Sean Whitfield - NURS 3450 Learning Guide Module 3 updated FA23 - PDF

NURS 3450 Maternity and Women’s Health Nursing Module 3 Active Learning Guide - Chapters 9, 10, & 11 Purpose/Over...

NURS 3450 Maternity and Women’s Health Nursing Module 3 Active Learning Guide - Chapters 9, 10, & 11 Purpose/Overview Active learning guides help students focus their study time using knowledge-level information, then concentrate on applying and analyzing knowledge to provide a context concerning the course and career skills. Students should review the active learning guide before engaging with the module content, then work to complete the guide both during and after engaging with the content. An active learning guide is not the same as a study guide or a test blueprint. It serves as a guide to help the student navigate the course and content. The active learning guide is not a complete composite of the information needed for the exam but a guide to navigating the content delivery. The Sherpath Lessons that are included in the modules will also help you with grasping the material. They are interactive and thorough. Instructions Review the active learning guide before you begin reading and engaging with other content in the module. Looking at the questions beforehand will preview the information you will be learning, including the key concepts and takeaways. As you work through the module content, complete the active learning guide. Some questions may be reflective and require that you finish all content before responding. Students will turn in the completed learning guide by the end of the module. Faculty will review and award points and return them to students to review prior to the exam. There are 10 points possible for this learning guide. Reading Focus Areas In the text, you will see essential boxes, such as Safety Alerts, which discuss issues related to the care of our population. Evidence-Based Practice boxes contain a summary of pertinent current research related to chapter topics. Clinical Reasoning Case Studies are found in each chapter. The answers are available to you through the Elsevier Evolve Student Resource that you may register for (no additional cost). Legal Tips boxes are scattered throughout the text to give you important information on the legal aspects of women’s health. Cultural Consideration boxes give additional thoughtful material for the nurse to include in providing women and families with culturally competent care. Medication Guides are present for many medications that are used in women’s health. There are also Nursing Care Plans for many conditions. Much of women’s health nursing consists of educating our patients. To that end, there are many Teaching for Self-Management boxes throughout the text.  NURS 3450 Maternity and Women’s Health Nursing Chapter 9 Infertility 1. To guide your reading, you can review the Sherpath Lesson: Infertility. 2. Review boxes 9.1 & 9.2 on page 168. There are multiple factors that affect fertility for both male and females. List the 3 main categories for the female factors, and give 2-3 examples of each category. Then list the 3 main categories for the male factors, giving 2-3 examples in each category. 3. Review infertility assessment techniques for male and female patients. Describe the hormones assessed in female patients and hysterosalpingogram. Use this table to summarize your reading. Assessment Types of testing done Rationale/nursing implications Female Detection of Over-the-counter ovulation Test the urine for the luteinizing Ovulation detection kits hormone (LH) surge at 24 to 36 hours before ovulation. Hormone Analysis Testing biochemical markers and/or Biochemical measures include ultrasound imaging of the ovaries serum follicle-stimulating hormone (FSH) and estradiol (E2) on day 2 through 5 of the menstrual cycle. Imaging Transvaginal ultrasound and Used to assess pelvic structures magnetic resonance imaging (MRI) (Fig. 9.2) for abnormalities such as uterine fibroids and ovarian cysts;to verify follicular development and maturity; and to assess thickness of the endometrium around the time of ovulation. Sonohysterography uses fluid infused into the uterus through the cervix to help define the uterine cavity, using transvaginal ultrasound. Male Semen Analysis Assesses sperm number, Semen is collected by ejaculation morphology, and motility. into a clean container or a plastic sheath that does not contain a spermicidal agent. Ultrasonagraphy Scrotal ultrasound Used to examine the testes for the presence of varicocele and to identify abnormalities in the scrotum and spermatic cord. Hormone Analysis Hormone analyses are done for Testosterone levels should be testosterone and gonadotropins drawn in the morning for (FSH or LH) when abnormal sperm accuracy, as levels falls  NURS 3450 Maternity and Women’s Health Nursing parameters are detected throughout the day. Further (azoospermia or oligozoospermia) or laboratory analyses may be when a man has atrophic testes. indicated based on the results of the initial testing. 4. Complete drug cards for the following medications: clomiphene citrate Action Thought to bind to estrogen receptors in the pituitary, blocking them from detecting estrogen Indications Ovulation induction Route Dose Nursing Interventions/Patient Vasomotor flushes, abdominal discomfort, nausea and vomiting, Education breast tenderness, ovarian enlargement 5. Complete the following:  Case study: Infertility. (2023). In Sherpath for Maternal newborn (Lowdermilk version) (12th ed.). Elsevier. Nancy is a 39-year-old G2 P0 who has been unable to conceive a child for the last 3 years. Nine years ago, Nancy experienced a ruptured appendix that resulted in uterine tube adhesions. Four years ago, she experienced a ruptured tubal pregnancy resulting in adhesions in her uterine tube. She underwent surgery to remove the adhesions, but it was unsuccessful. Nancy and her husband strongly desire to conceive a child, and she is seeking information about assisted reproductive therapies (ARTs) at a fertility center. Refer to your textbook for answers. a. What are the ethical and legal issues that need to be discussed with the infertile couple before treatment? Ethical Issues Informed Consent Autonomy Confidentiality Non-Maleficence/Beneficence Justice Impact on Relationships Use of Donor Gametes or Surrogacy Potential for Multiple Pregnancies Legal Issues Legal Parentage Consent Forms Custody Embryo Surrogacy Agreements Regulations and Compliance Insurance and Financial Considerations b. What is in vitro fertilization–embryo transfer (IVF-ET)?  NURS 3450 Maternity and Women’s Health Nursing IVF-ET is a very effective assisted reproductive fertility treatment that can handle a diverse scope of fertility issues. Why would this method be helpful in this case? This couple would be great candidates for this procedure for the following criteria: If the mother has injured or blocked fallopian tubes, IVF has the ability to avoid that route for the sperm to fertilized egg via the fallopian tubes. If the father’s sperm quality is compromised, with IVF It is possible to directly fertilze the egg in a lab. If this couple suffers from infertility that cannot be explained. IVF can be used. c. How are the risks of multiple gestations minimized? Monitoring and controlled ovarian stimulation Restrict the number of transferred embryos Assess embryo quality Chapter 10 Problems of the Breast 1. To guide your reading, you can review the Sherpath Lesson: Breast Disorders, Structural Defects, and Neoplasms 2. Compare the following benign breast conditions Condition Signs & Symptoms Diagnosis Treatment Fibrocystic changes Fibrocystic changes A first diagnostic Treatment for most often present as step in the case of a fibrocystic changes lumpiness in both breast lump is is usually breasts, although there ultrasonography to conservative. can be single simple determine if it is Management cysts. Symptoms fluid-filled or solid. depends on the usually develop about Fluid-filled cysts are severity of the a week before aspirated, and the symptoms. Dietary menstruation begins woman is changes and and subside about a monitored on a vitamin week after routine basis for supplementation menstruation ends. development of are one They include dull heavy other cysts. If the management pain that may radiate lump is solid, approach. to the shoulders and mammography is Although research upper arms, and a obtained, and a findings are sense of fullness and core needle biopsy contradictory, tenderness, often