Idea Transcript
CHAPTER 48 / Nursing Care of Women with Reproductive Disorders 1571
Nursing Care Plan A Woman with Endometriosis Angela Hall is a 31-year-old married accountant, who relates a history of severe dysmenorrhea and menorrhagia, a feeling of pelvic heaviness and pain that radiates down her thighs. Because of her discomfort, her husband has complained about the quality of their sex life and has expressed concerns about their plans for having children. Mrs. Hall reports being so tired she doesn’t care whether she has sex or not, and, in fact, would really prefer not to: “Sex hurts so much, I just can’t stand it.” Endometriosis is suspected, and a diagnostic laparoscopy has been scheduled.
ASSESSMENT Christine Brigham, RN, NP, interviews Mrs. Hall and makes the following assessments: BP 110/70, P 68, R 18, T 98.2°F (36.7°C). Mrs. Hall’s weight is 130 lb (59 kg) and within normal limits for her height. Review of laboratory findings indicate a hemoglobin level of 9.8 g/dL (normal range: 12 to 16 g/dL) and a hematocrit of 33.1% (normal range: 35% to 45%). Physical examination reveals pelvic tenderness on manipulation of the cervix, and small masses that are palpable on abdominal/pelvic examination.
DIAGNOSIS • Chronic pain, related to endometrial pelvic implants • Anxiety, related to effect of endometriosis on fertility • Deficient knowledge, related to diagnosis and treatment options • Ineffective sexuality patterns, related to the manifestations of endometriosis
EXPECTED OUTCOMES • Develop effective self-care measures to deal with the pain and discomfort. • Verbalize decreased anxiety. • Demonstrate understanding of the disease and treatment options. • Verbalize an improvement in sexual functioning and a decrease in interpersonal stress between herself and her husband.
Table 48–2
FIGO Staging Classification for Cervical Cancer
Stage
Description
0
Carcinoma in situ, intraepithelial carcinoma
I
Carcinoma that is strictly confined to the cervix
II
Involvement of the vagina, limited to the upper two-thirds of the vagina, or infiltration of the parametria (connective tissue surrounding the uterus) but not the side wall of the pelvis
III
Involvement of the lower third of the vagina or extension to the pelvic side wall
IV
Extension outside the reproductive tract
PLANNING AND IMPLEMENTATION • Identify the location, type, duration, and history of the pain. • Recommend analgesics and heat therapy. • Provide information on biofeedback, relaxation, and imagery to lessen pain. • Discuss with Mr. and Mrs. Hall the causes of endometriosis and its manifestations. • Encourage the Halls to discuss their feelings about the effect of the disease on their sex life, lifestyle, and fertility. • Refer the couple to the local mental health center if appropriate.
EVALUATION Two years after the initiation of treatment, Mr. and Mrs. Hall have become parents of a baby girl. Mrs. Hall states that the discomfort and other manifestations of endometriosis have eased. Relaxation and imagery have effectively minimized her pain and brought about improvement in her function as wife, mother, and sexual partner. Counseling has improved the interpersonal and sexual relations between the Halls. Dietary management has improved her anemia, although the menorrhagia persists. The Halls are trying to have a second child, understanding the advantages of rapid succession of pregnancies. They will be followed in the nursing clinic and referred to an infertility clinic if conception does not occur within 1 year.
Critical Thinking in the Nursing Process 1. Explain the pathophysiologic basis for Mrs. Hall’s anemia. 2. How would you handle the situation if Mr. and Mrs. Hall were extremely uncomfortable and embarrassed about discussing their sexual problems? 3. Develop a plan of care for Mrs. Hall for the nursing diagnosis, Situational low self-esteem, related to the manifestations of endometriosis. See Evaluating your Response in Appendix C.
Preinvasive cancer is limited to the cervix and rarely causes symptoms. Invasive cancer produces vaginal bleeding after intercourse or between menstrual periods, and vaginal discharge that increases as the cancer progresses. These changes are subtle, and may be more readily noticed by the postmenopausal woman. Manifestations of advanced disease include referred pain in the back or thighs, hematuria, bloody stools, anemia, and weight loss.
Risk Factors As described by the American Cancer Society (2001), risk factors for cervical cancer include infection of the external genitalia and anus with HPV, first intercourse before 16 years of age, multiple sex partners or male partners with multiple sex partners, a history of sexually transmitted infections, and infection with HIV. The most important risk factor is infection by