• Regular pelvic exams, pap tests
• Preventive counseling:
  • delaying 1st intercourse
  • avoiding HPV infection
  • safer sex
  • smoking cessation
  • HPV immunization

Preventive measures:

cervical cancer

sexual activity with lubrication

or 

vaginal dilator to avoid severe permanent vaginal stenosis

Side effect of brachytherapy/external beam radiation:

vaginal stenosis

Prevention:

• cumulative exposure to estrogen:
  • estrogen therapy w/out progestin
  • early menarche, late menopause
  • nulliparity, annovulation
• obesity, infertility, diabetes
• tamoxifen (med. for tx or prevention of breast cancer; may cause proliferation of the uterine lining)

Risk factors for uterine cancer:

dyspareunia

pain with intercourse

• slight bleeding after intercourse
• spontaneous bleeding
• vaginal discharge
• pain
• urinary & rectal symptoms
• DES exposure in utero

possible S&S of vaginal cancer (rare)

S&S of Ovarian Cancer

(leading cause of Gyn. cancer deaths in U.S.)

similar to interventions after other abdominal surgery

NSG Interventions:

after pelvic surgery

• admin. IV fluids to alleviate fluid & electrolyte imbalance
• admin. parenteral nutrition to provide adequate nutrition
• provide postop care after intestinal bypass to alleviate any obstruction
• controlling pain
• managing drainage tubes

Nsg Care:

Advanced ovarian cancer

(ascites, pleural effusion)

• frequent small meals
• decrease fluid intake
• administer diuretic agents
• provide rest

comfort measures for women with ascites:

• SOB
• hypoxia
• pleuritic chest pain
• cough

S&S of pleural effusion

(can be a complication of advanced ovarian cancer)

• advise pt to d/c anticoagulant meds, NSAIDS (such as aspirin), and Vitamin E prior to surgery
• pregnancy ruled out on day of surgery 
• may admin prophylactic antibiotics prior to surgery & d/c the next day
• prevention of thromboembolic events may include heparin and use of anti-embolism stockings or intermittent pneumatic compression device

Preop. for hysterectomy

• postop for abdominal surgery applies

Postop for hysterectomy:

• antiembolism stockings
• frequent position changes
• ambulate early in postop period
• DVT: assess for leg pain, redness, warmth, edema
• PE: assess for chest pain, tachycardia, dyspnea
• instruct pt to avoid prolonged sitting in a chair w/pressure at the knees, sitting with crossed legs, & inactivity

Nsg interventions to minimize risk of DVT & PE:

• best performed after menses
• should be taught/encouraged (but not overemphasized)
• teach about benefits of & limitations

BSE

(Breast self exam)

yearly beginning at 40 yrs. or 10 yrs earlier than youngest family member to develop breast cancer (but not less than 25 yrs. old)

Mammogram

• Preop: 
  • d/c any agents that can increase risk of bleeding (aspirin, NSAIDS, vitamin E supplements, herbal supplements such as gingko biloba, garlic, and warfarin (Coumadin))
  • may be instructed not to eat or drink for several hrs. or after midnight the night before the procedure
• Immediate Postop:
  • monitor effects of anesthesia
  • inspect surgical site for bleeding
• Postop:
  • review: care of biopsy site, pain mgmt., activity restrictions
  • pt must be able to tolerate fluids, ambulate & void before discharge
  • must have somebody to accompany her home
  • use of supportive bra is encouraged

Nsg mgmt:

biopsy

mastalgia

brease pain, may be cyclical or noncyclical

• recommend:
  • supportive bra both day/night
  • decrease salt & caffeine intake
  • take ibuprofen (advil) as needed for inflammation
  • Vit E or evening primrose may be helpful

Nsg Interventions:

mastalgia

• female (males do not get it as often)
• age over 50
• family hx, mutations of BRCA 1 or 2
• personal cancer hx
• early menarche, late menopause
• benign breast disease
• obesity, dietary fat, alcohol
• HRT (Hormone Replacement Therapy)

Breast Cancer:

risk factors

• Gene that helps prevent abnormal cell growth
• If mutation, increased risk of breast, ovarian, colorectal, prostate cancer
• Legal and insurance implications
• anxiety & depression surrounding testing process
• complex family dynamics

