Monday, June 7, 2010

Cervical cancer is the third most common cancer of the female reproductive system. Cancer of the cervix is one type of primary uterine cancer (the other being uterine-endometrial cancer) and is predominately epidermoid. Invasive cervical cancer is the third most common female pelvic cancer. The death rate from cervical cancer has steadily declined over the past 50 years owing to the increased use of the Papanicolaou exam, which detects cervical changes before cancer develops. Three types of cervical cancer are: Dysplasia, Carcinoma in situ (CIS) and Invasive carcinoma 
Preinvasive cancer ranges from minimal cervical dysplasia, in which the lower third of the epithelium contains abnormal cells, to carcinoma in situ, in which the full thickness of epithelium contains abnormally proliferating cells (also known as cervical intraepithelial neoplasia). Preinvasive cancer is curable in 75% to 90% of patients with early detection and proper treatment. If untreated, it may progress to invasive cervical cancer, depending on the form. 
CIS is carcinoma confined to the epithelium. The full thickness of the epithelium contains abnormally proliferating cells. Both dysplasia and CIS are considered preinvasive cancers and, with early detection, have a 5-year survival rate of 73% to 92%. 
In invasive disease, cancer cells penetrate the basement membrane and can spread directly to contiguous pelvic structures or disseminate to distant sites by way of lymphatic routes. In 95% of cases, the histologic type is squamous cell carcinoma, which varies from well-differentiated cells to highly anaplastic spindle cells. Only 5% of cases are adenocarcinomas. Invasive cancer typically occurs between ages 30 and 50; it rarely occurs younger than age 20. 

Cervical cancer stage (source: 
Cervical cancer is staged by the International Federation of Gynecology and Obstetrics (FIGO) staging system, which is based on clinical examination, rather than surgical findings. It allows only the following diagnostic tests to be used in determining the stage: palpation, inspection, colposcopy, endocervical curettage, hysteroscopy, cystoscopy, proctoscopy, intravenous urography, and X-ray examination of the lungs and skeleton, and cervical conization. 
The TNM staging system for cervical cancer is analogous to the FIGO stage. 

Stage 0 – full-thickness involvement of the epithelium without invasion into the stroma (carcinoma in situ) 
Stage I – limited to the cervix 
IA – diagnosed only by microscopy; no visible lesions 
          IA1 – stromal invasion less than 3 mm in depth and 7 mm or less in horizontal spread 
          IA2 – stromal invasion between 3 and 5 mm with horizontal spread of 7 mm or less 
IB – visible lesion or a microscopic lesion with more than 5 mm of depth or horizontal spread of more than 7 mm 
          IB1 – visible lesion 4 cm or less in greatest dimension 
          IB2 – visible lesion more than 4 cm 
Stage II – invades beyond cervix
          IIA – without parametrial invasion, but involve upper 2/3 of vagina
          IIB – with parametrial invasion 
Stage III – extends to pelvic wall or lower third of the vagina
          IIIA – involves lower third of vagina
          IIIB – extends to pelvic wall and/or causes hydronephrosis or non-functioning kidney 
IVA – invades mucosa of bladder or rectum and/or extends beyond true pelvis 
IVB – distant metastasis 

Causes for Cervical cancer 
Worldwide studies suggest that Causes for Cervical cancer is sexually transmitted human papillomaviruses (HPVs). Certain strains of HPV (16, 18, and 31) are associated with an increased risk of cervical cancer. Several predisposing factors have been related to the development of cervical cancer: intercourse at a young age), multiple sexual partners, and herpesvirus 2 and other bacterial or viral venereal infections. Genetic considerations While most risk factors for cervical cancer are environmental, some studies have found that the daughters or sisters of cervical cancer patients are more likely to get the disease. 

Complications of Cervical cancer 
Disease progression can cause flank pain from sciatic nerve or pelvic wall invasion and hematuria and renal failure associated with bladder involvement.

