(TAHBSO) Nursing Care Plan & Management

Notes

Nursing Care Plan & Management.Total abdominal hysterectomy bilateral salpingo oophorectomy (TAHBSO) is the removal of entire uterus, the ovaries, fallopian tubes and the cervix. TAHBSO is usually performed in the case of uterine and cervical cancer. This is the most common kind of hysterectomy. Removal of the ovaries eliminates the main source of the hormone estrogen, so menopause occurs immediately.

Indications

  • Endometriosis– is an abnormal condition in which endometrial tissue is found in internal sites other than the uterus. Overall incidence in women of reproductive age is 5% to 10%. Women in their mid-30s are most commonly affected, though it can appear anytime form first menses to menopause. There is a familial disposition.
  • Benign Uterine Tumors (Leiomyomas)– fibroids, fibromas, fibromyomas, fibroleiomyomas, and myomas.
  • Leiomyomas are benign uterine tumors that arise from the uterine muscle tissue. They are the most common tumors of the female genital tract and occur in 20% to 30% in women. They are seen more often in African-American women, and are more common in women approaching menopause.
  • Endometrial or Uterine Cancer- is the most common malignancy of the female genital reproductive system.

In 2007 the American Cancer Society estimated that 39,080 new cases of uterine cancer would be diagnosed in the United States with an estimated 7400 women dying of uterine cancer. The 5-year survival rate is 96% if the cancer is discovered at an early stage. It is most strongly related to an imbalance between estrogen and progesterone levels, resulting in excessive circulating estrogen.

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  • Ovarian Cancer– the second most common gynecologic cancer, accounts for 3% of cancer occurrence and 6% of cancer deaths in women and is the leading cause of death from reproductive malignancies in women. An estimated 22, 430 new cases of ovarian cancer are expected to be detected in the United States in 2007, with 15, 280 deaths. White women show higher rates of ovarian cancer than do African-American women. Early diagnosis of ovarian cancer is uncommon.

Risk and Side Effects

Hysterectomy has been found to be associated with increased bladder function problems, such as incontinence. When the ovaries are also removed, estrogen levels will fall. This removes the protective effects of estrogen on the cardiovascular and skeletal system. A menopausal woman has a three times greater risk of developing cardiovascular disease such as atherosclerosis, peripheral artery disease or of having a heart attack when compared to premenopausal women. Studies have also found that the risk of developing osteoporosis may increase.

Anatomy & Physiology

Internal Organs

1. 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. 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.

2. Vagina – is the thin in walled muscular tube about 6 inches long leading from the uterus to the external genitalia. It is located between the bladder and the rectum. It provides the passageway for childbirth and menstrual flow; it receives the penis and semen during sexual intercourse.

3. Fallopian Tubes (Two) –Each tube is about 4 inches long and extends medially from each ovary to empty into the superior region of the uterus. They 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.

4. Ovaries (two) – The ovaries are for oogenesis-the production of eggs (female sex cells) and for hormone production (estrogen and progesterone). They 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.

5. Cervix (or neck of the uterus ) -is the lower, narrow portion of the uterus where it joins with the top end of the vagina. It is cylindrical or conical in shape and protrudes through the upper anterior vaginal wall.

6. Urethra -is a tube that connects the urinary bladder to the genitals for removal out of the body. In males, the urethra travels through the penis, and carries semen as well as urine. In females, the urethra is shorter and emerges above the vaginal opening.

Diagnostic Procedures

  • Before any type of hysterectomy, women should have the following tests in order to select the optimal procedure:
  • Complete pelvic exam including manually examining the ovaries and uterus.
  • Up-to-date Pap smear .
  • Pelvic ultrasound may be appropriate, depending on what the physician
  • A decision regarding whether finds on the above. or not to remove the ovaries at the time of hysterectomy.
  • Complete blood count