BRCA 1 & 2 Mutations:

• decisional conflict (TX options):
  • decision making is often painful, difficult:
    • Remember: YOU are not making the decision for them (help pt to tease out what is important to them, list pros/cons & questions/concerns)
• Risk for Body Image Disturbance
• Ineffective individual coping
• Anticipatory grieving (loss of "perfect body", health/ability)
• Altered Role Performance

Mastectomy:

Preoperative care

PC's: homorrhage, infection, seroma, hemotoma, brachial plexus injury, lymphedema

short length of stay, often discharged w/drain still in place: teach to empty it & care for incision

Elevate arm, issues of balance w/large breast

BREAST RECONSTRUCTION: Smokers are not candidates (issues with grafting due to increased vasoconstriction)

Mastectomy:

Postop care

smokers are not candidates for breast reconstruction due to issues with grafting r/t increased vasoconstriction

PC's: infection, hemorrhage, etc.

TRAM: Transverse Rectus Abdominus Muscle Flap

Latissumus Dorsi Flap

(may still need an expansion implant)

Breast reconstruction

BSE on remaining breast;

To prevent lymphedema:

• long gloves for gardening, mitts in kitchen
• thimble (w/sewing)
• electric razor, sunscreen
• careful w/cuts, insect bites, avoid tight elastic cuffs in clothing, extremes of weather/temp

Mastectomy:

Learning needs

(may occur after either mastectomy or breast conservation; usually develops w/in 12 hrs of surgery)

• swelling, tightness, pain, & bruising of skin
• notify MD if gross swelling or increased bloody output from drain
• Compression wrap may be applied to incision for approx 12 hrs or pt may be returned to OR so incision may be reopened to id source of bleeding
• w/small hematoma, pt may take warm shower or apply warm compresses to help body absorb blood naturally

S&S of hematoma

(collection of blood inside a cavity)

may accumulate under breast incision after mastectomy or breast conservation or in the axilla

• swelling, heaviness, discomfort, and a sloshing of fluid

S&S of seroma

(collection of serous fluid)

• redness,
• warmth around incision,
• tenderness,
• foul smelling drainage,
• temp >100.4 (40 deg. C),
• chills

S&S of infection

• increased age
• obesity
• presence of extensive axillary disease
• radiation TX
• injury or infection to extremity

Risk factors for lymphedema:

• hand/arm care to prevent injury/trauma to affected extremity
• avoid bp, injections, blood draws to the affected extremity
• use sunscreen (higher than 15 SPF)
• insect repellent to avoid bites
• wear gloves for gardening
• cooking mitt to remove objects from oven
• avoid cutting cuticles (push them back)
• use electric razor for shaving armpit
• avoid lifting objects >5-10 lbs
• If trauma or break in skin occurs, wash area with soap & water & apply OTC antibacterial ointment
• observe the area & extremity for 24 hrs; if redness, swelling, or fever occurs: call MD or nurse

Lymphedema:

Preventive strategies:

ROM exercises 3x/day for 20 mins at a time until full ROM is restored (usually 4-6 wks);

analgesic 30 mins before exercise may help;

warm shower before exercise: provides comfort & loosens stiff muscles;

Brushing teeth, washing face, brushing hair are physically & emotionally therapeutic.

Avoid heavy lifting (5-10 lbs) for 4-6 wks.

May do normal household/work related activities.

Brisk walking, stationary bike, stepping machines may begin as soon as pt is able.

(gradual intro. of previous activities)

Postop: 

ALND & SNNB

Nsg mgmt:

Radiation

• Nausea
• vomiting
• bone marrow suppression
• taste changes,
• alopecia (hair loss)
• mucositis
• neuropathy
• skin changes
• fatigue
• possible 10 lb. wt gain
• temporary/permanent amenorrhea

S/E of Chemotherapy:

Breast Cancer

• instruct pt in use of antiemetics (minimize N&V)
• ease symptoms of mucositis by rinsing w/normal saline or sodium bicarbonate solution
• avoid hot/spicy foods
• use soft toothbrush
• may help pt obtain wig, scarves, turban
• guided imagery, meditation, relaxation exercises may help
• providing support, promoting open communication
• referrals to dietician, social worker, psychiatrist, etc.

Chemtherapy:

Nsg mgmt. 

