Transcript Chapter 34

Chapter 47
Female Reproductive
Disorders
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Learning Objectives
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List data to be collected when assessing the female reproductive
system.
Describe the nursing interventions for women who are
undergoing diagnostic tests and procedures for reproductive
system disorders.
Identify the nursing interventions associated with
douche, cauterization, heat therapy, and topical medications
used to treat disorders of the female reproductive system.
Explain the pathophysiology, signs and symptoms, complications,
diagnostic procedures, and medical or surgical treatment for selected disorders of the
female reproductive system.{AU: This bullet should wrap sooner on right
margin.}
Assist in developing a nursing care plan for patients with
common disorders of the female reproductive system.
Describe the nursing interventions for the patient who is
menopausal.
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Anatomy and Physiology of the
Female Reproductive System
• External genitalia
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Mons pubis
Labia majora
Labia minora
Clitoris
Pudendum
Bartholin’s glands
Skene’s glands
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Anatomy and Physiology of the
Female Reproductive System
• Internal genitalia
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Vagina
Uterus
Fallopian tubes
Ovaries
• Breasts
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Figure 47-1
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Figure 47-2
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Figure 47-3
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Anatomy and Physiology of the
Female Reproductive System
• Menstrual cycle
• Consists of ovarian cycle and uterine cycle
• Menstruation: passage through the vagina of a
mixture of blood and other fluids and tissue formed
in the lining of the uterus to receive the fertilized
ovum
• The length of the menstrual cycle averages
28 to 30 days, but it may be 21 to 40 days; affected
by stress, physical activity, and illness
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Figure 47-4
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Health History
• Chief complaint and history of present illness
• If existing problem, include related signs and symptoms and
onset, frequency, and effect on normal functioning
• Past medical history: menstrual history
• Age when menstruation began, date of onset of last period,
usual number of days between, amount of flow, number of
days of flow per period, use of tampons
• Menopause: age when menstruation ceased as well as
whether menopause occurred naturally or resulted from
surgery, chemotherapy, or radiation therapy
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Health History
• Past medical history: obstetric-gynecologic
• Term and preterm births, living children, abortions
• Blood type, Rh factor, rubella or rubella immunization
• Infections and sexually transmitted infections, cysts and
tumors, structural and functional abnormalities, infertility, and
stress incontinence
• Family history
• Diabetes mellitus, cancer, complications of pregnancy, multiple
pregnancies, genetic disorders, or congenital anomalies
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Health History
• Review of systems
• Symptoms and prescribed or self-selected treatments
• Commonly reported symptoms are pain, itching, burning,
vaginal bleeding between periods or after menopause, heavy
or prolonged bleeding with periods, vaginal discharge, urinary
frequency/urgency
• Functional assessment
• Includes a diet history, use of dietary supplements including
calcium and iron, exercise pattern, sexual history, occupational
exposure to potential teratogens, and effects of symptoms on
usual activities
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Physical Examination
• Measure vital signs, height, and weight
• Skin color, texture, and moisture noted. Breasts should be
examined for dimpling and abnormal skin texture
• Abdomen inspected for distention and palpated for tenderness.
