Pelvic Inflammatory Disease (PID) - Medical Surgical Notes PDF

**Pelvic Inflammatory Disease (PID), pg 4490** - Inflammatory condition of the pelvic cavity that may begin with cervicitis and result in infection in the reproductive organs. Ascending infection that results from a cervical infection (lecture) - Acute, subacute, recurrent or chron...

**Pelvic Inflammatory Disease (PID), pg 4490** - Inflammatory condition of the pelvic cavity that may begin with cervicitis and result in infection in the reproductive organs. Ascending infection that results from a cervical infection (lecture) - Acute, subacute, recurrent or chronic; localized or widespread - One of the biggest threats to a woman\'s fertility (lecture) - Causes: **Usually bacterial; MCC are Chlamydia and Gonorrhea,** sometimes attributed to a virus (CMV), fungus or parasite - Risk factors: early age at first intercourse, unsafe sex, sex with partner with STD, previous infection or history of STDs, bacterial vaginosis - **Clinical Manifestations** - **KNOW S/sx: dysuria, Dyspareunia, lower abdominal pelvic pain \["PID shuffle"\], and tenderness with menses**, **abnormal bleeding, Vaginal discharge, pain is worse with urination or defecation** - Progressive symptoms: really high fever, fatigue, rigor, malaise, anorexia, N/V, and HA - **Physical exam: KNOW cervical motion tenderness or "chandelier sign"** - **Pelvic exam that moves the cervix back and forth. If positive, there is significant pain and tenderness** - Problems: **ectopic pregnancy**, infertility, abscess, adhesions which affects all organs, recurrent pelvic pain - **KNOW** Inflammation causes scarring which narrows the fallopian tubes leading to **ectopic pregnancies** - **KNOW S/sx ectopic pregnancy:** Unilateral pain, shoulder pain, abnormal bleeding, dizziness/fainting, delayed menses, may have fever, etc. - Complications: **bacteremia with septic shock** and thrombophlebitis w/ emboli, **tubo-ovarian abscess, adhesions** - **Treatment** - **Broad-spectrum abx: Doxycycline, Azithromycin, and Ceftriaxone combination** "**DAC"** - Possible hospitalization with bedrest, fluids and IV pain meds & abx - NG tube/suction for abdominal distention if they have GI involvement (not in book) - Patients should be admitted if they are pregnant, no improvement from therapy, severe illness (fever, N/V), development of tubo-ovarian abscess, or inability to follow instructions or management outpatient therapy - Tubo-ovarian abscess: big abscess that can occur on the ovary OR in the fallopian tube; can be life-threatening if ruptures bc infectious pus will go into pelvic cavity - Nursing Management - **KNOW EDUCATE: chart 51-3, pg 4493** - **Healthy practices (proper nutrition/exercise/wt control), safe sex, social support** - **Emphasize finishing full course of abx** - **Proper perineal care \[wiping front to back\]** - **Teach s/s to report to hcp:** - Pelvic pain or abnormal discharge, particularly after sexual exposure, childbirth, unusual odor, dizziness, shoulder pain, delayed menses or pelvic surgery. - Pain, abnormal bleeding, delayed menses, faintness, dizziness, and shoulder pain (symptoms may indicate ectopic pregnancy). - **Follow-up appointment \[therapy, medical app., medications\] & yearly pap smear** - **Identify the need for health promotion, disease prevention, and screening activities.** - **Prevention and recurrent infections** - **Infection control for staff, patient and family (take proper precautions)** - Bed rest and semi-Fowlers to help with drainage - Record drainage amount and characteristics - Analgesics for pain, Heat to abdomen **Fistulas of the Vagina** - **KNOW Fistula** is an abnormal opening b/w two internal hollow organs or internal organ and exterior of body - **Clinical Manifestation depends on defect** - **Vesicovaginal fistula**: fistula b/t bladder & vagina causing urine to leak from bladder into vagina - **Rectovaginal fistula**: fistula b/t vaginal canal and rectum causing fecal incontinence & flatus passing through vagina - **S/sx: pressure, fecal matter in the vagina** - Diagnosis: symptoms, methylene blue dye/indigo carmine IV, cystoscopy or IV pyelography - Tampon Test: methylene blue dye instilled into bladder along with vaginal packing - Stained vaginal packing = vesicovaginal fistula - Medical Mgmt - **KNOW Tx the s/s**: **cleansing enemas, douching for cleaning, may have to do sitz bath, skin care and psychosocial support (main goal is to prevent infection)** - Symptomatic treatment but may need surgery; can reoccur - Often urinary or fecal diversion needed if large or multiple surgeries needed - Patient teaching: - **KNOW Rectovaginal fistula: low fiber and low-residue diet for healing** **Pelvic Organ Prolapse** - Pelvic floor muscles weaken w/ age & childbirth - **Cystocele** = downward displacement of bladder - s/s: pelvic pressure, stress incontinence, freq/urgency, back and pelvic pain - **Rectocele** = upward pouching of rectum that pushes vagina anteriorly/forward - S/sx: Rectal pressure, fecal incontinence, constipation, uncontrolled gas - **Enterocele** = protrusion of intestinal wall into the vagina - s/s: Pelvic pain & pressure, low back pain that's worse when lying down - Clinical Manifestations depend on prolapse location but all will have **dyspareunia** - Medical Mgmt - **KNOW Kegel exercises: Hold the pelvic floor muscles 10 sec, release, then repeat 30-80 times a day** - Pessary: soft, removable device inserted into vagina to provide support; "props everything up" - Surgery **Female Reproductive Cancer** - Malignant conditions: Cervical, Uterine, Ovarian, Vaginal, Vulvar - **s/s of vulvar cancer is ulceration that does not heal** - Nursing importance - **Annual pelvic exams and pap smears are painless and relatively inexpensive** - **VERY important for early detection (if found early/in situ, the survival rate is 100%)** - Provide a non-stressful environment - Educate patient about what will happen during the procedure - Allow the patient to ask questions - Nurses need to educate themselves on suggested time frame on procedure and ongoing clinical trials for treatment - Recommended Screening - **Cervical cancer screening (testing) should begin at age 21.** Women under age 21 should not be tested. - Women between ages 21 and 29 should have a Pap test every 3 years - HPV testing should not be used in this age group unless it is needed after an abnormal Pap test result. - HPV can cause dysplasia and cancer (lecture) - Women between the ages of 30 and 65 should have a Pap test plus an HPV test (called "co-testing") every 5 years. This is the preferred approach, but it is also OK to have a Pap test alone every 3 years. - Women over age 65 who have had regular cervical cancer testing with normal results should not be tested for cervical cancer. - **A woman who has been vaccinated against HPV should still follow the screening recommendations for her age group.** **Cancer of the Cervix, pg 4516** - Predominantly Squamous Cell Cancer, Adenocarcinoma or mixed adenosquamous carcinoma - If not detected, it may spread to pelvic lymph nodes - **Adenocarcinoma**: begins in the mucus-producing glands and are often due to HPV infections (her notes) **KNOW Chart 51-5 pg. 4517: Risk Factors for cervical cancer** - **RIsk factors to know: HPV types 16 and 18 and low socioeconomic status (may be related to early marriage and early childbearing)** - **Clinical Manifestation** - **Early:** thin, watery vaginal discharge after intercourse/douching - **Advanced/Late:** vaginal discharge, irregular bleeding, pain/bleeding with or after intercourse - **More Advanced**: dark-foul smelling discharge, irregular vaginal bleeding - The dark foul smell is form the tumor advancing and necrosis - **Most common symptom of cervical cancer is irregular bleeding** - As it advances further, bleeding gets worse, leg pain, dysuria, rectal bleeding & edema accompany - As it metastasizes, nerves may become involved which leads to pain, emaciation, anemia \[due to blood loss\], fistula formation, abscesses and secondary infections - Diagnosis - Abnormal Pap smear → biopsy → ID the dysplasia - CIN III, HGSIL, or carcinoma in situ (means that there is severe dysplasia that is in the cervix but has not extended beyond) - Early -- microscopic identification - Later -- abnormalities on pelvic exam - Stages (pg 4518-1419) - Invasive Stage -- **TNM**: T= tumor extent, N= lymph nodes involved, M= metastasis or spread of the disease - Stage will determine testing; labs, X-Ray, punch biopsy and colposcopy, D&C - **KNOW Colposcopy: allows the examiner to visualize the cervix and obtain a sample of abnormal tissue for analysis** - **Cervical cancer is mainly diagnosed by?** - **Pap smear, Colposcopy** - Medical Management - **Precursor or Preinvasive Cancer** - **KNOW Simple hysterectomy: removal of the uterus only** - **Used when not in child-bearing age** - **KNOW LEEP: thin wire loop is used to cut away tissue; removes abnormal cells** - **The gynecologist excises a small amount of cervical tissue, and the pathologist examines the borders of the specimen to determine if disease is present** - Cryotherapy or Laser\ Conization: cone shaped portion of cervix is removed - Used for child-bearing age and when tumor is excisable size - **Invasive Cancer** - Depends on stage, patient's age, general health, judgment and experience of healthcare provider - Tumor \< 3 mm: hysterectomy is treatment of choice - Tumor \> 3 mm: radical hysterectomy with pelvic/aortic node assessment - **NOT ON THE EXAM** Radical trachelectomy (pulls the cervix into the vagina, affected tissue is removed, and cervix is closed up) - [Radiation or Brachytherapy]: radioactive source placed into the vagina near the tumor to directly tx teh affected location; **pt will need an isolation room** - [Pelvic exenteration]: large portion of pelvic contents removed- very extensive with lots of possible complications so not often seen - **Chart 51-6 p. 4520** Surgical Procedures for Cervical Cancer - Total hysterectomy, radical hysterectomy, radical vaginal hysterectomy, bilateral pelvic lymphadenectomy, pelvic exenteration, and radical trachelectomy - Recurrence- w/I 2 years, upper quadrant of vagina and ureteral obstruction - Preventative - Frequent follow-up after surgery b/c the risk of recurrence is high and usually occurs within the first 2 years - Pelvic and Pap in all women-even older - Delay first intercourse, Avoid/protect against HPV infection (Immunize), Safe Sex, Stop smoking **Cancer of the Uterus (Endometrial cancer)** - Pathophysiology: **most are endometrioid \[originating in the lining of the uterus\]** - Type 1- MC- estrogen related, occurs in young, obese and perimenopausal -- low grade - Type 2- 10%- high grade older women and AA - Type 3- 10%- hereditary and genetic type, Lynch II syndrome - **KNOW Risk factors: Obesity**, Caucasian (2x more likely), smoking, family hx, early menarche, advanced age (usually \> 50, average is 63 years), unopposed estrogen therapy \[estrogen used without progesterone\], late menopause (after 52), prior use of tamoxifen - Prevention: taking birth control pills, pregnancy, IUD, exercise - **Clinical Manifestations: KNOW Menopausal experiencing bleeding \[biggest s/s\]**, thicker endometrium - Dx: if bleeding, HCP will do a endometrial aspiration/biopsy, transvaginal US can also be used - Grading Cancer/Tumor grade - The description of a tumor based on how abnormal the tumor cells and tumor tissue look under a microscope - An indicator of how quickly the tumor is likely to grow and spread. - Grading systems differ depending on the type of cancer. - May be one of the factors considered when planning treatment for a patient - [Grade 1]: the tumor cells and the organization of the tumor tissue appear close to normal - tumors tend to grow and spread slowly - [Grade 3 + 4]: cells of tumors do not look like normal cells and tissue - grow rapidly and spread faster than tumors with a lower grade. - Medical Management - Total or radical hysterectomy, Bilateral salpingo-oophorectomy and node sampling - Cancer antigen 125 Normal 0-35 units/ML - Stage depends on treatment - Adjuvant Radiation (chemo + radiation) - Vaginal brachytherapy, Whole pelvic radiotherapy - Progestin therapy - Provera; Megace/megestrol: slows growth, and helps treat s/s of hot flashes, night sweats, and weight gain) **Cancer of the Ovary/Ovarian cancer** - Pathophysiology: most common cause is epithelial tumors; also germ cell and stromal tumors - Most women w/ ovarian cancer have no known risk factors - Risk factors: **KNOW family history (most significant risk factor)**, breast cancer, elderly, low parity, obesity, early menarche, late menopause - Incidence increases after 40 yr old peaks in early 80s - **Mutation of BRCA1 gene are @ increase risk (28-40%)** - Pregnancy and PO birth control decreases risk - Family history: genetics/ prophylactic surgery - **KNOW S/sx:** - **Increased abdominal girth (most common sign), urinary urgency/retention, pelvic pain, bloating Pelvic pressure, Back and abdominal pain** - Nonspecific, Constipation, indigestion, flatulence, increased waist size, leg pain - **Dx: colposcopy** & biopsy - Chart 51-8, pg 4532 (main stages of ovarian cancer) - Treatment - Surgical removal of the ovaries and affected organs - Chemo: paclitaxel and carboplatin (can cause leukopenia, neurotoxicity, paraesthesia, and fever) - Liposomal therapy: doxorubicin - May have to administer IV fluids to alleviate fluid and electrolyte imbalances - If the pt develops ascites: provide small frequent measles, decrease fluid intake, give diuretics, and provide rest (book) - Nursing management - Based on s/s & tx, emotional & educational support, comfort measures, pain control, infection prevention \[b/c leukopenic & neutropenic\] - Increased fluid retention: administer IV fluids/electrolyte balance, TPN **Hysterectomy** - **Total**: remove uterus, ovaries and cervix (surgical incision) - **Vaginal**: uterus removed through vagina - **Supracervical**: uterus removed but leaves cervix's stump - **Radical**: removing tissue surrounding uterus, uterus, upper vagina, ovaries, fallopian tubes - Malignant conditions usually require total abdominal hysterectomy and bilateral salpingo-oophorectomy - **Nursing Management** - [Pre op]: prophylactic abx, rule out pregnancy by doing a pregnancy test, NO NSAIDS, vitamin E, or aspirin - [Post op]: monitor for hemorrhage/infection, voiding issues (nerve trauma can cause loss of bladder tone) - catheter is normally inserted b/c of proximity to area of surgery - Health history, PE, labs, psychosocial assessment - **KNOW Potential problems/complications: Hemorrhage, DVT, bladder dysfunction/distention** - Nursing dx: acute pain, deficient knowledge of perioperative. Aspects, **anxiety, disturbed body image** - **Body image: inability to have children & hormonal imbalance leading to depression & emotional sensitivity**