Management

Pre-operation
  1. Interprets and upholds policies and procedures as determined by administrative body.
  2. Identify knowledge and skills of peri- operative nursing.
  3. Identifies nursing care problems through pre-operative visit and assist in the solutions.
Intra-operation
  1. Ensures quality of care through proper use of instruments, equipments and supplies.
  2. Observes proper positioning of the patient and maintaining the dignity of the individual As well, thus, providing maximum safety and comfort.
  3. Identifies, prepares and send specimen obtained during operation for examination.
  4. Assess patient’s stability and should know to report to the attending physician/s.
  5. Carries out doctor’s post-operative order diligently.
  6. Observes, checks and record patient assessment and refer when necessary.
  7. Administers post-operative care.
  8. Submits sundry report and account for the supplies and equipment used.
  9. Responsible for the upkeep, Maintenance and care of equipment and instrument.
  10. Informs appropriate personnel when supplies are needed or equipment and instruments are out of order.
Post-operation
  1. Responsible for all the safekeeping of patient’s personal belongings endorse by OR nurse.
  2. Responsible for endorsing such items to patient’s relatives or floor nurse.
  3. Diligently carries out doctor’s orders as soon as possible.
  4. Check and record vital signs-blood pressure, pulse rate, O2 saturation, respiratory rate, temperature, color and condition of skin, if can move extremities every 15 minutes (or as often as possible or as indicated by the patient’s condition) on the Nurse’s Post Anesthesia Record.
  5. Observes and records neuro vital signs for neurological cases on the Neurological Vital Signs Form provided by the unit.
  6. Observes keenly the patient’s who might undergo post-operative complications like bleeding, shock, respiratory distress, thyroid storm and cardiac arrest.
  7. Notifies the anesthesiologist/ AMD immediately for any unusual symptoms manifested by the patient.

Prognosis

  • The prognosis following an uncomplicated hysterectomy is good, regardless of the type of procedure performed. Symptoms are usually relieved by the procedure, and a full return to normal activities can be expected.
  • When hysterectomy is performed for cancer of the cervix or uterus, the prognosis depends upon the extent and severity of the cancer. Early-stage or low-grade cancer has a generally good prognosis, whereas more advanced stages or high-grade cancer with extensive spreading (metastasis) has a poor prognosis.
  • The predicted outcome after salpingo-oophorectomy doesn’t depend on whether the procedure is unilateral or bilateral usually does not affect the outcome, because the effect of the procedure and the healing from the surgery occur at much the same rate for removal of one or both fallopian tubes and ovaries. However, hormonal complications for premenopausal women may arise if both ovaries are removed. After bilateral oophorectomy, the woman will be at increased risk for osteoporosis, coronary heart disease, lung cancer, and cognitive impairment (dementia) unless hormone replacement therapy is implemented, and will become infertile.

Exam

Hysterectomy Practice Exam (PM)*

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Nursing Care Plan

8 nursing care plans for TAHBSO:
Acute Pain

Nursing Diagnosis: Acute Pain secondary to surgical procedure

Due to surgical procedure done that needs a surgical incision there will be presence of trauma in the area that signals an actual tissue damage and inflammation, this damage will cause an inflammation of the nerves when the nerves are affected, there will be the presence of pain.

Possibly evidenced by

  • irritability
  • impaired physical mobility
  • disturbed sleep pattern
  • facial mask
  • diaphoresis
  • restlessness
  • facial grimaces

Desired Outcomes

  • Report pain is relieved/controlled.
  • Verbalize methods that provide relief.
  • Demonstrate use of relaxation skills and diversional activities.
Nursing Interventions Rationale
Establish rapport To gain trust
Emphasize ordered diet To encourage patient not to eat untolerated food
Monitor vital signs To obtain baseline data
Provide comfort measures To satisfy the confinement of patient
Encourage deep breathing To inhibit pain
Provide safety measure To prevent from injury
Develop communication review procedures/expectations and tell client when treatment will hurt To alter pain and diminish emotional stress
Administer analgesics as indicated to maximal dosage as needed To reduce concern of unknown and associated muscle tension & To maintain acceptable level of pain.
Hypothermia

Hypothermia is the sudden decrease of temperature. It is due to different factors such as exposure to cool environment, aging or medications. In a surgical procedure hypothermia occurs due to exposure to the cool environment in the OR. Anesthesia also affects body temperature. Inadequate clothing like the OR gown also contributes to heat loss.