The legs are inspected for swelling and palpated for tenderness
• Assesses the external genitalia for lesions, lumps, swelling, and
discharge
• Vagina and uterine cervix are inspected for lesions, growths,
discharge, and redness
• Vagina, abdomen, and rectum palpated for abnormalities
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Diagnostic Tests and Procedures
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Pelvic examination
Smears and cultures
Endometrial and cervical biopsies
Culdoscopy
Laparoscopy
Dilation and curettage
Mammography
Breast self-examination
Breast biopsy
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Figure 47-5A-C
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Figure 47-6
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Figure 47-5D
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Figure 47-7
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Figure 47-8
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Therapeutic Measures
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Douching
Cauterization
Application of heat
Topical medications
Surgical procedures
• Abdominal
• Vaginal
• Laparoscopic
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Disorders of the
Female Reproductive System
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Uterine Bleeding Disorders
• Pathophysiology
• Metrorrhagia
• Bleeding or spotting between menstrual periods
• Menorrhagia
• Menstrual periods with profuse or prolonged
bleeding
• Amenorrhea
• The absence of menses
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Uterine Bleeding Disorders
• Etiology and risk factors
• Symptoms of underlying factors, rather than being specific
definable conditions in themselves
• Causes: hormonal dysfunction, benign and malignant tumors,
coagulation disorders, systemic diseases, use of some
contraceptives, endometrial hyperplasia, inflammatory
processes, and systemic diseases
• Causes of amenorrhea include pregnancy; excessive weight
loss, physical activity, or stress; pituitary, hypothalamic, thyroid,
or adrenal disorders; ovarian failure; and uterine abnormalities
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Uterine Bleeding Disorders
• Medical diagnosis and treatment
• Colposcopy, biopsy, and cauterization as well as
laboratory analyses of blood components, hormone
levels, and tissue specimens or smears provide
diagnostic information
• Interventions
• Deficient Knowledge
• Anxiety
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Vulvitis and Vaginitis
• Pathophysiology
• Vulvitis
• Inflammation of the vulva
• Vaginitis
• Local inflammatory response to various factors
• Etiology and risk factors
• Two most common causes: Candida albicans (fungus, or yeast
infection) and Trichomonas vaginalis (protozoal infection)
• Signs and symptoms
• Include local swelling, redness, and itching
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Vulvitis and Vaginitis
• Complications
• Ascending infection
• Medical diagnosis
• Based on symptoms and on inspection of the vulva
and vagina
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Vulvitis and Vaginitis
• Medical treatment
• Specific to the causative agent
• Topical antifungal creams, oral antiprotozoals or antibiotics,
vaginal suppositories to reestablish normal vaginal flora,
topical/systemic estrogen replacement therapy, improved
diabetes control, and avoidance of offending chemical
agents
• Symptoms managed with frequent cleansing with neutral
agents; wearing cotton panties, cotton-crotched pantyhose,
and nonconstricting clothing; and heat in the form of sitz
baths and perineal irrigations
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Bartholin’s Gland Abscess
(Bartholinitis)
• Pathophysiology
• Edema and pus formation due to infectious microorganisms
occlude the duct of the affected gland and form an abscess
• Etiology and risk factors
• Commonly cultured organisms include normal intestinal
bacterial flora, Staphylococcus aureus, Streptococcus
pneumoniae, Trichomonas vaginalis, Neisseria gonorrhoeae,
and Mycoplasma hominis
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Bartholin’s Gland Abscess
(Bartholinitis)
• Signs and symptoms
• Perineal pain, fever, labial edema, chills, malaise,
and purulent discharge
• Complications
• Systemic infection
• Medical diagnosis
• Visual inspection; culture and sensitivity
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Bartholin’s Gland Abscess
(Bartholinitis)
• Medical treatment
• Oral analgesics and moist heat in the form of frequent sitz
baths or hot wet packs
• Surgical incision and drainage of the abscess
• Broad-spectrum antibiotics
• Nursing care
• Instruction to help patient comply with treatment
• Tactful instruction in basic perineal hygiene principles is in
order if the evidence indicates that inappropriate or inadequate
practices are being followed
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Cervicitis
• Pathophysiology
• Inflammation of the cervix
• Etiology and risk factors
• Infectious organisms, scraping of cells for diagnostic tests,
cryosurgery, use of vaginal tampons or medications, childbirth,
decreased estrogen levels after menopause, and use of oral
contraceptives
• Signs and symptoms
• Usually asymptomatic, although it may cause pain, visible
vaginal discharge, bleeding, or dysuria
• Complications
• Pelvic inflammatory disease
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Cervicitis
• Medical diagnosis and treatment
• Based on pelvic examination or results of Pap smear
• Treated with systemic or topical antimicrobial agents
• If related to menopause, topical or oral estrogen
• Nursing care
• Assisting with assessment procedures, patient support, and
teaching the patient to carry out the prescribed treatment and
posttreatment procedures
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Mastitis
• Pathophysiology
• Infection-induced inflammation of breast tissue in the lactating
woman
• Etiology and risk factors
• Staphylococcus aureus; Escherichia coli, streptococci
• Signs and symptoms
• Usually confined to one breast; may be asymptomatic except
for tenderness and low-grade (and often unsuspected) fever
• Symptomatic mastitis: localized pain, fever, tachycardia,
general malaise, and headache
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Mastitis
• Complications
• Abscess formation
• Medical diagnosis and treatment
• Diagnosis based on presenting symptoms
• Culture and sensitivity
• Treatment based on symptoms alone and consists
primarily of immediate and aggressive antibiotic
therapy
• Symptoms managed by frequent emptying of the
breast, heat, rest, and analgesics
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Mastitis
• Interventions
• Risk for Injury
• Deficient Knowledge
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Fibrocystic Changes
• Pathophysiology
• An exaggerated response to hormonal influences
• Excess fibrous tissue develops accompanied by
overgrowth of the lining of the mammary ducts,
proliferation of mammary ducts, and the formation of
cysts
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Fibrocystic Changes
• Etiology and risk factors
• Common among women who have never given birth,
have had a spontaneous abortion, and early
menarche and late menopause
• Signs and symptoms
• Smooth round lumps that are freely movable may
be felt; sometimes milky yellow or green discharge
from the nipple
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Fibrocystic Changes
• Medical diagnosis and treatment
• Diagnosis based on the physical exam and health
history. A mammogram or ultrasound may be used
• No specific cure for fibrocystic changes. Danazol
reduces symptoms; decreases estrogen production
• Nursing care
• Instruct the patient in self-examination and to
encourage scheduled professional
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Pelvic Inflammatory Disease
• Pathophysiology
• Infection that may affect any or all structures in pelvic portion
of reproductive tract and peritoneal cavity
• Etiology and risk factors
• Most PID cases from sexually transmitted organisms
• N. gonorrhoeae, Chlamydia trachomatis, and M. hominis
• Non-STI organisms also causative agents
• Staphylococcal, streptococcal, and other organisms
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Pelvic Inflammatory Disease
• Signs and symptoms
• May be a silent infection with no symptoms
• Symptomatic PID: with either the gradual onset of
dull, steady, low abdominal pain or the sudden
onset of severe abdominal pain, chills, and fever
• Other symptoms: dysuria, irregular bleeding, a foulsmelling vaginal discharge that may cause
inflammation and skin breakdown of the vulva,
dyspareunia (pain during intercourse)
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Pelvic Inflammatory Disease
• Complications
• Ectopic pregnancy, infertility, and chronic abdominal
discomfort
• Infection of the entire peritoneal cavity (peritonitis)
and systemic septic shock also are potential
complications
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Pelvic Inflammatory Disease
• Medical diagnosis
• Culture of the causative organism or organisms; sonography,
laparoscopy, and culdocentesis
• Medical treatment
• Rest; application of heat via warm compresses, a heating pad,
or sitz baths; and a regimen of analgesics and broad-spectrum
antibiotics
• Interventions
• Acute Pain
• Impaired Skin Integrity
• Deficient Knowledge
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Endometriosis
• Pathophysiology
• Endometrial cells deposited in the pelvic cavity
implant on structures within the cavity
• They continue to respond to menstrual cycle
hormonal stimulation
• Result is the periodically painful and potentially
destructive condition
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Endometriosis
• Etiology and risk factors
• Believed to occur in 10% of all women of
reproductive age
• Incidence and severity are greatest in women with
relatives who have endometriosis
• Signs and symptoms
• Dysmenorrhea; pain with defecation, dyspareunia,
and abnormal bleeding
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Figure 47-9
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Endometriosis
• Complications
• Constriction of pelvic structures by endometriosis-related
adhesions
• Medical diagnosis
• Visualization and excision of endometrial implants;
ultrasonography
• Medical treatment
• Nonsteroidal anti-inflammatory agents
• Gonadotropin-releasing hormone (GnRH) agonists or a
synthetic androgenic steroid
• Surgical management
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Endometriosis
• Nursing care
• The most significant nursing interventions are
validating that the pain is real and providing
information about pain relief measures