SERM = Selective Estrogen receptor modulator

(estrogen blocker, antineoplastic agent)

s/e: 

• increased endometrial cancer
• thromboembolic events (DVT, superficial phlebitis, PE)
• hot flashes, vaginal dryness/discharge, bleeding
• irregular menses
• nausea
• mood disturbances, headaches, lightheadedness
• hair loss, photosensitivity, visual changes
• osteoporosis
• sometimes aching bone pain w/initial TX

Adjuvant Hormonal therapy:

Tamoxifen (Nolvadex)

Raloxifine (Evista)

• Hot flashes: 
  • wear breathable, layered clothing
  • avoid caffeine & spicy foods
  • perform breathing exercises
  • meds: Vit E, antidepressants
  • acupuncture
• vaginal dryness
  • vaginal moisturizers (Replens)
  • lub. during intercourse
• N&V: bland diet, evening med.
• Musculoskeletal symptoms:
  • warm baths, nonsteroidal analgesics
• Risk of endometrial cancer
  • report any irregular bleeding to gyn for eval.
• Risk for thromboembolic event
  • report any redness, swelling, tenderness in lower extremities, or any unexplained SOB
• Risk for osteoporosis or fractures:
  • baseline bone density scan
  • regular wt-bearing exercises
  • Ca+ supp. w/Vit D
  • biphosphonates or cacitonin as prescribed

Adjuvant Hormonal therapy:

Side Effects and Mgmt.

elevate HOB 45 degrees & flex pt's knees (during 1st wk)

Pt must be cautioned not to have an MRI while tissue expander is in place - port contains metal.

Permanent implant does not contain metal.

Breathing, leg exercises essential.

NSG: assess flap & site: color, circ, temp

Breast reconstruction:

Nsg. Imp:

• Diagnostic phase: 
  • processing information
• Post surgical phase:
  • coping with loss
• Adjuvant therapy
  • making decisions
• Ongoing recovery
  • ongoing surveillance (balancing ongoing life "cancer survivor")

Stages of Adjustment

• multiple insults to cervix
• early age 1st intercourse
• early childbearing
• multiple partners
• uncircumcised partner
• HPV exposure
• smoking, nutritional issues
• DES in utero
• HIV association

Cervical Cancer Risk Factors

• leukorrhea (whitish discharge)
• bleeding between periods
• bleeding after menopause

S&S of cervical cancer

Endometrial cancer:

• S&S
• Risk Factors
• RX

vaginal or abdominal route

PCs: thrombophlebitis, DVT, urinary problems, infections, shock, hemorrhage, paralytic ileus

*normal to have bloody drainage, but huge gush or clots are a concern

*urinary problems are common: bladder knicked, kidney's perfusing

***be concerned if low output or trickle from vagina

Hysterectomy

• fistulas
• vaginal drainage
• ascites
• jaundice
• respiratory distress
• GI obstruction

Widespread pelvic disease:

End stage symptoms

• perineal care/incisional care
• s&s complications
• activity restrictions
• loss of menses 
• HRT 
• follow up care
• fear/anxiety (cancer could come back)

Hysterectomy:

Going home

• Bowel prep, fleets (keeps bowel empty)
• foley (keeps bladder small & out of field of radiation)
• antiembolic hose (SCDs)
• will be on bedrest
• examined under anesthesia & verified w/xrays
• afterloaded in room

Prep for radiation implant

• minimize time at bedside (be organized)
• film badges, lead shielding
• low residue diet, codeine to constipate (want applicator to stay in place)
• applicator removed by radiation oncologist:
  • get up slowly (dizzy), shower, peripads
  • dilator if not having regular intercourse
  • have been flat for so long, may want an enema, shower, etc.

Radiation implant:

NSG care

Risk factors:

• family hx
• industrialized countries
• irregular menses
• nulliparity
• infertility
• anovulatory or "incessant ovulators"
• talcum powder to perineum (adbestos)

Risk factors for ovarian cancer:

S&S:

• Bowel obstruction r/t tumor growth
• malignant ascites (SOB)
• pleural effusion (SOB)
  • elevate HOB
• swollen lower extremities
• blocked ureters lead to renal failure (death may be a relief)
• sepsis
• DVT
• malnutrition

Complications of Ovarian cancer: