Nursing Care Plan for Women Hysterectomized for Benign Causes

Nursing care plan for women hysterectomized for benign causes Hysterectomy (HT) is defined as surgical removal of the uterus. It is one of the most frequent surgical interventions performed worldwide. It is the second most common surgical procedure in women of reproductive age, after cesarean section, and the third most frequent intra-abdominal operation together with appendectomy and cholecystectomy.1 Hysterectomy is one of the most frequently used techniques for the treatment of benign uterine diseases, mainly abnormal uterine bleeding, prolapse or uterine fibroids. In North America, more than 600,000 hysterectomies are performed per year, this figure is lower, although it exceeds 150 cases per 100,000 women per year and it is one of the 15 most performed hospital procedures. 2 The largest number of hysterectomies are found in the ages 40-44, but they are also performed on younger women. Removal of the ovaries is not always necessary, unless there is ovarian cancer or they are polycystic. If both ovaries are removed, the woman will experience surgical menopause regardless of age. Patients who keep one or both ovaries intact have a 50% chance of experiencing menopause 5 years after their hysterectomy. 3 86% of the patients are multiparous and 14% nulliparous. 63% are hysterectomized due to benign pathology and 37% due to malignant causes, 80% undergo abdominal surgery and 20% vaginally. 11% are operated on urgently and 89% on a scheduled basis. 4 Hysterectomy can be done in three ways: 1. Subtotal hysterectomy: The uterus is removed, leaving the cervix, ovaries, and fallopian tubes. 2. Total hysterectomy: The uterus and cervix are removed, leaving the ovaries and fallopian tubes. 3. Radical hysterectomy: This is the most extensive procedure, the uterus, ovaries, fallopian tubes and lymph nodes in the pelvis are removed. 5 The approaches to hysterectomy in benign diseases are: abdominal hysterectomy (HA), vaginal hysterectomy (HV), laparoscopic hysterectomy (LH) and robotic hysterectomy (HR). If there are no contraindications, it is advisable to do it by vaginal approach; When the vaginal approach is not possible, the abdominal and laparoscopic approaches have pros and cons that must be considered in the decision-making process. 6-8 (ANNEX I) The morbidity of this surgical procedure is currently low regardless of the approach, but we must take into account that it carries risks and complications related to anesthesia, bleeding, injury to neighboring organs, and vaginal infection. Regardless of the technique used, total hysterectomy leads to blood loss, shortens the length of the vagina, alters sexual function, and can damage the genitourinary tract. Most hysterectomies are performed for benign causes, to increase the quality of life of patients, however, it can lead to long-term postoperative problems such as sexual dysfunction and urinary incontinence. 9-10 It must also be taken into account that this intervention is a risk factor for developing self-esteem conflicts and that the health professional must deal with the fears, beliefs and anxiety of the patients to prevent depressive symptoms after discharge. Many times this is due to a woman's ignorance and false beliefs about hysterectomy. This is why education and emotional support throughout the nursing process is very important. 4,10,12 In most cases, the patient decides to undergo the intervention, that is, it is a chosen procedure and not an emergency operation, whose The objective is to cure or alleviate the symptoms related to their gynecological problems (myomatosis, condylomatosis, fibrosis, etc.), which negatively affect the quality of life of patients. 12 However, considering hysterectomy only as a relief of the symptoms or the treatment of a disease, would not be a global vision of what the woman lives, distancing us from the real situation that they and their partners go through. 13-14 The importance of nursing in the care of hysterectomized women resides in the fact that despite the common nature of surgery, there is a deficit in the education they receive. In most cases, patients decide to undergo the intervention without understanding the consequences of the removal of the uterus. We must focus on educating patients, highlighting what they really want and need to know about the care before, during and after this surgery and its consequences. Women who are well informed feel more secure and supported in this experience. Information prior to hospitalization has better results than that provided during it. 15-17 The nursing professional must provide comprehensive, multidisciplinary and quality care, based on the needs of the person, throughout the process, to improve the quality of life of patients. We must approach care from a holistic perspective, taking into account the physical, psychological and social aspects It is important to establish an empathic relationship with the woman who is going to be intervened, and to have fluent communication in order to identify the main needs and prioritize the care of watch out. 18 JUSTIFICATION For this reason, this Nursing Care Plan will be carried out for women who have been hysterectomized for benign causes; to publicize the possible physical and psychological complications triggered by this intervention, such as: urinary incontinence, alteration of sexual and reproductive function, and depression, facilitating its prevention. As well as educating patients, providing all the necessary information to prepare them physically and psychologically. Treatment must be individualized; we must ensure a correct physical evolution and facilitate the emotional and psychological expression of patients. So that with good care from the nursing team, coping with the intervention is improved and the development of long-term problems is prevented, improving the quality of life of hysterectomized patients. 