• Patient teaching based on treatment method
selected and includes anticipatory guidance and
treatment-specific instructions
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Cysts
• A closed saclike structure that is lined with
epithelium and that contains fluid, semisolid, or
solid material
• Classified as neoplasms and may be benign or
malignant; majority are benign
• See Table 47-3, p. 1054
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Fibroid Tumors
• Pathophysiology
• Benign and common
• Fibroid tumors grow slowly during reproductive
years but atrophy after onset of menopause
• Etiology and risk factors
• Exact cause unknown; widely thought that fibroids
form and grow in response to stimulation by
estrogen, primarily estradiol
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Fibroid Tumors
• Signs and symptoms
• May be asymptomatic, but the most common
symptoms are menstrual irregularities—
menorrhagia and dysmenorrhea
• Complications
• Infertility, crowding and malpositioning of the fetus
during pregnancy, degenerative changes from
interruption of blood supply
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Fibroid Tumors
• Medical diagnosis
• On examination, uterus is enlarged and distorted
• Medical treatment
• Many need no treatment; tumors atrophy after menopause
• Myomectomy may be performed
• Nursing care
• Assist physician or nurse practitioner with diagnostic
procedures and provide support to the patient
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Cystocele and Rectocele
• Pathophysiology
• Vaginal disorders caused by weakness of
supportive structures between the vagina and
bladder (cystocele) or the vagina and rectum
(rectocele)
• Etiology and risk factors
• During pregnancy and childbirth, the muscles that
support the pelvic floor may be weakened
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Cystocele and Rectocele
• Signs and symptoms
• Dyspareunia, lower back and pelvic discomfort, and
recurrent bladder infections
• Medical diagnosis and treatment
• Diagnosis based on inspection and palpation
• Treatment may include pelvic floor (Kegel)
exercises; pessary; anterior colporrhaphy and
posterior colporrhaphy
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Cystocele and Rectocele
• Assessment
• Problems related to urinary and bowel function
• If surgery planned, assess patient’s understanding
of the procedure, the pre- and postoperative care,
and the patient’s concerns
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Cystocele and Rectocele
• Interventions
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Stress Incontinence
Constipation
Sexual Dysfunction
Risk for Infection
Acute Pain
Risk for Injury
Deficient Knowledge
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Uterine Prolapse
• Uterus descends into the vagina from its usual
position in the pelvis
• First degree: cervix is above vaginal introitus
• Second degree: cervix protrudes from the introitus
• Third degree: vagina is inverted and both the cervix
and the body of the uterus protrude from the
introitus
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Uterine Prolapse
• Etiology and risk factors
• The supporting ligaments may be congenitally weak
or become stretched during pregnancy or injured
during childbirth, resulting in weakening of support
• Signs and symptoms
• Dyspareunia, backache, and a feeling of pelvic
heaviness and pressure
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Figure 47-10
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Uterine Prolapse
• Complications
• In second- and third-degree prolapse, protruding uterine
portion subject to trauma and may become eroded and
necrotic
• Medical diagnosis
• First-degree: diagnosed by pelvic examination
• Second- and third-degree prolapse: readily detected
by visual inspection
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Uterine Prolapse
• Medical treatment
• Vaginal hysterectomy with anterior and posterior colporrhaphy
• Pessaries may be used for women who are poor surgical risks
or who refuse surgical treatment
• Interventions
• When a pessary is the treatment, explain importance of
frequent examinations by a physician or nurse practitioner, the
need to report pessary-related discomfort to the health care
provider, and the need for pessary care
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Retroversion and Retroflexion,
Anteversion and Anteflexion
• Uterus normally at 45-degree angle anterior to the
vagina; cervix points downward toward the posterior
vaginal wall
• Retroversion: backward tilt, with the cervix pointed
downward toward the anterior vaginal wall
• Retroflexion: body of uterus bends back on itself
• Anteversion: entire uterus tilts forward at a sharper
angle to the vagina
• Anteflexion: uterus bends forward, folding on itself
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Figure 47-11
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Figure 47-12
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Retroversion and Retroflexion,
Anteversion and Anteflexion
• Etiology and risk factors
• Weakening and stretching of the round, broad, and
uterosacral ligaments and weakened pelvic floor
musculature related to childbearing the most
common causes
• Signs and symptoms
• Most uterine displacement is asymptomatic,
although dyspareunia and low back pain may occur
with retroversion