  • Ureteric obstruction 
  • Intermenstrual PV bleed 
  • Vesicovaginal fistula 
  • Post-menopausal PV bleed 
  • Uterine enlargement 
  • Menorrhagia 

Nursing Assessment
Patient’s history, early cervical cancer usually asymptomatic, establishes a thorough history with particular attention to the presence of the risk factors and the woman’s menstrual history. assess a history of later symptoms of cervical cancer, including abnormal bleeding or spotting between periods or after menopause, metrorrhagia or menorrhagia, dysparuenia and postcoital bleeding; leukorrhea in increasing amounts and changing over time from watery to dark and foul; and a history of chronic cervical infections. Determine if the patient has experienced weight gain or loss; abdominal or pelvic pain, often unilateral, radiating to the buttocks and legs, or other symptoms associated with neoplasms, such as fatigue. The patient history includes abnormal vaginal bleeding, such as a persistent vaginal discharge that may be yellowish, blood-tinged, and foul-smelling; postcoital pain and bleeding; and bleeding between menstrual periods or unusually heavy menstrual periods. The patient history may suggest one or more of the predisposing factors for this disease. 
Physical Examination. Pelvic examination. Observe the patient’s external genitalia for signs of inflammation, bleeding, discharge, or local skin or epithelial changes. Palpate for motion tenderness of the cervix (Chandelier’s sign); a positive Chandelier’s sign (pain on movement) usually indicates an infection. Also examine the size, consistency (hardness may reflect invasion by neoplasm), shape, mobility (cervix should be freely movable), tenderness, and presence of masses of the uterus and adnexa. If the cancer has advanced into the pelvic wall, the patient may report gradually increasing flank pain, which can indicate sciatic nerve involvement. Leakage of urine may point to metastasis into the bladder with formation of a fistula. Leakage of stool may indicate metastasis to the rectum with fistula development. 

Diagnostic test
Papanicolaou examination ((Pap smear) Colposcopy followed by punch biopsy or cone biopsy The Vira/Pap test to examination of the specimen’s deoxyribonucleic acid (DNA) structure to detect HPV 

Nursing diagnosis
Common nursing diagnosis found in nursing care plans for Cervical Cancer:

  • Pain (acute) related to postprocedure swelling and nerve damage 
  • Anxiety 
  • Fear 
  • Impaired physical mobility 
  • Impaired skin integrity 
  • Ineffective coping 
  • Ineffective sexuality patterns 
  • Risk for infection Sexual dysfunction 

Cervical cancer is the third most common cancer of the female reproductive system. Cancer of the cervix is one type of primary uterine cancer (the other being uterine-endometrial cancer) and is predominately epidermoid. Invasive cervical cancer is the third most common female pelvic cancer. The death rate from cervical cancer has steadily declined over the past 50 years owing to the increased use of the Papanicolaou exam, which detects cervical changes before cancer develops.

Nursing Key outcomes
Pain control; Pain: Disruptive effects; Well-being, after nursing interventions patient will Report feeling less pain. Report feelings of reduced anxiety. Verbalize her concerns and fears related to her diagnosis and condition. Maintain joint mobility and range of motion. Free from breakdown. Demonstrate adaptive coping behaviors. Resume normal sexual activity patterns to the fullest extent possible. Remain free from signs or symptoms of infection. The patient and partner will express feelings and perceptions about changes in sexual performance.

