Nursing care plans for Cervical Cancer

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: http://en.wikipedia.org) 

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
Collaborative 
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.
Independent 
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

Biopsy
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.

Cryosurgery
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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Nursing Care Plans for Abruptio Placentae (Placenta Abruption)

Abruptio placentae also called placental abruption occur when the placenta prematurely separates from the uterine wall, usually after the 20th week of gestation, producing hemorrhage. This disorder may be classified according to the degree of placental separation and the severity of maternal and fetal symptoms. It is characterized by a triad of symptoms: vaginal bleeding, uterine hypertonus, and fetal distress. It can occur during the prenatal or intrapartum period. Abruptio placentae is most common in multigravidas usually in women older than age 35 and is a common cause of bleeding during the second half of pregnancy. On heavy maternal bleeding generally necessitates termination of the pregnancy. The fetal prognosis depends on the gestational age and amount of blood lost. The maternal prognosis is good if hemorrhage can be controlled. 

Grading System for Abruptio Placentae (placenta abruption) 

• Grade 0 Less than 10% of the total placental surface has detached; the patient has no symptoms; however, a small retroplacental clot is noted at birth. 
• Grade I approximately 10%–20% of the total placental surface has detached; vaginal bleeding and mild uterine tenderness are noted; however, the mother and fetus are in no distress. 
• Grade II Approximately 20%–50% of the total placental surface has detached; the patient has uterine tenderness and tetany; bleeding can be concealed or is obvious; signs of fetal distress are noted; the mother is not in hypovolemic shock. 
• Grade III More than 50% of the placental surface has detached; uterine tetany is severe; bleeding can be concealed or is obvious; the mother is in shock and often experiencing coagulopathy; fetal death occurs. 

Central abruption, the separation occurs in the middle, and bleeding is trapped Between the detached placenta and the uterus, concealing the hemorrhage 

Marginal abruption, separation begins at the periphery and bleeding accumulates between The membranes and the uterus and eventually passes through the cervix, becoming an external hemorrhage. 

Causes for Abruptio Placentae (placenta abruption) 

The cause of abruptio placentae is unknown; however, any condition that causes vascular changes at the placental level may contribute to premature separation of the placenta. Predisposing factors include: Traumatic injury. Placental site bleeding from a needle puncture during amniocentesis, Chronic or pregnancy-induced hypertension. Multiparity Short umbilical cord Dietary deficiency Smoking Advanced maternal age Pressure on the vena cava from an enlarged uterus. 

The spontaneous rupture of blood vessels at the placental bed may result from a lack of resiliency or to abnormal changes in the uterine vasculature. The condition may be complicated by hypertension or by an enlarged uterus that can’t contract sufficiently to seal off the torn vessels. Consequently, bleeding continues unchecked, possibly shearing off the placenta partially or completely. 

Complications for Abruptio Placentae (placenta abruption) 

Hemorrhage and shock. Renal failure, Disseminated intravascular coagulation. Maternal and fetal death. 

Nursing Assessment

Abruptio placentae produce a wide range of clinical effects, depending on the extent of placental separation and the amount of blood lost from maternal circulation. Obtain patient history obstetric history. Determine the date of the last menstrual period to calculate the estimated day of delivery and gestational age of the infant. Inquire about alcohol, tobacco, and drug usage, and any trauma or abuse situations during pregnancy Mild Abruptio placentae with marginal separation usually report mild to moderate vaginal bleeding, vague lower abdominal discomfort, and mild to moderate abdominal tenderness. Moderate Abruptio placentae are about 50% placental separation usually report continuous abdominal pain and moderate, dark red vaginal bleeding. Onset of symptoms may be gradual or abrupt. Vital signs may indicate impending shock. Palpation reveals a tender uterus that remains firm between contractions. Severe Abruptio placentae about 70% placental separations patient usually report abrupt onset of agonizing, unremitting uterine pain (described as tearing or knifelike) and moderate vaginal bleeding. Vital signs indicate rapidly progressive shock. Palpation reveals a tender uterus with board like rigidity. Uterine size may increase in severe concealed abruptions. Psychosocial Assessment to understanding patient’s situation and also the significant other’s degree of anxiety, coping ability, and willingness to support the patient 

Diagnostic tests for Abruptio Placentae (placenta abruption) 

Pelvic examination under double setup Ultrasonography Decreased hemoglobin level Decreased platelet count. Periodic assays for fibrin split products aid in monitoring the progression of abruptio placentae and in detecting DIC. 

Treatment for Abruptio Placentae (placenta abruption) Medical Treatment management goals of abruptio placentae are to assess, control, and restore the amount of blood lost and to deliver a viable infant and prevent coagulation disorders. After determining the severity of placental abruption and appropriate fluid and blood replacement, prompt cesarean delivery is necessary if the fetus is in distress. If the fetus isn’t in distress, monitoring continues; delivery is usually performed at the first sign of fetal distress. 

Nursing diagnosis

Primary nursing diagnosis fluid volume deficit related to blood loss. Common nursing diagnosis fond in Nursing Care Plans for Abruptio Placentae (placenta abruption): Acute pain Anxiety Deficient fluid volume Dysfunctional grieving Fear Ineffective coping Ineffective tissue perfusion: Cardiopulmonary  

Key outcomes  the patient will: 

Express feelings of comfort. Express feelings of reduced anxiety. Communicate feelings about the situation. Discuss fears and concerns. Use available support systems, such as family and friends, to aid in coping. Remain hemodynamically stable. Patient’s fluid volume will remain within normal parameters. 

Nursing interventions

Monitor Vital sign; blood pressure, pulse rate, respirations, central venous pressure, intake and output, and amount of vaginal bleeding. Monitor fetal heart rate electronically. If vaginal delivery is elected, provide emotional support during labor. Because of the neonate’s prematurity, the mother may not receive an analgesic during labor and may experience intense pain. Reassure the patient of her progress through labor, and keep her informed of the fetus’s condition. Encourage the patient and her family to verbalize their feelings. Help them to develop effective coping strategies. Refer them for counseling, if necessary. 

Patient teaching discharge and home healthcare guidelines

Teach the patient to identify and report signs of placental abruption, such as bleeding and cramping. Explain procedures and treatments to allay patient’s anxiety. Teach the patient to notify the doctor and come to the hospital immediately if she experiences any bleeding or contractions. Prepare the patient and her family for the possibility of an emergency cesarean delivery, the delivery of a premature neonate, and the changes to expect in the postpartum period. Offer emotional support and an honest assessment of the situation. Tactfully discuss the possibility of neonatal death. Inform the patient that the neonate’s survival depends primarily on gestational age, the amount of blood lost, and associated hypertensive disorders. Inform the patient that frequent monitoring and prompt management greatly reduce the risk of death. 

After Postpartum Patient teaching discharge and home healthcare guidelines 

Give the usual postpartum instructions for avoiding complications. Inform the patient that she is at much higher risk of developing abruptio placentae in subsequent Pregnancies. Instruct the patient on how to provide safe care of the infant. Provide a list of referrals to the patient and significant others to help them manage their loss, If the fetus has not Survived

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Nursing Care Plans for Preeclampsia-Eclampsia Pregnancy Induced Hypertension PIH

Preeclampsia-Eclampsia

Nursing care plans, Pregnancy Induced Hypertension (PIH) is a potentially life-threatening disorder that usually develops after the 20th week of pregnancy. It typically occurs in Nulliparity women and may be nonconvulsive or convulsive.Preeclampsia continues to have a massive impact on maternal and prenatal morbidity/mortality 

Preeclampsia, the nonconvulsive form of the disorder, is marked by the onset of hypertension after 20 weeks of gestation. It develops in about 7% of pregnancies and may be mild or severe. The incidence is significantly higher in low socioeconomic groups. The classic diagnostic triad included hypertension, proteinuria, and edema. Recently, the National High Blood Pressure Education Working Group recommended eliminating edema as a diagnostic criterion because it is too frequent an observation during normal pregnancy to be useful in diagnosing preeclampsia 

Eclampsia, preeclampsia with seizures, the occurrence of seizures defines eclampsia. It is a manifestation of severe central nervous system involvement. The convulsive form occurs between 24 weeks’ gestation and the end of the first postpartum week. The incidence increases among women who are pregnant for the first time, have multiple fetuses, and have a history of vascular disease. 

Severe Preeclampsia

Mild Preeclampsia

·      Blood pressure >160 mm Hg systolic or >110 mm Hg diastolic on two occasions at least 6 hours apart while the patient is on bed rest  ·      Proteinuria of 5 g or higher in 24-hour urine specimen or 3+ or greater on two random urine samples collected at least 4 hours apart ·      Oliguria < 500 mL in 24 hours ·      Cerebral or visual disturbances ·      Pulmonary edema or cyanosis ·      Epigastrica or right upper quadrant pain ·      Impaired liver function ·      Thrombocytopenia ·      Fetal growth restriction

·       Blood pressure  > 140/90 mm Hg but  < 160/110 mm Hg on two occasions at least 6 hours apart while the patient is on bed rest ·       Proteinuria > 300 mg/24 h but < 5 g/24 h ·       Asymptomatic