Possibly evidenced by

  • reduction in body temperature below normal range
  • shivering
  • cool skin
  • pallor
  • slow capillary refill
  • cyanotic nail beds
  • hypertension
  • tachycardia

Desired Outcomes

  • Patient will display core temperature within normal range
  • Patient will demonstrate behaviors to monitor and promote normothermia
Nursing Interventions Rationale
Establish rapport To gain trust
Monitor  vital signs To obtain baseline data
Remove wet clothing and prevent pooling of antiseptic solutions under client in OR These measures protect patient from heat loss
Wrap in warm blanket To promote heat
Avoid use of heat clamps or hot water bottles Surface rewarming can lead to rewarming  shock due to surface vasodilation
Administer medications to prevent shivering To avoid increasing in temperature
Use hyperthermia blanket To warm patient
Administer fluids during rewarming To prevent hypovolemic shock
Keep client quiet To reduce potential for fibrillation in cold heart
Provide well-balance high calorie diet To replenish glycogen stores and nutritional balance
Perform range-of-motion exercises, provide support hose, reposition, do cough/deep breathing exercises, avoid restrictive clothing To reduce circulatory stasis
Protect skin by repositioning, applying lotion and avoid direct contact with heating appliance or blanket impaired circulation can result in severe tissue damage
Provide patent airway with humidified oxygen when used To provide heat
Hyperthermia

Organisms release endotoxin which stimulates the release of pyrogens from the leukocytes resetting the body’s internal thermostat to febrile level then there will be activation of hypothalamus which will result to an increase in epinephrine and heparin, vasoconstriction of cutaneous vessels. Then heat will be produce as peripheral vasodilation results in skin flushing and skin which is warm to touch.

Possibly evidenced by

  • increase in body temperature above normal range
  • flushed skin, warm to touch
  • tachycardia
  • seizures or convulsions

Desired Outcomes

  • Patient will maintain core temperature within normal range
  • Patient will be free from complications of hyperthermia
Nursing Interventions Rationale
Establish rapport To gain trust
Monitor  vital signs To obtain baseline data
Monitor body temperature every 4 hours or more often if indicated To evaluate effectiveness of interventions
Loosen patient’s clothing and remove blankets To promote heat loss through radiation and conduction
Apply ice bags to axilla or groin and do TSB To promote heat loss through evaporation
Administer antipyretic as ordered To reduce fever
Observe patient for confusion or disorientation Changes LOC may result from tissue hypoxia
Determine patient’s preference for liquids Offering patient liquids he prefers promotes adequate hydration
Keep liquids at bedside and within reach To allow patient easy access
Monitor intake and output accurately To identify changes and progress of the treatment
Administer I.V fluid as ordered These measure prevents excessive loss of water, sodium chloride and potassium
Give patient oresol To replace lost fluid and electrolytes
Provide supplemental oxygen To offset increase oxygen demands and consumption
Anxiety

Due to upcoming surgical procedure patients are usually experiencing anxiety. The brain signals our body part to initiate responses such as fatigue, nausea and abdominal pain.

Possibly Evidenced By

  • Patient may raise concerns due to change in life event
  • fear
  • nausea
  • abdominal pain
  • fatigue
  • sleep disturbance
  • urinary hesitancy
  • poor eye contact
  • extraneous movement
  • restlessness
  • irritability
  • anorexia
  • insomnia
  • impaired attention
  • Trembling, hand tremors

Desired Outcomes

  • Patient will verbalized awareness of feelings of anxiety
  • Patient will appear relaxed and report anxiety is reduced to a manageable level
Nursing Interventions Rationale
Establish rapport To gain trust
Monitor  vital signs To obtain baseline data
Listen attentively; allow patient to express feelings verbally To allow patient to identify anxious behaviors and discover source of anxiety
Identify and reduce as many environment stressors Anxiety commonly results from lack of trust in the environment
Provide accurate information about the situation Helps the patient what is reality based
Provide comfort measures like back rub and soft music To decrease autonomic response to anxiety
Use cognitive therapy To correct faulty catastrophic interpretations of physical symptoms
Refer patient to professional mental health resources To provide ongoing mental health assistance
Fatigue

