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GYNAECOLOGICAL CONDITIONS NSC 329 – Reproductive Health 11 Unit 2 By Mrs. Patience Arinola Adamolekun Course Objectives At the end of the course, the students should be able to : Explain diagnostic and treatment procedures in management of patients w...
GYNAECOLOGICAL CONDITIONS NSC 329 – Reproductive Health 11 Unit 2 By Mrs. Patience Arinola Adamolekun Course Objectives At the end of the course, the students should be able to : Explain diagnostic and treatment procedures in management of patients with gynaecological conditions Participate in the care of patients with gynaecological conditions Provide information and counsel on STIs and HIV DESCRIPTION OF THE VULVA The vulva is the outer part of the female genitals. The opening of the vagina or vestibule The labia majora or outer lips The labia minora or outer lips The clitoris The opening of the urethra VULVA Inflammation means swelling of the vulva area. (swelling, redness, tenderness and warm to touch.) Causes Sex Allergic reaction Pregnancy - growing uterus Yeast infection - thick white discharge, intense itchiness, burning sensation, pain or soreness and rashes Management – personal and perineal hygiene, positioning, anti fungal cream, oral antibiotics etc What is vulva irritation? This is itching, burning or discomfort of the vulva area The skin of the vulva is extremely delicate, making it suscepstible to a wide range of conditions. Irritation of the vulva is relatively common in women of all ages, with skin conditions and infections often being the cause. A small part of the vulva or sometimes the entire vulva can be affected. Most cases improve with treatment, but there are few rare conditions that can become serious if left untreated. Prompt investigation and treatment of vulva irritation is important. If left unaddressed, irritation can become a source of discomfort and worry. Signs and symptoms Redness and/or swelling Burning and/or itching Skin cracking or splitting (fissuring) Whitening of skin Associated vaginal inflammation and/or discharge. Treatment There are many treatment options depending on the cause of the vulva irritation. These include local treatments (corticosteroid cream, barrier ointment, gel, vaginal cream and tablets) mycoten and oral treatments. At times both oral and barrier ointment may be used. Vagina Cancer It is a rare form of cancer that most commonly occurs in the cells that line the surface of the vagina Symptoms Unusual vagina bleeding after intercourse or menopause Watery vagina discharges A lump or mass in the vagina Painful urination Frequent urination Constipation Pelvic pain VAGINA CANCER Bartholin’s glands The Bartholin’s glands are located on each side of the vaginal opening. They are about the size of a pea. They produce fluid that keeps the vagina moist. The fluid travels to the vagina through ducts (tubes). If they become blocked, fluid can flow back and accumulates in the duct causing swelling or a cyst. Is called Bartholin’s gland cysts. They’re almost always benign, or non- cancerous. It’s soft and painless, and often doesn’t lead to any symptoms. But if the Bartholin’s cyst grows large, it can become uncomfortable and lead to pain in vulva when you have sex, walking, or sitting down. If vulva is swollen, red, tender, and hot, that means the cyst has become infected and has caused an abscess in one of the Bartholin’s glands. Biopsy may be done. Causes Unknown it may be due to a sexually transmitted infection (STI) like gonorrhea. About two out of 10 women can expect to get a Bartholin's gland cyst at some point. It typically happens in 20s. They are less likely to develop as you age. Vaginitis This is an inflammation of the vagina. 1/3 of women will have symptoms of vaginitis sometime during their lives. Vaginitis affects women of all ages but is most common during the reproductive years. It normally results from an infection (a bacterial, yeast, or viral infection). The patient typically has a discharge, itching, burning, and possibly pain. It is a common condition, and most women will have it at least once at some time in their life. The vagina is the muscular canal that runs from the cervix to the outside of the body, lined by a mucus membrane. Contd It has an average length of about 6 to 7 inches. The only part of the vagina that is normally visible from the outside is the vaginal opening Also may be as a result of low levels of estrogen. When the vagina and vulva are both inflamed, it is known as vulvovaginitis. Causes of Vaginitis A change in the balance of the yeast and bacteria that normally live in the vagina can result in vaginitis. This causes the lining of the vagina to become inflamed. Factors that can change the normal balance of the vagina include the following: Use of antibiotics Changes in hormone levels due to pregnancy, breastfeeding, or menopause Douching Spermicides Sexual intercourse Infection Symptoms of vaginitis Irritation of the genital area Discharge that may be white, gray, watery, or