in is performed on any some practitioners the upper outer suspicious lumps advocate reducing quadrants of the (Obeng-Gyasi, consumption of or breasts. There may be Grimm, Hwand, et eliminating fat and increased breast al., 2018). methylxanthines engorgement and (i.e., colas, coffee, density and in rare tea, chocolate). cases, nipple discharge. Some practitioners Physical examination suggest that  NURS 3450 Maternity and Women’s Health Nursing Condition Signs & Symptoms Diagnosis Treatment may reveal excessive women take mild nodularity that often diuretics shortly feels like peas (Sandadi before menses as et al., 2022). Women in well as decreasing their 20 s report the alcohol intake most severe pain. (Sandadi, Rock, Women in their 30 s Orr, et al., 2022). have premenstrual Some symptom pain and tenderness, relief may be and small multiple achieved by nodules are usually refraining from present. Women in both smoking and their 40 s usually do consuming not report severe pain, alcohol. but cysts will be tender Recommended and often regress in pain relief size. A woman with measures include fibrocystic change can analgesics or have cysts that nonsteroidal manifest as painful antiinflammatory enlarging lumps in her drugs (NSAIDs) breasts. Cysts are such as ibuprofen, common in wearing a premenopausal supportive bra, women who are not and applying heat receiving estrogen to the breasts. therapy. The cysts are soft on palpation, well Most women differentiated, and report relief while movable. Deeper cysts, taking oral especially aggregations contraceptives (De of cysts, are Silva, 2018). indistinguishable by Danazol and palpation from tamoxifen have carcinomas, which are also been used malignant growths that with varying infiltrate surrounding degrees of success tissue. for severe cases (Sasaki, et al., 2018). Evening primrose oil can be effective for some women, although adequate evidence of its benefit is lacking. It is important to stress  NURS 3450 Maternity and Women’s Health Nursing Condition Signs & Symptoms Diagnosis Treatment that women may need to try several approaches for a number of months before noting improvement. Surgical removal of nodules is attempted only in rare cases. In the presence of multiple nodules, the surgical approach involves multiple incisions and tissue manipulation and may not prevent the development of more nodules. Fibroadenoma A common solid mass Diagnosis is made Surgical excision of the breast is a by a review of the may be necessary fibroadenoma, client history and if the lump is composed of glandular physical suspicious or if the and stromal tissue. It is examination. symptoms are the most common type Mammography, severe. of tumor seen in ultrasonography, or Fibroadenomas do women in their 20 s magnetic resonance not respond to and 30 s but can occur imaging (MRI) and either dietary at any age. These core needle changes or tumors tend to shrink biopsies may be hormonal therapy. after menopause. used to determine Periodic Fibroadenomas are the type of lesion. observation of firm, nontender, masses through solitary masses with physical regular borders, most examination or often located in the mammography upper outer quadrant may be all that is (Ajmal, Khan, & Van necessary for Fossen, 2022). masses not Occasionally a woman requiring surgical with a fibroadenoma intervention. experiences tenderness in the mass during the menstrual cycle. Fibroadenomas do not increase in size  NURS 3450 Maternity and Women’s Health Nursing Condition Signs & Symptoms Diagnosis Treatment in response to the menstrual cycle (in contrast to fibrocystic lesions). The mass tends to remain the same size or increase in size slowly over time. Fibroadenomas increase in size during pregnancy and decrease in size as a woman ages. 3. Create drug cards for the following medications: Tamoxifen Action A selective estrogen receptor modulator that exerts antiestrogenic effects; attaches to hormone receptors on cancer cells and prevents natural hormones from attaching to the receptors. Indications For treatment of advanced-stage or metastatic breast cancer; treatment of early-stage breast cancer after breast cancer surgery and radiation therapy; to reduce the incidence of breast cancer in women at high risk. Route Administered daily, orally Dose dose can vary depending on the reason for taking tamoxifen. Nursing The medication may be taken on an empty stomach or with food. Interventions/Patient Missed doses should be taken as soon as possible, but taking two Education: doses at once is not recommended. A barrier or nonhormonal form of contraception is recommended in premenopausal women because tamoxifen may be harmful to the fetus if pregnancy should occur. Client counseling should concentrate on annual Papanicolaou (Pap) test (if no hysterectomy), annual eye examination, bone density testing every 3 years, and liver function tests (LFTs) every 6 months. Patient Education: Common side effects include hot flashes, night sweats, nausea, vaginal discharge, mood swings, weight gain, and cataracts. Hair loss is an uncommon effect. Serious side effects include deep vein thrombosis, increased risk of endometrial cancer, and stroke. Symptoms of these serious side effects include abnormal vaginal bleeding, leg swelling or tenderness, chest pain, shortness of breath, weakness or numbness of extremities, sudden severe headache, and chemical hepatitis.  NURS 3450 Maternity and Women’s Health Nursing Letrozole Action An aromatase inhibitor; inhibits the conversion of androgens to estrogen. Indications For adjuvant treatment of early breast cancer in postmenopausal women who have received 5 years of tamoxifen therapy; first-line treatment of postmenopausal women with hormone receptor- positive or hormone receptor-unknown locally advanced or metastatic cancer; adjuvant treatment of postmenopausal women with hormone receptor-positive early breast cancer. Route Orally, daily Dose dosage dependent upon individual woman. Nursing The medication may be taken on an empty stomach or with food. Interventions/Patient Missed doses should be taken as soon as possible, but taking two Education: doses at once is not recommended. The woman should use caution if driving or using machinery because this medication may cause drowsiness or dizziness. Patient Education: Common side effects include hot flashes, nausea, increased sweating, joint or muscle pain, fluid retention, vaginal dryness, constipation, dizziness, fatigue, and headache. Severe side effects include serious allergic reactions (e.g., rash, hives, difficulty breathing), vomiting, chest pain, intense bone pain, and calf pain or tenderness. 4. List the risk factors for breast cancer (be specific). Non-Modifiable Some risk factors are nonmodifiable (i.e., cannot be changed) such as heredity, sex, age, family history, and reproductive history (e.g., time of menarche, menopause, and time of first live birth). The length of time on unopposed estrogen is a significant risk factor. Having a personal history of breast cancer is a constant risk factor, leading to a risk for developing a second malignancy. Menarche before age 12 and menopause after age 55 increase breast cancer risk due to longer exposure to hormones. Having fibrocystic disease with any of the previously discussed proliferative diseases with atypia increases the risk of breast cancer. Higher breast density is associated with increased risk; in addition, greater density may make interpretation of mammography more difficult. Diethylstilbestrol (DES), a drug used several decades ago to maintain pregnancy, is slightly correlated with elevated risk. Another risk factor is family history of breast or ovarian cancer in a first degree relative or multiple relatives(ACS, 2021a; CDC, 2021). Modifiable Some risk factors for breast cancer are modifiable; these are related to lifestyle behaviors and decisions about childbearing and use of hormones. Breast cancer risk is increased among women who are overweight or obese after menopause, consume moderate to high amounts of alcohol, are physically inactive, and take some type of hormone therapy (e.g., hormone- replacement therapy during menopause for more than 5 years, oral contraceptives). Never  NURS 3450 Maternity and Women’s Health Nursing having children, first pregnancy after the age of 30, and not breastfeeding also increase breast cancer risk (ACS, 2021a; CDC, 2021). BOX 10.1 Risk Factors Included in the Breast Cancer Risk Assessment Tool Age of woman Number of first-degree relatives affected Age of woman at menarche Age of woman at first live birth Number of breast biopsies History of atypical hyperplasia in biopsy specimens 5. What are the clinical manifestations of breast cancer? When breast cancer is detected either as a palpable lump or as an ill-defined thickening in the breast, it is usually painless. One might see nipple retraction, skin dimpling or skin changes to the nipple, or redness with edema and pitting of the skin, which is suggestive of a locally advanced and aggressive form of breast cancer. Lymph nodes are always clinically examined to determine the extent of the clinical stage. Clinical staging helps in understanding the parameters of the breast problem and whether lymph node involvement is suspected. The clinical stage helps providers decide how to proceed with treatment. This stage is determined by a combination of the TNM system, the grading system, and a biomarker determination (NCI, 2022) (Table 10.3). It sorts stage by size of tumor, lymph node, and whether metastasis is involved. It is the pathologic stage, which is determined after surgery, that really correlates with overall prognosis and risk for recurrence at 2, 5, or 10 years. 6. Describe the 4 types of surgical alternatives for breast cancer (from your textbook). Radiation Radiation is recommended for women who have BCS and for some women following a mastectomy with the goal of decreasing incidence of local recurrence (ACS, 2021d). Radiation to the breast destroys tumor cells remaining after manipulation and handling of the tumor during surgery. Women with positive axillary lymph nodes may receive radiation therapy after mastectomy and axillary lymphadenectomy. It is recommended for women with negative lymph nodes who have a tumor greater than 5 cm or positive surgical margins (Sandadi et al., 2022). The risk of local recurrence depends on the extent of breast resection, tumor margins, technical details of radiation therapy, and use of adjuvant systemic therapy. Although radiation after BCS is standard protocol, some large breast tumors (owing to the disease being locally advanced) may be irradiated before surgery to facilitate easier surgical removal. Side effects of radiation therapy include swelling and heaviness in the breast, sunburn-like skin changes in the treated area, and fatigue. Changes to the breast tissue and skin usually, but not always, resolve in 6 to 12 months. The breast may become smaller and firmer after radiation therapy. Radiation therapy in the area of the axilla can cause lymphedema of the arm on the affected side. Close medical follow-up is important after conservative surgery and radiation. Recommended guidelines include a  NURS 3450 Maternity and Women’s Health Nursing breast physical examination every 4 to 6 months for 5 years and then yearly. A mammogram is recommended 6 months after radiation and then annually (National Comprehensive Cancer Network [NCCN], 2022). A variety of radiation methods are widely used. These include the following (ACS, 2021d): Accelerated breast radiation. External beam radiation for 6 weeks, 5 days a week, can be inconvenient for a woman. Research has been conducted to develop ways to shorten this time frame and still deliver the therapy needed to prevent recurrence of this disease. Accelerated radiation was created with this goal in mind and delivers a slightly larger dose of radiation over a 3-week period. Skin changes (resembling sunburn) can be slightly more prevalent because of the more intense period of time and corresponding dosage. Brachytherapy. Initially created for other types of cancer, such as prostate, this form of radiation enables the client to complete her radiation in an even shorter time and is not delivered via external beam. Instead, a deflated balloon is inserted into the space left by the lumpectomy and is filled with saline. The balloon is left in place until the margins are confirmed as clear. The balloon is removed and replaced with another balloon specifically created to allow radiation to be inserted within it. Radiation rods or seeds are inserted into the balloon each day for 5 days, and the radiation is completed, at which time the balloon is removed. This enables partial breast radiation to be delivered, recognizing that most local recurrences happen at or near the location of the original cancer. Partial breast radiation. Intraoperative radiation is done at the time of surgery in the operating room. Indications are for small, less aggressive tumors. This technique is not yet standard of care. Adjuvant Systemic Therapy Chemotherapy administered soon after surgical removal of the tumor is referred to as adjuvant chemotherapy. The role of adjuvant chemotherapy (chemotherapy and endocrine therapy) in treating breast cancer is either to eradicate or to impede the growth of micrometastatic (microscopic cell metastasis) disease. Often it is not possible to detect the presence of micrometastasis at the time of initial treatment, and when it is present, mutations can occur in the tumor cells. These mutations make tumor cells resistant to the effects of chemotherapeutic agents despite tumor sensitivity to drug therapy being greatest when the tumor burden is small. Consequently, the prediction cannot be made with confidence that all tumors of 1 cm or less can be cured with initial local and regional treatment. The early introduction of systemic adjuvant therapy, as determined by the estimated risk of tumor recurrence in certain subsets of women with node-negative disease, is a prudent course of treatment. Adjuvant therapy may help to destroy undetected cancers that were not surgically removed (Lindberg, 2022). For women diagnosed with early-stage breast cancer and favorable prognostic factors (hormone receptor positive and HER2/neu negative), a special pathology test may help determine the woman’s risk of recurrence. This test, called Oncotype DX, provides a score that represents the likelihood of her specific cancer recurring. Such information can be useful for a woman whose known benefit for receiving chemotherapy may be minimal based on her prognostic factors from the tumor itself. For women with a low score, commonly, only hormonal therapy is recommended, and for women with a high score, chemotherapy is strongly considered.  NURS 3450 Maternity and Women’s Health Nursing Neoadjuvant therapy is systemic treatment given before surgery. The goal is to reduce tumor burden, making breast-conserving treatment an option. Hormonal Therapy To determine whether a woman is a candidate for hormonal therapy, a receptor assay is done. After the entire tumor or a portion is removed by biopsy or excision, a pathologist examines the cancer cells for ERs and PRs. The presence of a receptor on the cell wall indicates that the woman is positive for that type of hormone receptor. If these receptors are present, the growth of the woman’s breast cancer can be influenced by estrogen, progesterone, or both. It is unknown exactly how these hormones affect breast cancer growth. Bilateral oophorectomy may benefit women diagnosed with their first breast cancer before age 50 by reducing exposure to endogenous estrogen. For women with BRCA1 or BRCA2 mutations, a prophylactic salpingo-oophorectomy greatly reduces the risk of ovarian cancer and can reduce the risk of breast cancer by 50% (O’Donnell, Axilbund, & Euhus, 2018). There are two hormonal or endocrine therapy drug classes, selective estrogen receptor modulators (SERMs) and aromatase inhibitors (AIs). Tamoxifen, the oldest and longest used drug, is an oral antiestrogen medication that mimics progesterone and estrogen. Tamoxifen attaches to the hormone receptors on cancer cells and prevents natural hormones from attaching to the receptors. When tamoxifen fits into the receptors, the cell is unable to grow. Tamoxifen has been shown to decrease the risk of local and distant recurrences of breast cancer by about 50% and mortality by about 30% (Smith & Stearns, 2018). Adjuvant hormonal therapy with tamoxifen for 5 years is recommended for most premenopausal women with breast cancer whose tumors are hormone receptor positive. The ideal length of adjuvant endocrine therapy has been studied. For premenopausal women, some clinicians recommend 10 years of therapy. For women who develop menopause after 5 years, AIs for 5 additional years may be considered (see Medication Guide: Tamoxifen). Chemotherapy Chemotherapy drugs are most often given in combination regimens, which have been shown to improve or increase the disease-free survival time after therapy. These regimens, used for adjuvant treatment of node-positive and node-negative tumors, are constantly changing in response to new evidence. The decision to recommend adjuvant chemotherapy is based on ER and HER2 receptor status, stage of disease, and genetic tumor phenotyping with either MammaPrint or Oncotype DX (Santa-Maria & Gradishar, 2018). With the advent of HER2 therapies, breast cancer survival rates have improved. The specific genotypes provide guidance to oncologists on which ER- positive women would benefit from adjuvant chemotherapy. Adjuvant chemotherapy is recommended for triple-negative breast cancer, as this subtype is particularly aggressive with metastases occurring early (Santa-Maria & Gradishar). Premenopausal women with early-stage ER-positive breast cancer usually receive adjuvant chemotherapy. Chemotherapy with multiple drug combinations is used in the treatment of recurrent and advanced breast cancer with positive results. First-line single agents for women with locally  NURS 3450 Maternity and Women’s Health Nursing advanced or metastatic breast cancer include paclitaxel (Taxol, Onxol), docetaxel (taxotere, Docefrez), epirubicin (Ellence, Pharmorubucin PFS, Pharmorubcin RDF), doxorubicin (Adriamycin, Adriamycin PFS, Adriamycin RDF), pegylated liposomal doxorubicin (Doxil), capecitabine (Xeloda), vinorelbine (Navelbine), and gemcitabine (Gemzar, Infugem). Combination regimens and sequential single agents can be used as well (NCCN, 2022). The use of trastuzumab (Herceptin, Trazimera, Kanjinti, Ogivri) and pertuzumab (Perjeta) has increased response rates and decreased recurrences. Because chemotherapy drugs kill rapidly reproducing cells, treatment also affects normal body cells that rapidly reproduce (red and white blood cells, gastric mucosa, and hair). Thus chemotherapy can cause leukopenia, neutropenia, thrombocytopenia, anemia, gastrointestinal side effects (nausea, vomiting, anorexia, mucositis), and partial or full hair loss. Chemotherapy treatments are usually administered in ambulatory care settings once or twice per month. During the informed consent process, before the treatment is selected, the woman and her family members should be educated about the names of the medications, routes of administration, treatment schedule, timing and ordering of medications, length of time of administration, reimbursed and unreimbursed costs of therapy, potential side effects, management of side effects, possible changes in body image (e.g., full or partial hair loss), recovery time after treatment (necessitating lost work time), and need for a caregiver to transport the woman to treatment and to care for her afterward. Depending on the medications used, the treatments can include IV, subcutaneous, and oral administration. Often a long-term central venous catheter is inserted when the woman will be receiving chemotherapy for an extended period or when she will receive medications that may damage the vein. The presence of a central venous catheter, hair loss, loss of part or all of her breast, menopause, and possible infertility all have the potential to cause a change in body image and increase emotional distress. Treatment with chemotherapy, hormonal therapy, or a combination of the two often causes changes in reproductive function. A premenopausal woman may experience these changes along with symptoms of menopause and possible infertility. It is not known whether hormonal therapy to ease the effects of menopause is safe for women with breast cancer; therefore it is not recommended. For this reason, the nurse must use other measures to help the woman cope with menopause (see Chapter 6). Women receiving chemotherapy and their partners must understand that chemotherapy can be teratogenic, that is, chemotherapy agents can cause congenital abnormalities. Any woman who is of childbearing age and receiving chemotherapy, even though no longer menstruating, must use birth control. Although a woman may not be menstruating, she may still be able to become pregnant. Oral contraceptives are not recommended because they contain hormones that may assist in the growth of cancer. A birth control method must be chosen with the assistance of a gynecologist and a medical oncologist, and it must be used before chemotherapy begins and continue to be used until the medical oncologist and gynecologist agree that it is safe to discontinue. 7. What are 8-10 teaching points for a woman who has had a mastectomy without reconstruction? TEACHING FOR SELF-MANAGEMENT  NURS 3450 Maternity and Women’s Health Nursing After a Mastectomy Without Reconstruction Wash hands well before and after touching incision area or drains. Empty surgical drains twice a day and as needed, recording the date, time, drain sites (if more than one drain is present), and amount of drainage in milliliters in the diary you will take to each surgical checkup until your drains are removed (before discharge, you may receive a graduated container for emptying drains and measuring drainage). Avoid driving, lifting more than 10 lb., or reaching above your head until given permission by the surgeon. Take medications for pain as soon as pain begins. Perform arm exercises as directed. Call your surgeon if inflammation or swelling of the incision or the arm occurs. Avoid tight clothing, tight jewelry, and other causes of decreased circulation in the affected arm. Until drains are removed, wear loose-fitting underwear (e.g., camisole) and clothes, pinning surgical drains inside of clothing (you will be taught how to do this safely). After drains are removed and surgical sites are healing and still tender, wear a mastectomy bra or camisole with a cotton-filled, muslin temporary prosthesis. Temporary prostheses of this type are often available from Reach to Recovery. Avoid depilatory creams, strong deodorants, and shaving of affected chest area, axilla, and arm. Sponge bathe for the first 48 hours; then you may shower. Thoroughly dry yourself afterward and reapply fresh dressings. Return to the surgeon’s office for incision check, drain inspection, and possible drain removal as directed. Contact Reach to Recovery or a breast center nursing staff member for assistance in obtaining an external prosthesis and lingerie when dressings, drains, and staples are removed, and wound is healing and nontender. If not done before surgery, contact your insurance company for information about coverage of prosthesis and wig, if needed. Obtain prescriptions for prosthesis and wig to submit with receipts of purchase for these items to the insurance company. If insurance does not pay for these items, contact the hospital or agency social worker or local American Cancer Society for assistance. Keep follow-up visits for physical examination, mammography, and testing to detect recurrent breast cancer. Expect decreased sensation and tingling at incision sites and in the affected arm for weeks to months after surgery. Resume sexual activities as desired. Take pain medications, if needed, as prescribed by your care provider. Participate in breast cancer survivor support group if desired. Encourage mother, sisters, and daughters (if applicable) to have annual professional breast examinations and mammography (if appropriate). Modified from American Cancer Society (2022). Mastectomy. Retrieved from https://www.cancer.org/cancer/breast-cancer/treatment/surgery-for-breast-cancer/ mastectomy.html. 8. What are some of the psychological/emotional interventions that the nurse should provide after a breast cancer diagnosis?  NURS 3450 Maternity and Women’s Health Nursing Nursing interventions might include the following: Discuss the intervals for and facets of breast screening including professional examination and mammography (Table 10.2). In women with breast implants, special views (called push backs) of the breast and precautions to avoid rupture of the implant during mammography may be needed. Provide written educational materials and refer the woman to reliable websites. Encourage the woman to verbalize fears and concerns about treatment and prognosis. Provide specific information regarding the woman’s condition and treatment including dietary changes, drug therapy, comfort measures, complementary and alternative therapies, stress management, and surgery. Describe pain-relieving strategies in detail and collaborate with the primary health care provider to ensure effective pain control. Encourage the woman to discuss feelings about body image. Refer to a stress management resource if needed to cope with long-term consequences of benign breast conditions. 