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Retroversion and Retroflexion,
Anteversion and Anteflexion
• Complications
• Difficulty with conception
• Nursing care
• If pessary is inserted, provide instructions similar to
those described for uterine prolapse
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Vaginal Fistulas
• Abnormal passageways between the vagina and other
pelvic organs
• Vesicovaginal fistula
• Between the vagina and the urinary bladder
• Urethrovaginal fistula
• Between the urethra and the vagina
• Rectovaginal fistula
• Located between the vagina and the rectum
• Surgical correction is often needed, although some
small fistulas close spontaneously
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Breast Cancer
• Etiology and risk factors
• White non-Hispanic women have highest incidence
of breast cancer
• African-American women most likely to die from it
• Family history important; risk rises if one or more
first-degree family members has had breast cancer
and if that cancer was premenopausal and bilateral
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Breast Cancer
• Prognosis
• When cancer is confined to the breast, the 5-year relative
survival rate is 96.8%; cancer spread to surrounding tissue, 5year rate is 75.9%; disease has metastasized, the rate is
20.6%
• Signs and symptoms
• Painless breast tissue thickening or lump
• Late symptoms include dimpling of the skin, nipple discharge,
nipple or skin retraction, edema, dilated blood vessels,
ulceration, and hemorrhage
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Breast Cancer
• Complications
• Infiltration of adjacent breast and axillary tissue and
metastasis to distant sites
• Medical diagnosis
• Clinical breast examination; mammogram; breast
ultrasound, digital mammography, or MRI
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Breast Cancer
• Medical treatment
• Lumpectomy, simple mastectomy, and radical mastectomy
(see Figure 47-14, p. 1065)
• Staging: the tumor-node-metastasis classification
• Critical factor determined—whether the cancer cells are
estrogen receptors or nonreceptors
• Tamoxifen: selective estrogen receptor modulator (SERM)
prescribed for the estrogen receptors
• Chemotherapy, hormone therapy, radiation therapy, biologic
therapy, or a combination of these may be employed before,
during, or after surgery
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Figure 47-13
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Figure 47-14
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Breast Cancer
• Interventions
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Disturbed Body Image
Risk for Injury
Impaired Physical Mobility
Deficient Knowledge
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Figure 47-15
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Cervical Cancer
• Etiology and risk factors
• Research indicates that the risk for cervical cancer
is increased in women who have been infected with
the human papillomavirus or HIV
• Additional factors: cigarette smoking, initial sexual
intercourse in early adolescence, multiple sexual
partners, dietary deficiencies in folic acid and in
vitamins A and C
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Cervical Cancer
• Signs and symptoms
• Early cervical cancer is asymptomatic
• Advanced cancer also may be asymptomatic or may
be associated with blood-tinged or frank bloody
vaginal discharge, menstrual irregularities, or
bleeding after intercourse
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Cervical Cancer
• Complications
• Invasion of cervical cancer into adjacent structures
• Medical diagnosis
• Tissue specimens obtained by multiple punch biopsy,
endocervical curettage, or conization
• Medical treatment
• Mild dysplasia: with loop electrosurgical excision
• Localized carcinoma (in situ): with laser destruction,
cryosurgery, or conization alone; total hysterectomy may be
performed if childbearing is not desired
• Invasive cancer: radiation, surgery, or both
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Ovarian Cancer
• Etiology and risk factors
• Family or personal history of ovarian cancer; a personal history of
ovarian dysfunction or of breast, endometrial, or colorectal cancer;
high-fat diet; nulliparity; early menarche and late menopause
• Signs and symptoms
• Asymptomatic in its early stage
• Advanced: abdominal pain and bloating, GI symptoms such as
flatulence and urinary tract complaints
• Complications
• Spread to the peritoneum, omentum, and bowel surface via direct
invasion, peritoneal fluid, and the lymphatic and venous systems
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Ovarian Cancer
• Medical diagnosis
• Pelvic and rectal examinations; abdominal and vaginal
ultrasound; exploratory laparotomy or laparoscopy
• Medical treatment
• Depends on the staging of the tumor
• Options include surgery (usually total abdominal hysterectomy
and bilateral salpingo-oophorectomy), systemic or
intraperitoneal chemotherapy, intraperitoneal radioisotope
instillation, and external radiation therapy
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Vulvar Cancer
• Etiology and risk factors
• Cause unknown, but it may be related to STIs,
particularly human papillomavirus
• Other factors: diabetes mellitus, hypertension
• Signs and symptoms
• Commonly reported symptom is pruritus
• Also pain and bleeding