foamy Dyspareunia Foul or fishy vaginal odor DIAGNOSIS High vaginal swab Sample of the discharge from the vagina can be tested. Treatment Treatment will depend on the cause of the vaginitis. Treatment may be either with a pill or a cream or gel that is applied to the vagina. FISTULA A fistula is an abnormal tortuous opening between two internal hollow organ or between an internal hollow organ and the exterior of the body. It may be congenital in nature, sustained during surgery, vaginal delivery, radiation therapy Types Vesico vagina fistulae Recto vagina fistulae Vesico vaginal fistulae Vesicovaginal fistula (VVF) is an abnormal opening between the bladder and the vagina that results in continuous and unremitting urinary incontinence. This is an abnormal fistulous tract extending between the bladder and the vagina that allows the continuous involuntary discharge of urine into the vaginal vault. In addition to the medical ordeal from these fistulas, they often have a profound effect on the patient's emotional well-being. Rectovaginal fistulae There is fecal incontinence. The combination of fecal discharge with leukorrhea results in malodor that is difficult to control. Aetiology A rectovaginal fistula may result from: Injury during childbirth Crohn's disease or other inflammatory bowel disease Radiation treatment or cancer in the pelvic area Complication following surgery in the pelvic area Symptoms Passage of gas, stool or pus from your vagina Foul-smelling vaginal discharge Recurrent vaginal or urinary tract infections Irritation or pain in the vulva, vagina and the area between your vagina and anus (perineum) Pain during sexual intercourse Classification according to size Small 6cm Obstetric Fistula A medical condition in which a hole develops in the birth canal as a result of child birth Between the vagina and rectum Ureter or bladder Resulting in incontinence of urine or feces Cervix Cervical erosion- Is a common condition caused when cells inside the cervical canal are present on the outside surface of the cervix.(neck of the womb) The columnar epithelium proliferates more rapidly than squamous epithelium resulting into ectopy (erosion). The columnar epithelium secrets mucin and the pregnant woman may present with increase vaginal discharge. This can be seen during cervical screening as the area appears red. There may be blood stained due to rupture of capillaries of the endocervical epithelium. Or bleeding after sexual intercourse. There may be history of low back ache dysmenorrhoea, menorrhagia and dyspareunia Cervical ectomy does not cause any harm and it heals without medical treatment. Management Treatment is done using heat/cautery, which hardens the soft cells and prevent them from bleeding. Silver nitrate is used to cauterise/ burn Polyps These are small, fragile, bright red , fleshy, benign growth which may cause bleeding. Its usually removed by torsion and sent for microscopic examination. Polyps and erosion are diagnosed on speculum examination done at early stage of pregnancy or part of investigation for local cause of vaginal bleeding and may occur due to an increase in estrogen level. Cancer Carcinoma of the cervix occurs in approximately 1 : 5000 women of child bearing years and a very serious complication during pregnancy There is no evidence to suggest that it become invasive during pregnancy Treatment is prescribed for the mother and husband if to terminate the life of the normal healthy baby or to allow pregnancy to continue with the risk of shortening the mother’s life Cancer of the Cervix Management Regular ultrasonic scan to assess the growth and development of the baby Continuation of pregnancy will culminate into caesarean section followed by radical hysterectomy and excision of pelvic lymph nodes and radiation therapy Adequate blood transfusion Physical care and support will be needed Endometritis This is inflammation of the endometrium, the inner lining of the uterus. Postpartum endometritis is an infection of the endometrium after childbirth It can also be divided into pregnancy- related (obstetric) or non-obstetric. It can be described as acute and chronic: Acute endometritis - is characterized by the presence of more than five neutrophils in a 400 power field in the endometrial glands. Endometritis Cont The acute form is usually from an infection that passes through the cervix as a result of an abortion, during menstruation, following childbirth, or placement of an IUD. Chronic endometritis is characterised by the presence of more than one plasma cell, (and lymphocytes) in a 120 power field in the endometrial stroma. Chronic endometritis is more common after menopause. Spreading to the tubes and ovaries is called salpingo-oophoritis Causes Gram-positive cocci - Staphylococcus spp., Group A and B Streptococcus spp. Gram-negative - Escherichia coli, Klebsiella spp., Chlamydia trachomatis, Proteus spp., Enterobacter spp., Gardnerella vaginalis, Neisseria spp. Anaerobes - Bacteroides spp., Peptostreptococcus spp. Others - Mycoplasma