Due to poor physical condition after surgical procedure, body insist demands of nutrition and oxygen that results to fatigue

Possibly Evidenced By

  • Pale skin
  • Impaired physical mobility
  • Irritability
  • Weakness
  • Pain
  • Activity intolerance
  • Stress

Desired Outcomes

  • patient will demonstrate an increase energy output with presence of fatigue
  • patient will perform activities of daily living and participate in desired activities at level of ability

Nursing Interventions

Nursing Interventions Rationale
Establish rapport To gain trust
Monitor vital signs To obtain maintenance data
Evaluate the need for individual assistance and discuss lifestyle changes imposed by fatigue state To determine degree of fatigue
Establish realistic activity goals with client Enhance commitment in promoting optimal outcomes
Instruct client in ways to monitor responses to activity and significant signs and symptoms To indicate the need to alter activity level
Sexual Dysfunction

Dysfunction of the female reproductive system can produce depression and even anxiety. The patient experiences this due to deficient knowledge about the dysfunction and the decrease in sexual desire.

Nursing Diagnosis: Sexual Dysfunction related to altered body structure and function

Possibly Evidenced By

  • problem such as loss of sexual desire
  • inability to achieved desired satisfaction
  • conflicts involving values
  • alteration in relationship with SO
  • Change of interest in self and others

Desired Outcomes

  • patient will identify stressors in lifestyle that may contribute to the dysfunction
  • patients will verbalize understanding of individual reasons for sexual problems
Risk for Infection

The skin considered as the first line of defense against any foreign organism when surgical procedure impaired the skin, possible entry of microorganism therefore may cause infection.

Nursing Diagnosis: Risk for infection secondary to surgical incision

Possibly Evidenced By

  • Weakness
  • Pallor-with dry and intact dressing on the area.
  • Pain over the incision
  • Irritability
  • Presence of intact dressing
  • Impaired physical mobility
  • Diaphoresis
  • Fever
  • Seizures

Desired Outcomes

  • Patient shall identify and demonstrate intervention to prevent infection
Nursing Interventions Rationale
Establish rapport To gain trust
Monitor V.S. To obtain baseline data
Note signs and symptoms of sepsis To reduce complication and monitor for infection
Provide wound healing such as cleaning of wound To reduce risk for infection
Provide care, change dressing as needed To promote healing to the incision
Encourage increase intake of Vitamin C as ordered To prevent infection to increase immune resistance
Encourage deep breathing exercise To facilitate non-pharmacological pain management
Risk for Deficient Fluid Volume

Decrease intravascular, interstitial, or intracellular fluid refers to dehydration. Fluid volume deficit or hypovolemia occurs from a loss of body fluid or the shift of fluids into the third space or reduced fluid intake. Common sources for fluid loss are the gastrointestinal tract, polyuria and increased perspiration. It also occurs to patient who underwent surgery. In an operation the patient is losing too much body fluid through blood loss that can lead to deficient fluid.

Possibly Evidenced By

  • thirst
  • weakness
  • decrease urine output
  • sudden weight loss
  • decrease skin turgor
  • dry mucous membranes
  • sunken eyeballs
  • change in mental state

Desired Outcomes

  • patient will identify risk factors and appropriate interventions
  • patients will demonstrate behaviors or lifestyle changes to prevent development of fluid volume deficit
Nursing Interventions Rationale
Establish rapport To gain trust
Monitor vital signs To obtain maintenance data
Encourage increase oral fluid intake To replace lost fluids
Provide supplemental fluids as ordered Prevents peak in fluid level
Monitor intake and output To ensure accurate picture of fluid status
Provide safety measures Confusion can lead to accidents
Encourage the use of oresol To replace loss electrolyte.

Postoperative Care

  1. Determines patient’s immediate response to surgical intervention.
  2. Monitor patient’s physiologic status.
  3. Assess patient’s pain level and administers appropriate pain relief measures.
  4. Maintains patient’s safety(airway, circulation, prevention of injury)
  5. Administer medication, fluid and blood component therapy, if prescribed.
  6. Assess patient’s readiness for transfer to in hospital unit or for discharge home based on institutional policy.