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Vulvar Cancer
• Complications
• Invades adjacent structures or metastasizes via the lymphatic
system
• Medical diagnosis
• Localized lesions: conservative removal of the malignant
tissue by laser surgery; topical chemotherapy
• For wider, deeper, or invasive lesions, radical surgical removal
through hemivulvectomy or vulvectomy and bilateral dissection
of groin lymph nodes or through pelvic exenteration
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Vaginal Cancer
• Etiology and risk factors
• No definite cause has been identified
• Risk factors: STIs, previous diagnosis of cervical/vulvar cancer,
previous radiation therapy, and intrauterine exposure to
diethylstilbestrol
• Signs and symptoms
• In early and most treatable form, usually is asymptomatic
• Later symptoms: burning sensation, discharge that may have a foul
odor, dyspareunia, spotting after intercourse, and bleeding
• Complications
• Invasion of adjacent structures and metastasis
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Vaginal Cancer
• Medical diagnosis and treatment
• Most cases detected during inspection of vagina and from Pap
smears
• Definitive diagnosis made via colposcopy and biopsy of
suspicious areas followed by tissue studies
• Treatment
• In situ (localized) cancer: treated relatively simple with local laser
surgery or cryosurgery
• More radical treatment indicated if cancer is more invasive
• Possible treatments either alone or in combination include topical
chemotherapy, internal or external radiotherapy, partial or total
vaginectomy, and pelvic exenteration
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Care of the Patient with Cancer of the
Cervix, Ovaries, Vulva, or Vagina
• Assessment
• Signs and symptoms and possible risk factors
• When reviewing the systems, related changes or problems:
fatigue, pain, bowel or bladder dysfunction
• Effects of the symptoms on normal functioning
• Patient may react to the diagnosis with anxiety, fear,
depression, anger, or withdrawal
• A complete physical examination should be done
• Physician/nurse practitioner performs a pelvic examination that
may reveal lesions, masses, and lymph node enlargement
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Care of the Patient with Cancer of the
Cervix, Ovaries, Vulva, or Vagina
• Interventions
•
•
•
•
•
Anxiety and Fear
Disturbed Body Image
Ineffective Sexuality Pattern
Ineffective Family Coping
Risk for Injury
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Infertility
• Etiology and risk factors
• Conception depends on a number of factors
• Timing and techniques used for sexual intercourse
• Production and release of a healthy ovum and numerous
(200 million/ejaculate) healthy sperm
• Anatomically and physiologically correct female and male
reproductive systems
• Biochemical compatibility between female vaginal-cervicalfallopian environment and male ejaculate
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Infertility
• Medical diagnosis
• Based on data obtained from exhaustive
psychosocial and physical health and sexual health
histories of both partners
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Infertility
• Medical treatment
• See Table 47-5
• Interventions
•
•
•
•
Situational Low Self-Esteem
Ineffective Sexuality Pattern
Ineffective Coping
Deficient Knowledge
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Menopause
• Cessation of menstruation; end of reproductive
capacity
• Natural menopause part of normal aging; surgical
menopause from removal of the ovaries
• May begin as early as age 35 but more commonly
occurs between ages 40 and 55
• Process from earliest signs to complete cessation of
menstruation usually is 2 years or less
• A woman is said to be menopausal when she has not
had a menstrual period for 1 year
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Menopause
• Signs and symptoms
• Hot flashes typically accompanied by perspiration and
sometimes faintness
• Also vaginal dryness, insomnia, joint pain, headache, and
nausea
• Without estrogen, the uterus becomes smaller, vagina
shortens, and vaginal tissues become drier
• Breast tissue may lose its firmness, and pubic and axillary hair
becomes sparse
• Supporting pelvic structures relax, causing stress incontinence
• Emotional instability, irritability, and depression
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Menopause
• Medical treatment
• Estrogen therapy
• Drugs used to control hot flashes include clonidine
patches, Bellergal-S, venlafaxine, and paroxetine
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Menopause
• Nursing diagnosis, goal, and outcome criterion
• Nursing diagnosis: Ineffective Management of
Therapeutic Regimen related to lack of
understanding of the effects and treatment of
menopause
• Goal of nursing care is effective management of
prescribed therapy and decreased signs and
symptoms of menopause
• Outcome criterion is reduced symptoms
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Menopause
• Interventions
• Patient’s understanding of menopause and how she feels
about it
• May need reassurance that her symptoms and responses are
normal
• If drug therapy, instruct regarding self-medication
• Women who wish to prevent “menopausal” pregnancy should
use a reliable form of contraception for at least 1 year following
cessation of menses
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