spp., Ureaplasma spp., tuberculosis. Diagnosis of Endometritis The diagnosis - endometrial biopsy Ultrasound may show presence or absence of retained tissue within the uterus. Uterine fibroid Uterine fibroids are benign (not cancerous) growths that develop from the uterine muscle of the uterus(myometrium) They also are called leiomyomas or myomas. The size, shape, and location of fibroids can vary greatly. They may be inside the uterus, on its outer surface or within its wall, or attached to it by a stem-like structure. A fibroid may remain very small for a long time and suddenly grow rapidly, or grow slowly over a number of years. Uterine Fibroid Cont. A woman may have only one fibroid or many of varying sizes. A fibroid may remain very small for a long time and suddenly grow rapidly, or grow slowly over a number of years. Fibroids are most common in women aged 30– 40 years, but they can occur at any age. Fibroids occur more often in blacks Uterine Fibroid Classification They are classified based on location in the uterus; Subserosal (fibroid projecting outside the uterus) Intramural(within the myometrium) Submucosal(projecti ng into the uterine uterine cavity) Risk factors African descent Age greater than 30- 40 years Early menarche Family history Nulliparity obesity Symptoms abnormal uterine bleeding usually excessive menstrual bleeding —pelvic pressure —Menstrual pain (cramps) —Vaginal bleeding at times other than menstruation Anemia (from blood loss) Pain-In the abdomen or lower back (often dull, heavy and aching. —Difficulty urinating or frequent urination —Constipation, rectal pain, or difficult bowel movements DIAGNOSTIC INVESTIGATION Ultrasound- use of sound waves to create a picture of the uterus and other pelvic organs. (tranducer). Lab test- to determine anemia Hysteroscopy- uses a slender device (the hysteroscope) to see the inside of the uterus. It is inserted through the vagina and cervix (opening of the uterus). Hysterosalpingography- is a special X-ray test. It may detect abnormal changes in the size and shape of the uterus and fallopian tubes. Sonohysterography- is a test in which dye is introduced into the uterus through the cervix. Ultrasonography is then used to show the inside of the uterus. The fluid provides a clear picture of the uterine lining. Laparoscopy- uses a slender device (the laparoscope)which is inserted through a small cut just below or through the navel. Fibroids on the outside of the uterus can be seen with the laparoscope Management The treatment of uterine fibroids should be tailored to the size and location of the tumors, the patient’s age, symptoms, desire to maintain fertility and access to treatment. The ideal treatment satisfies four goals; Relief of signs and symptoms, sustained reduction of the size of fibroids, maintenance of fertility and avoidance of harm. Management Drug therapy is an option for some women with fibroids. Medications may reduce the heavy bleeding and painful periods that fibroids sometimes cause Hormonal contraceptives Tranexamic acid NSAIDS Hormone therapy (GnRH) SURGICAL MANAGEMENT Myomectomy is the surgical removal of fibroids while leaving the uterus in place. Fibroids do not regrow after surgery, but new fibroids may develop. If they do, more surgery may be needed. Hysterectomy is the removal of the uterus. The ovaries may or may not be removed. Hysterectomy is done when other treatments have not worked or when the fibroid is very large. Fallopian abnomalities Fallopian tubes: inflammation, abnormalities – long and short tube; cul-de-sac in the tube, absence, ectopic pregnancy, salpingitis etc Fallopian tube The fallopian tube is an essential component of the normal reproductive process. The tube, which connects the peritoneal space to the endometrial cavity It captures the egg after ovulation and transports the sperm from the uterus to the fertilization site in the ampulla (the middle portion of the tube). The ampulla serves as the physiologic site for final gamete maturation, fertilization, and early embryonic development. What is salpingitis? Salpingitis is inflammation of the fallopian tubes. Salpingitis is a type of pelvic inflammatory disease (PID). PID refers to an infection of the reproductive organs. Inflammation can spread easily from one tube to the other, so both tubes may become affected. If left untreated, salpingitis can result in long-term complications. Salpingitis is one of the most common causes of female infertility. When not treated, the infection may permanently damage the fallopian tubes so that the eggs released each menstrual cycle can't meet up with sperm. Scarring and blockage of the fallopian tubes is the most frequent long-term complication of (PID). Types of salpingitis It is categorized as either acute or chronic. Acute salpingitis- here the fallopian tubes become red and swollen, and secrete extra fluid so that the inner walls of the tubes often stick together. The tubes may also stick to nearby structures such as the intestine Also the fallopian tube may fill with pus. But in rare cases, the tube ruptures and causes a dangerous infection of the abdominal cavity (peritonitis). Chronic salpingitis usually follows an acute attack. Causes of salpingitis Gonococcus (which causes gonorrhoea) Mycoplasma Staphylococcus Streptococcus. The bacteria can be introduced in a number of ways, including: sexual intercourse Insertion of an IUD (intra-uterine device) Miscarriage Abortion Childbirth Appendicitis. Symptoms Asymptomatic. When symptoms are present, client may experience: Foul-smelling vaginal discharge Yellow vaginal discharge Pain during ovulation, menstruation, or sex Spotting between periods Dull lower back pain Abdominal pain Nausea Vomiting Fever Frequent urination Who’s at risk? Those who have had an STI Have unprotected sex Have multiple sexual partners Have one partner who has multiple sexual partners INVESTIGATIONS Blood and urine tests. Swab test of vagina and cervix. Transvaginal or abdominal ultrasound. Hysterosalpingogram- This is a special type of X-ray that uses an iodine-based dye injected through the cervix. Laparoscopy- This minor surgical helps to view the length of the tube General examination - check for localized tenderness and enlarged lymph glands on pelvic examination Management Oral or intravenous antibiotics to fight bacterial infection. Sex partners will also require antibiotics. Encourage them to get tested for STIs. If the infection has caused scars or adhesions surgery will be required to remove the damaged areas. If fallopian tubes are filled with fluid, surgery is done to drain the fluid or remove the fluid-filled area. Complications Spread of infection to other areas of the body, including the uterus and ovaries Long-term pelvic and abdominal pain Tubal scarring Adhesions Blockages Infertility Abscesses in the fallopian tubes Ectopic pregnancy Abnormalities of fallopian tube The normal length is 7 -12 cm in length and less than 1cm in diameter. Long tube- more than 12cm Short tube- less than 7cm Cul de sac – closed/dead at one end Fallopian tube agenesis- a type of mullerian anomaly which is the absence of one of both fallopian tubes. Ectopic pregnancy An ectopic pregnancy occurs when a fertilized ovum implants outside the normal uterine cavity. It is a common cause of morbidity and occasionally of mortality in women of reproductive age. The aetiology of ectopic pregnancy remains uncertain although a number of risk factors have been identified. Its diagnosis can be difficult. In current practice, in developed countries, diagnosis relies on a combination of ultrasound scanning and serial serum beta-human chorionic gonadotrophin (β-hCG) measurements. CONTD May be as a result of damage or distortion of the fallopian. Implantation can occurs at any point on the tube. Lower mild lower abdominal pain with an occasional attack of sharp, stabbing pain with nausea Other signs of pregnancy may not be present Shock Ultrasonic scan may assist in diagnoses Surgical intervention is always required Abdominal pregnancy A rare and life threatening condition where the embryo or fetus is growing and developing outside the uterus but in the abdomen. The fetus usually dies and calcifies but a few go to term. Delivery is usually by laparotomy but often baby do have compression deformities Pelvic floor disorders Involves dropping down (prolapse) of the bladder, urethra, small intestine, rectum, uterus, or vagina caused by weakness of or injury to the ligaments, connective tissue, and muscles of the pelvis. Women may feel pressure or a sense of fullness in the pelvis or have problems with urination or bowel movements. A pelvic examination is done while a woman bears down to make abnormalities more obvious. The pelvic floor is a network of muscles, ligaments, and tissues that act like a hammock to support the organs of the pelvis: the uterus, vagina, bladder, urethra, and rectum. If the muscles become weak or the ligaments or tissues are stretched or damaged, the pelvic organs or small intestine may drop down and protrude into the vagina. If the disorder is severe, the organs may protrude all the way through the opening of the vagina and outside the body. Predisposing factors Having a baby, particularly if the baby is delivered vaginally Being obese Having an injury, as may occur during hysterectomy (removal of the uterus) or another surgical procedure Aging Frequently doing things that increase pressure in the abdomen, such as straining during bowel movements or lifting heavy objects Rectocele A rectocele develops when the rectum drops down and protrudes into the back wall of the vagina. It results from weakening of the muscular wall of the rectum and the connective tissue around the rectum. A rectocele can make having a bowel movement difficult and may cause constipation. Women may be unable to empty their bowels completely. Some women need to place a finger in the vagina and press against the rectum to have a bowel movement. Prolapse of the Bladder Rectum prolapse Enterocele This develops when the small intestine and the lining of the abdominal cavity (peritoneum) bulge downward between the vagina and the rectum. It occurs most often after the uterus has been surgically removed (hysterectomy). An enterocele results from weakening of the connective tissue and ligaments supporting the uterus or vagina. An enterocele often causes no symptoms. But some women feel a sense of fullness or pressure or pain in the pelvis. Pain may also be felt in the lower back. Cystocele and cystourethrocele A cystocele develops when the bladder drops down and protrudes into the front wall of the vagina. It results from weakening of the connective tissue and supporting structures around the bladder. When aurethrocele and cystocele occur together, they are called a cystourethrocele. Contd Women with either of these disorders may have stress incontinence (passage of urine during coughing, laughing) If severe, these disorders can cause overflow incontinence (passage of urine when the bladder becomes too full) or urinary retention. After urination, the bladder may not empty completely. Sometimes a urinary tract infection develops. If the nerves to the bladder or urethra are damaged, women who have these disorders may develop urge incontinence (an intense, irrepressible urge to urinate, resulting in the passage of urine). Prolapse of the uterus The uterus drops down into the vagina. Caused by weakening of the connective tissue and ligaments supporting the uterus. The uterus may bulge in the following ways: - Only into the upper part of the vagina - Down to the opening of the vagina - Partly through the opening - All the way through the opening, resulting in total uterine prolapse (procidentia) The extent of the drop determines the severity which are. Uterine prolapse Signs and symptoms Pain in the lower back or over the tailbone Difficulty having a bowel movement Pain during sexual intercourse Feeling of heaviness or pressure—a feeling that pelvic organs are dropping out. However, many women have no symptoms. Total uterine prolapse can cause pain during walking. Sores may develop on the protruding cervix (the lower part of the uterus) and cause bleeding, a discharge, and infection. Prolapse of the uterus may cause a kink in the urethra. A kink may hide urinary incontinence if present or make urinating difficult. Prolapse of the vagina In prolapse of the vagina, the upper part of the vagina drops down into the lower part, so that the vagina turns inside out. The upper part may drop part way through the vagina or all the way through, protruding outside the body and causing total vaginal prolapse. Total vaginal prolapse may cause pain while sitting or walking. Diagnosis A pelvic examination – Speculum A woman may be asked to bear down (as when having a bowel movement) or to cough. She may be examined while standing with one foot on a stool. The resulting pressure in the pelvis from bearing down, coughing, and/or standing may make a pelvic floor disorder more obvious. If a woman has a problem with the passage of urine or urinary incontinence, a flexible viewing tube may be used to view the inside of the bladder (a procedure called cystoscopy) or the urethra (a procedure called urethroscopy). These procedures helps to determine whether drugs or surgery is the best treatment. If the bladder is not functioning well, women are more likely to need surgery. If sores are present biopsy may be done to check for cancer. Management 1. Pelvic floor exercises 2. Insertion of a pessary : A device called a pessary may be inserted into the vagina to support the pelvic organs. 3. Surgery Exercises Pelvic floor exercises : Kegel exercises Heel slides exercises Marches is also called toe taps Pessaries Pessaries are especially useful for women who are waiting for surgery or who do not want or cannot have surgery. A pessary may be shaped like a diaphragm, cube, or doughnut. Some can be inflated Some women choose to wear the pessary constantly. Other women choose to remove the pessary sometimes (for example, overnight). Women are taught how to insert and remove the pessary for cleaning. Pessaries may cause a foul-smelling discharge. The discharge can be reduced by regular cleaning. Surgery Surgery is done if symptoms persist after women have tried pelvic floor exercises and a pessary. Vaginal surgery: Surgery is done through the vagina rather than the abdomen. In such cases, no external incision is needed. Abdominal surgery: One or more incisions are made in the abdomen. Abdominal surgery includes the following: Laparotomy: An incision that is several inches long is made in the abdomen. Laparoscopic surgery: A viewing tube (laparoscope) and surgical instruments are inserted through several tiny incisions in the lower part of the abdomen. For rectoceles, enteroceles, cystoceles, and cystourethroceles colporrhaphy may be done). Post Surgery If vaginal prolapse is severe and women do not plan to be sexually active, another option is vaginal obliteration here, most of the vagina's lining is removed, and the vagina is stitched shut After surgery to correct a pelvic floor disorder, a catheter is often inserted in the bladder to drain the urine for up to 24 hours. If urinary incontinence is present or would occur after this surgery, surgery to correct incontinence can usually be done at the same time. Then the catheter to drain urine may need to remain in place longer. Lifting, straining, and standing for a long time should be avoided Cord prolapse This is when the cord is felt at the vagina following rupture of the membranes or is felt on vaginal examination to be coming down below the presenting part. Incidence is about 1 in 300 deliveries Associated factors Transverse lie, breech Prematurity Multiple gestation Placenta praevia. Cord prolapse Aim is to preserve the membranes and to expedite the delivery Gently feel the cord to check if there are pulsations. If pulsating the fetus is alive. Determine the lie and the presenting part, if transverse, mother requires caesarean operation. Perform vaginal examination to determine status of the labour. Prevent presenting part pressing on the cord. Manually displace the presenting part. Palpate the bladder, catheterize if full. Allow her to lie on knee elbow position Refer for ceasaran section Pelvic inflammatory disease PID is an infection of the fallopian tubes, ovaries, and the surrounding areas of the pelvis. It can damage a female’s reproductive organs. PID usually is caused by sexually transmitted diseases (STDs). Breast abnormalities BREAST ENGORGEMENT Occurs around the 3rd -4th day post partum. The breast is hard, painful and heavy. The mother may develop a pyrexia, engorgement result from an increase in the blood volume in the breast with accompanying oedema. Early feeding helps to prevent engorgement. The condition may occur when the baby is unable to feed efficiently because he is not correctly attached to the breast. MANAGEMENT Management should be aimed at enabling the baby to feed well. Sometimes a breast pump can be used for the same purpose Bath the breast in hot water before feeds and gently stroke them with soapy hands towards the nipple. Quicker resolution will occur if the baby is allowed to feed completely from the 1st breast before being offered the other one In severe cases the only solution will be the gentle use of a pump. The mother’s fluid intake should not be restricted as this has no direct effect on breast function MASTITIS This is inflammation of the breast, it may occur as the result of an infective process but in over 50% of cases there is no infective component initially. One or more adjacent segment is inflamed and appear as a wedge shaped area of redness and swelling. It is extremely important that breast feeding from the affected breast continues, otherwise milk stasis will increase further and provide ideal condition for pathogenic bacteria to replicate. MANAGEMENT Position and attach baby properly when breast feeding. Encourage mother to allow baby to finish the 1st breast before putting baby to 2nd breast If no improvement during the period, antibiotics should be given BREAST ABCESS A fluctuant swelling develops in a previously inflamed area, pus may be discharged from the nipple. Simple needle aspiration may be effective or incision and drainage may be necessary. It may not be possible to feed from the affected breast for a few days but breast feeding should be commenced as soon as possible. SORE AND DAMAGED NIPPLES The cause is almost always trauma from the baby’s mouth and tongue, which result from incorrect attachment of the baby to the breast. Correct attachment and positioning will provide immediate relief from pain and will also allow rapid healing to take place. Resting the nipple also enables healing to take place but makes the continuation of lactation much more complicated because it is necessary to express the milk and to use some other means of feeding the baby. CRACKED NIPPLE The nipples are tender and painful, the mother is asked to report early. Early recognition and prompt treatment will result in more rapid healing. The milk is expressed manually, baby is taken off breast, ointment can be applied sparingly to bring about soothing. CARE OF THE BREAST Daily washing is all that is necessary for breast hygiene. The normal skin flora are beneficial to the baby. Brassieres may be worn in order to provide comfortable support and are useful if they leak and breast pads are used. What is Breast Cancer ? Breast tissue growing without control and moving to other parts of the body It can grow and stay for years or kill in months Not fully understood but it is still being studied all over the world Why does breast cancer occur ? Non- Modifiable; ◦Poor diet modifiable; ◦Smoking ◦Gender ◦Alcoholism ◦Age ◦Drugs ◦Obesity ◦Races ◦Lack of exercise ◦Hereditary ◦Environmental ◦Some diseases pollution PLEASE NOTE A- Admission R – Reassurance I- Investigation D- Diet E - Elimination D - Drugs E – Examination P – Psychological support O- Observation P- Pain management/ positioning A- Advice on discharge Assignment