Nursing interventions nursing care plans for Cervical Cancer 
Analgesic administration; Pain management; Meditation; Transcutaneous electric nerve stimulation (TENS); Hypnosis; Heat/cold application
If you assist with a biopsy, drape and prepare the patient as for a routine Pap test and pelvic examination. Have a container of formaldehyde ready to preserve the specimen during transfer to the pathology laboratory. Assist the physician as needed, and provide support for the patient throughout the procedure. If you assist with cryosurgery or laser therapy, drape and prepare the patient as for a routine Pap test and pelvic examination. Assist the physician as necessary, and provide support for the patient throughout the procedure. Preinvasive lesions (CIS) can be treated by conization, cryosurgery, laser surgery, or simple hysterectomy (if the patient’s reproductive capacity is not an issue). All conservative treatments require frequent follow-up by Pap tests and colposcopy because a greater level of risk is always present for the woman who has had CIS Administer analgesics and prophylactic antibiotics, as ordered.
Listen to the patient’s fears and concerns, and offer reassurance when appropriate. Encourage her to use relaxation techniques to promote comfort during diagnostic procedures. When a patient requires surgery, prepare her mentally and physically for the surgery and the postoperative period. After any surgery, monitor vital signs every 4 hours. Watch for and immediately report signs of complications, such as bleeding, abdominal distention, severe pain, and wheezing or other breathing difficulties. Encourage deep breathing and coughing. Check to see whether the radioactive source is to be inserted while the patient is in the operating room (preloaded) or at bedside (afterloaded). If the source is preloaded, the patient returns to her room hot and safety precautions begin immediately. Remember that safety precaution time, distance, and shielding begin as soon as the radioactive source is in place. Inform the patient that she will require a private room. Check the patient’s vital signs every 4 hours Assist the patient with range-of-motion arm exercises. Avoid leg exercises and other body movements that could dislodge the source. If ordered, administer a tranquilizer to help the patient relax. Provide activities that require minimal movement. Watch for treatment complications by listening to and observing the patient and monitoring laboratory studies and vital signs. When appropriate, perform measures to prevent or alleviate complications.

Patient teaching, discharge and home healthcare guidelines for patients with Cervical Cancer: 
Be sure the patient and family understand any pain medication prescribed, including dosage, route, action, and side effects. Reassure the patient that this disease and Cervical Cancer care treatment should not radically alter her lifestyle or prohibit sexual intimacy. Tell to the patient all the post procedure complications. Ensure that the patient understands the need for ongoing Pap smears if appropriate. Vaginal cytological studies are recommended at 4-month intervals for 2 years, every 6 months for 3 years, and then annually. Explain the importance of complying with follow-up visits to the gynecologist and oncologist. Stress the value of these visits in detecting disease progression or recurrence

Explain to the patient that she may feel pressure, minor abdominal cramps, or a pinch from the punch forceps. Reassure her that the pain will be minimal because the cervix has few nerve endings.

Explain to the patient that the procedure takes about 15 minutes, during which time the physician uses refrigerant to freeze the cervix. Caution to the patients that she may experience abdominal cramps, headache, and sweating, but reassure her that she will feel little, if any, pain.

Laser surgery
Explain to the patient the laser surgery procedure takes about 30 minutes and may cause abdominal cramps. After excision biopsy, cryosurgery, or laser therapy, tell the patient to expect a discharge or spotting for about 1 week. Advise her not to douche, use tampons, or engage in sexual intercourse during this time. Caution her to report signs of infection. Stress the need for a follow-up Pap test and a pelvic examination in 3 to 4 months and periodically thereafter. Also, tell her what to expect postoperatively if a hysterectomy is necessary.

Preloaded internal radiation therapy
Tell to the patient that preloaded internal radiation therapy procedure requires hospital stay, bowel preparation, a povidoneiodine vaginal douche, a clear liquid diet, and nothing by mouth the night before the implantation. It also requires an indwelling urinary catheter. Inform the patient that preloaded internal radiation therapy is performed in the operating room under general anesthesia.

After loaded internal radiation therapy
Explain to the patient that a member of the radiation team implants the source after the patient returns to her room from surgery. Remind the patient to watch for and report uncomfortable adverse effects, warn the patient to avoid people with obvious infections during therapy. Inform the patient that vaginal narrowing caused by scar tissue can occur after internal radiation. Describe the complications that can occur after high-dose radiation therapy.

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