9. Complete the following:  Case study: Problems of the breast. (2023). In Sherpath for Maternal newborn (Lowdermilk version) (12th ed.). Elsevier. D.F. is a 27-year-old female who presents to the gynecologist’s office for her yearly examination complaining of bilateral breast pain and tenderness. Subjective Data  Last menstrual cycle: 18 days ago  Pain is dull pain  Breasts feel heavy and tender  Performs monthly breast self-exams Objective Data: Breasts moderate size, evenly pigmented, bilaterally symmetric, and hang equally with smooth contour. Venous patterns bilaterally similar. Breasts firm, smooth, elastic without tenderness, lumps, or nodules. Areola round, nipples protruding, symmetric, soft, pliable, smooth, and intact without discharge. Axillary lymph nodes are not palpated. a. What other questions should the nurse ask about the breast pain? ◦ How bad is your pain on the scale of 1-10? ◦ When did the pain start? ◦ How long does the pain last? ◦ Is it localized pain or does it spread out? b. What are some of the causes of breast pain? Perimenopausal years. Fibrocystic changes. Cyclic pain. Noncyclic pain. Diffuse pain. Focal pain. Breast Pain (Mastalgia)  NURS 3450 Maternity and Women’s Health Nursing Breast pain occurs in many women at some time in their reproductive years, especially the perimenopausal years. The symptom of breast pain commonly is associated with fibrocystic changes that were previously discussed (Sandadi et al., 2022). Breast pain is unusual in breast cancer; if it is present, it is more likely (though uncommon) only in a locally advanced breast cancer. The character and pattern of breast pain are important in understanding how to manage this symptom. It is important to distinguish between cyclic versus noncyclic pain and diffuse versus focal pain. Cyclic pain is commonly associated with fibrocystic changes; it is diffuse and bilateral whereas noncyclic pain is related to a cyst and is localized. Patterns can provide a clue as to whether or not the pain is hormonal or related to a specific etiology—a cyst or trauma from external injury or surgery (Sandadi et al., 2022). Diagnostic procedures may include serologic tests for prolactin and human chorionic gonadotropin (hCG) levels in premenopausal women, ultrasound, mammography, and aspiration and biopsy for cysts. Treatment depends on the cause and severity of the pain and may include the measures described for pain relief related to fibrocystic changes such as dietary changes (reduced fat and methylxanthine intake), NSAIDs, hormone treatment (danazol), and evening primrose oil (Sasaki et al., 2018). Mammary Duct Ectasia Mammary duct ectasia characterized by dilated ducts most commonly manifests during the perimenopausal period. It is uncommon in postmenopausal years. The incidence is higher in women who smoke or who have congenital nipple inversion or malformation. Pathologically, the ducts are dilated with thick walls. Ducts fill with epithelial secretions, and common skin bacteria may enter the duct, causing mastitis. There is fibrotic stroma, rupture, and leakage of secretion into surrounding tissue that results in inflammation and fat necrosis. Characteristic signs include pain, redness of the skin, nipple inversion, and nipple discharge of varying colors. Fever can be present or absent. The breast tissue is thickened and inflamed, suggestive of mastitis, but abscess formation is also possible. Management includes pain medication and antibiotics. Applying heat to the breast, wearing a supportive bra, and sleeping on the unaffected side may provide comfort. It may be necessary to wear a breast pad if leaking occurs. An abscess is usually treated with surgical incision and drainage. Recurrence rates are higher in women who smoke (Hamwi & Winters, 2021). c. Develop a problem list from objective and subjective data. Problem List Primary Problem Breast Pain (Mastalgia): Dull Associated Symptoms Breast Tenderndess: Possibly related to menstrual cycle. Cyclical mastalgia Fibrocysticchanges.  NURS 3450 Maternity and Women’s Health Nursing d. What should be included in the plan of care? Assessment of a woman with a benign breast condition should include a careful history and physical examination. The history should focus on the woman’s risk factors for breast diseases, events related to the breast mass, and health maintenance practices. (Risk factors for breast cancer are discussed later in this chapter.) Information related to the breast symptoms should include how, when, and by whom the symptoms were discovered. The interval between discovery and seeking care is crucial. The following client information is documented: presence of pain, whether symptoms increase with menses, dietary habits, smoking habits, use of oral contraceptives or hormone replacement therapy, personal history of breast cancer, and family history of breast cancer. The American Cancer Society (ACS, 2022e) no longer recommends breast self-examination (BSE). It is important for the nurse to be aware, however, that many women discover breast cancer symptoms (e.g., a lump) through regular daily activities. Therefore women should be encouraged to be familiar with their breasts. Some women desire to learn BSE, and nurses can provide this teaching (see Teaching for Self-Management: Breast Self-Examination in Chapter 4). The woman’s emotional status, including her stress level, fears, and concerns and her ability to cope also should be assessed. Physical examination may include assessment of the breasts for symmetry, masses (size, number, consistency, mobility), and nipple discharge. Nursing interventions might include the following: Discuss the intervals for and facets of breast screening including professional examination and mammography (Table 10.2). In women with breast implants, special views (called push backs) of the breast and precautions to avoid rupture of the implant during mammography may be needed. Provide written educational materials and refer the woman to reliable websites. Encourage the woman to verbalize fears and concerns about treatment and prognosis. Provide specific information regarding the woman’s condition and treatment including dietary changes, drug therapy, comfort measures, complementary and alternative therapies, stress management, and surgery. Describe pain-relieving strategies in detail and collaborate with the primary health care provider to ensure effective pain control. Encourage the woman to discuss feelings about body image. Refer to a stress management resource if needed to cope with long-term consequences of benign breast conditions. e. Based on the readings, subjective, and objective data, what is the most likely cause of breast pain for this patient? Fibrocystic changes most often present as lumpiness in both breasts, although there can be single simple cysts. Symptoms usually develop about a week before menstruation begins and subside about a week after menstruation ends. They include dull heavy pain that may radiate to the shoulders and upper arms, and a sense of fullness and tenderness, often in the upper outer quadrants of the breasts. There may be increased breast engorgement and density and in rare cases, nipple discharge. Chapter 11 Structural Disorders & Neoplasms of the Reproductive System  NURS 3450 Maternity and Women’s Health Nursing 1. To guide your reading, you can review the Sherpath Lesson: Breast Disorders, Structural Defects, and Neoplasms. 2. Compare the following structural disorders & benign disorders of the reproductive system: Condition Signs & Symptoms Treatment Prolapsed uterus Seeing or feeling tissue Treatment for uterine prolapse bulge out of the vagina depends on the degree of prolapse.  