Cause of preeclampsia

The cause of preeclampsia is unknown, it is often called the “disease of theories” because many causes have been proposed, yet none has been well established. Geographic, ethnic, racial, nutritional, immunologic, and familial factors may contribute to preexisting vascular disease, which, in turn, may contribute to its occurrence. Age is also a factor. Adolescents and primiparas older than age 35 are at higher risk for preeclampsia. However, a growing body of evidence suggests that maternal vascular endothelial injury plays a central role in the disorder. Other theories include a long list of potential toxic sources, such as autolysis of placental infarcts, autointoxication, uremia, maternal sensitization to total proteins, and pyelonephritis.

Risk Factors for Preeclampsia

• Age less than 20 years or more than 35 years 
• Nulliparity 
• Multiple gestation 
• Hydatidiform mole 
• Diabetes mellitus 
• Thyroid disease 
• Chronic hypertension 
• Renal disease 
• Collagen vascular disease 
• Antiphospholipid syndrome 
• Family history of preeclampsia 

Complications of Preeclampsia

Generalized arteriolar vasoconstriction is thought to produce decreased blood flow through the placenta and maternal organs. This decrease can result in:

• Intrauterine growth retardation (or restriction), 
• Placental infarcts, and 
• Abruptio placentae. 

Other possible complications include

• Stillbirth of the neonate, 
• Seizures, 
• Coma, 
• Premature labor, 
• Renal failure 
• Hepatic damage in the mother. 

Treatment for Preeclampsia

Early recognition is the key to Preeclampsia treatment. Therapy for patients with preeclampsia is intended to halt the progress of the disorder specifically, the early effects of eclampsia, such as seizures, residual hypertension, and renal shutdown, and to ensure fetal survival. Some physicians advocate the prompt inducement of labor, especially if the patient is near term; others follow a more conservative approach. Therapy may include:

• Complete bed res. 
• An antihypertensive, such as methyldopa or hydralazine 
• Magnesium sulfate to promote diuresis, and reduce blood pressure. 

Nursing diagnosis

Common nursing diagnosis found in Nursing care plans Preeclampsia-Eclampsia Pregnancy Induced Hypertension PIH

• Activity intolerance 
• Disturbed sensory perception (visual) 
• Disturbed thought processes 
• Excess fluid volume 
• Fear 
• Impaired urinary elimination 
• Ineffective coping 
• Ineffective tissue perfusion: Cerebral, peripheral 
• Excess Fluid Volume related to pathophysiologic changes of gestational hypertension and increased risk of fluid overload 
• Ineffective Tissue Perfusion: Fetal Cardiac and Cerebral related to altered placental blood flow caused by vasospasm and thrombosis 
• Risk for Injury related to seizures or to prolonged bed rest or other therapeutic regimens 
• Anxiety related to diagnosis and concern for self and fetus 
• Decreased Cardiac Output related to decreased preload or antihypertensive therapy

Nursing outcome nursing interventions, Nursing care plans Preeclampsia-Eclampsia Pregnancy Induced Hypertension PIH

Nursing Interventions

• Control I.V. fluid intake using a continuous infusion pump. 
• Monitor intake and output strictly; notify health care provider if urine output is less than 30 mL/hour. 
• Monitor hematocrit levels to evaluate intravascular fluid status.
• Monitor vital signs every hour. 
• Auscultate breath sounds every 2 hours, and report signs of pulmonary edema (wheezing, crackles, shortness of breath, increased pulse rate, increased respiratory rate). 
• Position on side to promote placental perfusion. 
• Monitor fetal activity. 
• Evaluate NST to determine fetal status. 
• Increase protein intake to replace protein lost through kidneys. 
• Instruct on the importance of reporting headaches, visual changes, dizziness, and epigastric pain. 
• Instruct to lie down on left side if symptoms are present. 
• Keep the environment quiet and as calm as possible. 
• If patient is hospitalized, side rails should be padded and remain up to prevent injury if seizure occurs. 
• If patient is hospitalized, have oxygen and suction setup, along with a tongue blade and emergency medications, immediately available for treatment of seizures. 
• Assess DTRs and clonus every 2 hours. Increase frequency of assessment as indicated by patient's condition. 

Evaluation: Expected Outcomes

• No evidence of pulmonary edema; urine output adequate 
• FHR within normal range; reactivity present 
• No seizure activity 
• Expresses concern for self and the fetus 
• Maintaining bed rest and pursuing diversional activities 
• BP and other vital parameters stable

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