or laser treatment for endometriosis. Rarely, exploratory laparotomy may be done for staging cancer or to assess effects of chemotherapy.
Dilation and curettage (D&C) with biopsy (endometrial/cervical): Permits histopathological study of cells to determine presence/ location of cancer.
Schiller’s test (staining of cervix with iodine): Useful in identifying abnormal cells.
Complete blood count (CBC): Decreased hemoglobin (Hb) may reflect chronic anemia, whereas decreased hematocrit (Hct) suggests active blood loss. Elevated white blood cell (WBC) count may indicate inflammation/infectious process.
Sexually transmitted disease (STD) screen: Human papillomavirus (HPV) is present in 80% of patients with cervical cancer.
NURSING PRIORITIES
1. Support adaptation to change.
2. Prevent complications.
3. Provide information about procedure/prognosis and treatment needs.
DISCHARGE GOALS
1. Dealing realistically with situation.
2. Complications prevented/minimized.
3. Procedure/prognosis and therapeutic regimen understood.
4. Plan in place to meet needs after discharge.
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