Feeling Pessaries can be useful in mild prolapse and are recommended by many health heaviness or care providers as the first-line pulling in the management of uterine prolapse pelvis (Clemons, 2021). Although some health  Feeling like the care providers recommend estrogen bladder doesn't therapy, there is no evidence that the use of estrogen therapy provides any empty all the measurable difference in the condition way when you (Rogers & Fashokun, 2022). If these use the conservative treatments do not correct bathroom the problem or the degree of prolapse  Problems with is significant, a variety of reconstructive leaking urine, or obliterative surgical interventions can be considered, including vaginal also called hysterectomy with a vaginal vault incontinence suspension (see later discussion under  Trouble having “Medical and Surgical Management”) a bowel (Jelovsek, 2021). movement and needing to press the vagina with your fingers to help have a bowel movement  Feeling as if you're sitting on a small ball  Feeling as if you have vaginal tissue rubbing on clothing  Pressure or discomfort in  NURS 3450 Maternity and Women’s Health Nursing Condition Signs & Symptoms Treatment the pelvis or low back  Sexual concerns, such as feeling as though the vaginal tissue is loose  NURS 3450 Maternity and Women’s Health Nursing Condition Signs & Symptoms Treatment Cystocele In mild cases of anterior Treatment for a cystocele includes use prolapse, you may not of a vaginal pessary or surgical repair. notice any signs or An anterior repair (colporrhaphy) is the surgical procedure usually done for symptoms. When signs large symptomatic cystoceles. This and symptoms occur, surgery involves placement of the they may include: bladder back into its normal position  A feeling of and supportive stitch insertion to hold fullness or together the muscles and tissue pressure in your surrounding the bladder. An anterior repair is often combined with a vaginal pelvis and hysterectomy. Physical therapy may be vagina recommended. Use of Kegel exercises  In some cases, a helps strengthen pelvic floor muscles bulge of tissue and may relieve some of the symptoms in your vagina of pressure caused by the cystocele that you can see (National Institute of Diabetes and Digestive and Kidney Diseases, 2020). or feel  Increased pelvic pressure when you strain, cough, bear down or lift  Problems urinating, including difficulty starting a urine stream, the feeling that you haven't completely emptied your bladder after urinating, feeling a frequent need to urinate or leaking urine (urinary incontinence)  NURS 3450 Maternity and Women’s Health Nursing Condition Signs & Symptoms Treatment Rectocele A small posterior vaginal Small rectoceles may not need prolapse (rectocele) treatment. A woman with mild might cause no symptoms may get relief from a high- fiber (e.g., 25 g or more daily) diet and symptoms. an increase in fluid intake, stool Otherwise, you may softeners, or mild laxatives. Vaginal notice: pessaries and Kegel exercises may be useful. Large rectoceles that are  A soft bulge of causing significant symptoms are tissue in the usually repaired through one of vagina that numerous surgical approaches might come including vaginally, transanally, via the through the perineum, and abdominally (open or laparoscopically) (American Society of opening of the Colon & Rectal Surgeons, 2020): vagina  Trouble having A posterior repair (colporrhaphy) is the a bowel usual procedure. This surgery is movement performed vaginally and involves  Feeling pressure shortening the pelvic muscles to provide better support for the rectum. or fullness in Anterior and posterior repairs can be the rectum performed at the same time and with  A feeling that vaginal hysterectomy. Even though the the rectum has surgery corrects the anatomic position not completely and goals to correct bowel problems emptied after a are usually met, the woman may still have lingering bowel concerns bowel (Guldbrandsen, Kousgaard, Bjørk, & movement Glavind, 2021).  Sexual concerns, such as feeling embarrassed or sensing looseness in the tone of the vaginal tissue  NURS 3450 Maternity and Women’s Health Nursing Condition Signs & Symptoms Treatment Follicular cyst Most ovarian cysts cause If the cyst does not rupture, it usually no symptoms and go shrinks after two or three menstrual away on their own. But a cycles. large ovarian cyst can cause:  Pelvic pain that may come and go. You may feel a dull ache or a sharp pain in the area below your bellybutton toward one side.  Fullness, pressure or heaviness in your belly (abdomen).  Bloating. Corpus luteum cyst Clinical manifestations Corpus luteum cysts usually disappear associated with a corpus without treatment within one or two luteum cyst include pain, menstrual cycles. tenderness over the ovary, delayed menses, and irregular or prolonged menstrual flow.  NURS 3450 Maternity and Women’s Health Nursing Condition Signs & Symptoms Treatment Dermoid cyst Epidermoid cyst Treatment is usually laparoscopic signs and symptoms surgical removal. include:  A small, round bump under the skin, often on the face, neck or trunk  A tiny blackhead plugging the central opening of the cyst  A thick, smelly, cheesy substance that leaks from the cyst  An inflamed or infected bump  NURS 3450 Maternity and Women’s Health Nursing Condition Signs & Symptoms Treatment Polycystic ovarian Clinical manifestations The treatment for PCOS depends on syndrome include obesity, hirsutism symptoms that are of greatest concern (excessive hair growth), to the woman. Lifestyle modifications irregular menses or (e.g., losing weight) and management amenorrhea, acne, hair of presenting symptoms such as thinning, skin darkening infertility, irregular menses, and (often in the creases of hirsutism are the focus. Lifestyle the neck and groin and modifications can be very effective in under the breasts), regulating menses, preventing development of skin tags, progression to type 2 diabetes mellitus and infertility. More than for women who have not already 50% of women with PCOS developed this condition, and lowering have prediabetes or cardiovascular risk (Barbieri & diabetes (Office on Ehrmann, 2022b). Oral contraceptives Women’s Health, 2021). (OCs) are the usual treatment for Affected women who do irregular menses if pregnancy is not not have diabetes are at desired because they inhibit LH and increased risk for decrease testosterone levels. OCs can metabolic syndrome also lessen acne to some degree. including development of Spironolactone, an antiandrogen, is type 2 diabetes mellitus; frequently used with an OC. In severe all women with PCOS are cases, gonadotropin-releasing hormone at risk for development (GnRH) analogs may be used to treat of hypertension, hirsutism if OCs are not effective. If cardiovascular disease, pregnancy is desired, ovulation- sleep apnea, and inducing medications can be prescribed endometrial cancer (Barbieri & Ehrmann). Metformin and (Office on Women’s other insulin medications for type 2 Health) diabetes also are used to lower insulin, testosterone, and glucose levels, which in turn can reduce acne, hirsutism, abdominal obesity, amenorrhea, and other PCOS symptoms (Barbieri & Ehrmann). Women with PCOS should be monitored for development of type 2 diabetes, metabolic syndrome, and risk for cardiovascular disease.  NURS 3450 Maternity and Women’s Health Nursing Condition Signs & Symptoms Treatment Leiomyomas Most women are If symptoms are mild, follow-up care asymptomatic; abnormal may suffice to observe for growth or uterine bleeding is the changes in size. Nonsteroidal most common symptom antiinflammatory drugs (NSAIDs) may of fibroids. If the tumor is be prescribed for pain; OCs inhibit very large, pelvic ovulation and may relieve symptoms by circulation may be reducing circulating levels of estrogen compromised, and and progesterone. Intrauterine devices surrounding viscera may (IUDs) can be used for women who do be displaced. A woman not desire estrogen in OCs. For clients may report a backache, who do not desire pregnancy in the low abdominal pressure, future, hysteroscopic fibroid resection constipation, UI, or is the preferred treatment. Secondary dysmenorrhea (painful lines of treatment include GnRH menstruation). Nausea analogs (antagonists and agonists) and and vomiting may occur if uterine artery embolization; relugolix, a the tumor obstructs the gonadotropin-releasing hormone intestines. The woman (GnRH) antagonist, has been shown to also may notice an be particularly effective in reducing abdominal mass if the menstrual blood loss (Stewart, 2022). tumor is large. Anemia can occur if the woman For clients with submucosal fibroids has excessive bleeding. who wish to preserve fertility, hysteroscopic myomectomy is The tumors appear to be recommended. For clients with influenced by the nonsubmucosal fibroids, abdominal presence of estrogen. myomectomy (laparoscopic or open) is Fibroids can affect recommended (Stewart, 2022). implantation and A woman who prefers medication for maintenance of treatment will need information about pregnancy. During prescribed drugs, their actions and side pregnancy the tumors effects, and routes of administration. can produce Women who are receiving GnRH complications such as agonists (to decrease the size of the miscarriage, preterm fibroid) need instruction on the fact labor, or dystocia that regrowth will occur after the (difficult labor). The treatment is stopped. A small loss in severity of the symptoms bone mass and changes in lipid levels seems to be directly also can occur; therefore long-term use related to the size and is not recommended. Amenorrhea may location of the tumors. occur; however, women who want to avoid pregnancy should use a nonhormonal or barrier method of contraception. 3. Complete the following:  NURS 3450 Maternity and Women’s Health Nursing  Case study: Structural disorders and neoplasms of the reproductive system. (2023). In Sherpath for Maternal newborn (Lowdermilk version) (12th ed.). Elsevier. Tracey is a 54-year-old G3 P3 with multiple large leiomyomas. Her symptoms include abnormal uterine bleeding, abdominal pain and pressure, dysmenorrhea, and urinary incontinence. Tracey was treated with GnRH agonist medications to reduce the size of the leiomyomas, but this was unsuccessful. Her gynecologist has recommended that she have an abdominal hysterectomy. Tracey is admitted to an OB/GYN unit and is scheduled to the hysterectomy in the morning. a. What are leiomyomas? Leiomyomas, also known as fibroid tumors, fibromas, myomas, or fibromyomas, are slow- growing benign tumors arising from the muscle tissue of the uterus; they are classified based on their uterine layer position (Stewart & Laughlin-Tommaso, 2021). They are the most common benign tumors of the reproductive system, which can affect any woman yet are more common after the age of 40. They occur more often in Black women, in women who have never been pregnant, and in women who began menarche before the age of 10 (Stewart & Laughlin-Tommaso). Fibroids also occur more often in women who are overweight (Dolan et al., 2022). They rarely become malignant. Because their growth is influenced by ovarian hormones, these benign tumors can become quite large when the woman is pregnant or taking hormone therapy. They often spontaneously shrink after menopause when circulating ovarian hormones diminish (Dolan et al.). What are the signs & symptoms of a leiomyoma? Most women are asymptomatic; abnormal uterine bleeding is the most common symptom of fibroids. If the tumor is very large, pelvic circulation may be compromised, and surrounding viscera may be displaced. A woman may report a backache, low abdominal pressure, constipation, UI, or dysmenorrhea (painful menstruation). Nausea and vomiting may occur if the tumor obstructs the intestines. The woman also may notice an abdominal mass if the tumor is large. Anemia can occur if the woman has excessive bleeding. The tumors appear to be influenced by the presence of estrogen. Fibroids can affect implantation and maintenance of pregnancy. During pregnancy the tumors can produce complications such as miscarriage, preterm labor, or dystocia (difficult labor). The severity of the symptoms seems to be directly related to the size and location of the tumors. b. Why is a hysterectomy the treatment of choice? Hysterectomy A total hysterectomy (removal of the entire uterus) is the treatment of choice if bleeding is severe or if the fibroid is obstructing normal function of other organs (Cunningham, Leveno, Dashe, et al., 2022). An abdominal or vaginal surgical approach depends on the size and location of the tumors. Why is an abdominal hysterectomy recommended in this case? For example, abdominal hysterectomy is usually performed for leiomyomas larger than a uterus would be at 12 to 14 weeks of gestation or for multiple leiomyomas. The uterus is removed through either a vertical or a transverse incision. Vaginal approaches can be used for smaller tumors. In both abdominal and vaginal approaches, the uterus is removed from the supporting ligaments (broad, round, and uterosacral). These ligaments are then attached to the  NURS 3450 Maternity and Women’s Health Nursing vaginal cuff, allowing maintenance of normal depth of the vagina (Fig. 11.10). Alternatives to these procedures are laparoscopic-assisted vaginal hysterectomy (LAVH) and laparoscopic- assisted supracervical hysterectomy (LASH). LAVH converts an abdominal procedure to a vaginal procedure by using a laparoscope in the abdomen to assist with removal of the uterus. LAVH allows the cervix to remain. The following Evidence-Based Practice box presents updated information on whether a hysterectomy is indicated for a woman with benign disease. c. What preoperative assessments are needed? Preoperative Assessments needed before surgery include the woman’s knowledge of treatment options, her desire for future fertility if she is premenopausal, the benefits and risks of each procedure, preoperative and postoperative procedures (Boxes 11.1 and 11.2), and the recovery process. If the woman demonstrates understanding of this information, she can make an informed decision about treatment, give informed consent to the procedure if one is desired, and feel a sense of control over the surgical experience. Resources on helping women to make decisions about treatment can be found on the Fibroid Treatment Collective website (www.fibroids.org). Psychologic assessment is essential, particularly for a woman who is scheduled for a hysterectomy. Areas to be explored include the significance of the loss of the uterus for the woman, misconceptions about effects of surgery, and adequacy of her support system. Women who have not completed their childbearing, who believe that their self-concept is related to having a uterus (to be a complete woman), who feel that sexual functioning is related to having a uterus, or who have too little or too much anxiety about the surgery may be at risk for postoperative emotional reactions. The nurse can work with the interprofessional health care team to be sure that resources are in place to support these women during this life transition. d. Tracey has an abdominal hysterectomy under spinal anesthesia without complications. She is back on the OB/GYN unit. What are the priorities in postoperative care? Box 11.2 Postoperative Care After Hysterectomy Monitor vital signs every 15 minutes until stable, then every 4 hours for 48 hours or more frequently as ordered Remind client to turn, cough, deep breathe every 2 hours for 24 hours Assist her to splint incision with hands or pillow Incentive spirometry if ordered Leg exercises every 2 to 4 hours and sequential compression devices (SCDs) until ambulatory Assess for bleeding Abdominal: assess dressing or incision Vaginal: perineal pad count (one saturated pad in less than 1 hour is excessive; vaginal bleeding is usually minimal) Monitor laboratory values, especially hemoglobin and hematocrit Assess lung sounds Assess bowel sounds and monitor bowel function Monitor intake and output Foley catheter may be in place for 24 hours after abdominal surgery  NURS 3450 Maternity and Women’s Health Nursing After vaginal hysterectomy, urinary retention may occur because of manipulation of the urethra during surgery; if client does not void within 4 hours, notify the health care provider Assess abdominal incision or vagina for signs of infection Observe for signs of complications Abdominal hysterectomy: assess for signs of wound evisceration, pulmonary embolism, thrombophlebitis, pneumonia, bowel obstruction, bleeding (incisional or vaginal) Vaginal hysterectomy: assess for signs of urinary tract infection, urinary retention, wound infection, vaginal bleeding Pain relief Pharmacologic measures: patient-controlled analgesia or epidural opioids may be ordered for the first 24 hours, followed by oral analgesics and nonsteroidal antiinflammatory drugs Nonpharmacologic measures: breathing and relaxation exercises, position changes, guided imagery, application of heat to the abdomen (abdominal hysterectomy), and sitz baths or ice packs for the perineum (vaginal hysterectomy); ambulation may relieve gas pains Psychologic assessments Assess for depression or other emotional reactions Assess support systems Assess sexual concerns e. Tracey is being discharged from the hospital after 2 days. What information will you include as part of discharge teaching? TEACHING FOR SELF-MANAGEMENT Care After Myomectomy or Hysterectomy Eat foods high in protein, iron, and vitamin C to aid in tissue healing; include foods with high fiber content; and drink six to eight 8-oz. glasses of water daily. Rest when tired; resume activities as comfort level permits. Avoid vigorous exercise and heavy lifting for 6 weeks. Avoid sitting for long periods. Resume driving when comfort allows or on advice from health care provider. If taking narcotics for pain relief, refrain from driving completely until you are no longer taking narcotics. Avoid tub baths, intercourse (vaginal rest), and douching until after your follow-up examination; thereafter, follow your health care provider’s recommendation regarding sexual intercourse. Tub baths and douching may continue to be discouraged. When vaginal intercourse is resumed, water-soluble lubricants may decrease discomfort. Report the following symptoms to your health care provider: vaginal bleeding, gastrointestinal changes, persistent postoperative symptoms (cramping, distention, change in bowel habits), and signs of wound infection (redness, swelling, heat, or pain at incision site). Keep your follow-up appointment with your health care provider.  NURS 3450 Maternity and Women’s Health Nursing 4. For malignant neoplasms, provide summaries for the following 3 conditions and their incidence, signs/symptoms, treatment (general): Type of Cancer Risk Factors Incidence Signs/Symptoms General Treatment Ovarian Women at risk Non-Hispanic It may be Surgery include women White women of asymptomatic (laparotomy or with obesity; North American and detected on laparoscopy) is later-in-life or northern ultrasound the usual pregnancies or European descent imaging, or there treatment. Timing nulliparity; use of and older women may be depends on hormone therapy have the highest abdominal evaluation of risks following incidence of pain/discomfort. to the woman and menopause; ovarian cancers the fetus. Ideally, family history of (ACS). The spread surgery is ovarian, of ovarian cancer performed colorectal, or is by direct between 16 and breast cancer; extension to 20 weeks of and genetic adjacent organs, gestation. conditions but distal spread Radiation is including HNPCC can occur through contraindicated at and mutations in the lymph system any time during the BRCA1 and to the liver and the pregnancy, BRCA2 genes. the lungs. whereas Research chemotherapy regarding possible can be considered causes such as in the second or androgens, third trimester if talcum powder, absolutely and diet are needed. In most ongoing, with cases, the current evidence prognosis is good not substantiating due to diagnosis any of these as in the early definitive causes stages; the 5-year (ACS, 2021a). survival rate after Protective factors ovarian cancer against ovarian during pregnancy cancer include use ranges from 72% of birth control to 90% (Dluski, pills for 5 or more Mierzynski, years; having Poniedzialek- given birth; Czajkowsha, et al., surgical tubal 2020). Because ligation, ovary symptoms of removal, or ovarian cancer are  NURS 3450 Maternity and Women’s Health Nursing hysterectomy; similar to signs of and breastfeeding pregnancy (e.g., for a year or more frequent (Centers for urination, Disease Control sensation of and Prevention abdominal [CDC], 2021b). bloating, fatigue, constipation), it is recommended that clients report these symptoms right away to their obstetric health care provider. Endometrial Certain risk Numerous studies The cardinal sign Collaborative factors have been have correlated of endometrial efforts are associated with the use of cancer is needed to care the development exogenous abnormal uterine for a woman with of endometrial estrogens bleeding (e.g., endometrial cancer, including (unopposed postmenopausal cancer. Care obesity (especially stimulation, i.e., bleeding and management by upper body fat absence of premenopausal an localization), progesterone) in recurrent interprofessional nulliparity, postmenopausal menorrhagia). team includes infertility, late women with an Late signs include understanding onset of increased a appropriate menopause, incidence of mucosanguineous treatment diabetes mellitus, uterine cancer. vaginal discharge, modalities. hypertension, Tamoxifen taken low back pain, or PCOS, and family by women for low pelvic pain. A Surgical options history of ovarian breast cancer also pelvic include total or or breast disease has been related examination may radical (Creasman & to a slight reveal the hysterectomy, Miller, 2018). increase in presence of a bilateral salpingo- There appears to endometrial uterine oophorectomy, be an increased cancer (Creasman enlargement or and, if needed, risk for & Miller; mass. lymphadenectom endometrial Breastcancer.org, y. Choice is based cancer in families 2022). on staging and with hereditary the client’s nonpolyposis preoperative colorectal cancer health status. (HNPCC). Total Hormone hysterectomy or imbalance, radical however, seems hysterectomy to be the most (abdominal significant risk hysterectomy  NURS 3450 Maternity and Women’s Health Nursing factor. with wide excision of parametrial tissue laterally and uterosacral ligaments posteriorly) is often used to treat this condition. Radiation can be used when there has been cancerous extension to the cervix; this use is considered in relation to an increasing risk of development of lymphedema when radiation is used (Cohn, 2022). Adjuvant therapy with chemotherapy may also be considered. Progestational therapy—use of medroxyprogeste rone (Provera) and megestrol (Megace)—is often used to slow the growth of endometrial cancer. These drugs usually do not cause acute side effects. Tamoxifen and LH-releasing hormone agonists goserelin (Zoladex) and leuprolide (Lupron) are often  NURS 3450 Maternity and Women’s Health Nursing used, and aromatase inhibitors including letrozole (Femara), anastrozole (Arimidex), and exemestane (Aromasin), which usually are used in breast cancer treatment, are being explored for best use (ACS, 2019). Cervical Risk factors for The incidence of Preinvasive Treatment for persistent HPV cervical cancer in cancer of the invasive cancer infections include the United States cervix is often includes surgery, early age is highest among asymptomatic, radiation therapy, (younger than 20 Hispanic and but as the cancer and years) at first Black women. progresses, chemotherapy. coitus, multiple Factors that may symptoms often Microinvasive (more than two) influence this become apparent. cancer is usually sexual partners, a increased Heavy or irregular treated with sexual partner incidence include vaginal bleeding conization, but a with a history of decreased access and postcoital hysterectomy is multiple sexual to screening bleeding are often done if partners, high opportunities or classic symptoms childbearing is not parity, and follow-up of cervical cancer; desired. The belonging to a treatment (US watery, mucoid, choice of lower Cancer Statistics purulent, or treatment for socioeconomic Working Group, malodorous early-stage status group. 2022; see discharge may invasive cancer is Potential risk Community Focus also be present. hysterectomy or factors include box). Late symptoms chemoradiation long-term (5 or include rectal therapy (ACS, more years) use bleeding, 2021c). A radical of OCs, having hematuria, pelvic hysterectomy is human or lower back performed if the immunodeficiency pain, and vaginal cancer has virus (HIV) or passage of stool. extended beyond another condition Diagnosis includes the cervix but not that is taking a history to the pelvic wall. immunocomprom that includes Locally advanced ising, cigarette information about stages of cervical smoking, having menstrual and cancer usually are given birth to sexual activity, treated with three or more particularly external and  NURS 3450 Maternity and Women’s Health Nursing children, and sexually internal radiation intrauterine transmitted therapy and exposure to infections and chemotherapy. diethylstilbestrol abnormal Late stages are (DES) (CDC, bleeding episodes usually treated 2021a; Massad, (Frumovitz, with radiation and 2018; Tewari & 2022a). A pelvic chemotherapy. Monk, 2018). Low examination may levels of beta- be normal or may carotene, vitamin reveal a visible C, and folate are lesion. being investigated as potential risk The most widely factors (Tewari & used method to Monk; Yuanxing, detect preinvasive Yang, Wang, et cancer is the Pap al., 2020). test, which can detect the majority of cervical changes. Professional organizations offering cervical screening guidelines include the ACS (2021b) (Box 11.5) and the US Preventive Serv