17-18 OBJECTIVES General purpose: Prepare a Nursing Care Plan for women who have been hysterectomized for benign causes to make known possible long-term problems, as well as the actions to be carried out to prevent them; so as to improve the convalescence period and the quality of life of patients. Main goal: Prevent possible long-term complications in hysterectomized women such as urinary incontinence, sexual dysfunction and improve their emotional state. Specific objectives: Provide all the necessary information to the hysterectomized patient about the intervention and the female genital tract, its subsequent care and possible physical and emotional consequences, to reduce anxiety related to the intervention and improve coping with the situation. Improve the self-perception of the hysterectomy patient and promote a good relationship between her and her partner, to prevent problems in sexual relations. Improve the quality of life of the hysterectomized patient during their longterm hospital stay, controlling postoperative pain and ensuring a correct physical evolution. METHODOLOGY To update the subject, and in the application of the competences of the University Nursing Degree Curriculum, a bibliographic review has been carried out, for which books, theses and databases such as SciELO, Pubmed and Cochrane. For the standardization of nursing diagnoses, outcome criteria, and key interventions, the NANDA-NIC-NOC taxonomy was used. As keywords for the search, the following were considered: "hysterectomy", "complications", "depression", "incontinence", "sexuality", "education", "laparoscopic", shortening to complete free access articles published between the years 2006-2016. DATAB ASE SciELO PubMed SEARCH PROFILE AND hysterecto my sexuality AND hysterecto my education AND hysterecto my complications AND hysterecto my laparoscopic Hysterecto my AND depression ITEMS FOUND SELECTED ITEMS ITEMS USED 7 5 3 8 4 3 2 8 1 2 2 f i f t e e n F o u r . 4 3 1 2 4 Cochran e Hysterecto my AND postoperati ve incontinenc e Hysterectomy F i v e 4 7 1 4 1 0 1 3 1 BOOK S TITLE AUTHOR Herdman Nursing Diagnoses, Definitions and T, Classification 2015-2017 (NANDA). Kamitsuru 10th S. Bulechek GM, Edition. Nursing Interventions Butcher HK, Classification (NIC). 6th Dochterman Edition. YEAR 2014 2014 JM, Wagner CM. Moorhead S, Nursing Outcomes Classification (NOC). Johnson M, 5th Edition. 2014 Maas ML, Swanson E. AUTHOR Ajú Coy JA. Arias Arias PC, Tenezaca Alao DA. Montenegro Castañeda IK. THE SIS TITLE Depressive state in pre and posthysterectomized patients, abdominal and / or vaginal route. Prevalence and causes of hysterectomy in women treated in the gynecology and obstetrics department of the José Carrasco Arteaga Hospital in the city of Cuenca in the year 2012. Nursing care in the perioperative period of hysterectomy. Luis Heysen Inchásticategui-Chiclayo Hospital, Peru 2013. YEAR 2015 2014 2014 STAGES OF THE NURSING PROCESS ASSESSMENT For the elaboration of the nursing care plan, the first thing that is carried out is an assessment using the functional patterns of M. Gordon. 21 Reflected in the following table: Table 1: M. Gordon Functional Patterns. Own elaboration. PATTERN 1: PERCEPTION OF HEALTH. There is a lack of knowledge on the part of the hysterectomized woman about the intervention and its consequences, as well as the necessary physical and emotional care. PATTERN 2: NUTRITIONALMETABOLIC. PATTERN 3: ELIMINATION. There is no alteration in this pattern. The risk of developing stress urinary incontinence increases, due to surgical trauma from the removal of the uterus. PATTERN 4: ACTIVITY-EXERCISE Their activities are limited, depending on the degree of pain that the patient presents and her urinary incontinence problems. PATTERN 5: SLEEP-REST PATTERN 6: COGNITIVE-PERCEPTIVE. There is no alteration in this pattern. There is no alteration in this pattern. PATTERN 7: SELF- The myths and beliefs in relation to the uterus and the PERCEPTION - SELF- fact of being a woman, as well as the lack or scarcity of CONCEPT. information, alter the emotional pattern of the hysterectomized woman. PATTERN 8: ROLE-RELATIONSHIPS The relationship with the sentimental partner is affected since the woman feels that she has lost value as such and / or sexual attractiveness associated with the loss of fertility. PATTERN 9: SEXUALITY Due to the removal of the uterus there is an alteration in - REPRODUCTION the sexual function of the woman, due to fears, on the part of the patient and / or her partner. Reproductive function is also impaired. PATTERN 10: STRESS TOLERANCE The patient presents concerns about her new state, with anxiety and lack of coping with her new situation. PATTERN 11: VALUES - BELIEFS The spiritual and / or religious values and beliefs are altered after the removal of the uterus. DIAGNOSTICS OF EPHERMERY The main nursing diagnoses, their interventions and results are presented below, using the NANDA, NIC and NOC taxonomy. 22-24 Table 2: Main Nursing Diagnoses, Interventions and Results. Own elaboration. NURSING DIAGNOSTICS (00126) Deficient knowledge r / c misinterpretation of information m / p exposure of misconception. NIC NOC 5618: Teaching: procedure / treatment of the hysterectomized patient. 5606: Teaching: individual. 5250: Support in decision making. (00120) Low situational self-esteem r / c alteration of body image m / p self-negative verbalizations. NIC NOC 5270: Emotional support. 5400: Enhancement of self-esteem. 0906: Decision making. 1606: Participation in decisions about healthcare. 2002: Personal well-being. 1205: Self-esteem. 1208: Depression level. 1409: Self-control of depression. ( 00059) Sexual dysfunction r / c alteration of body structure or function m / p real or perceived limitation imposed by hysterectomy. NIC NOC 7110: Encourage family involvement. 1200: Body image. 1207: Sexual identity. 5220: Improved body image. 2001: Spiritual health. 5248: Sex counseling. 2609: Family support during treatment. 5426: Facilitate spiritual growth. (00069) Ineffective coping r / c situational crisis due to surgical intervention m / p anxiety. NIC NOC 5230: Increase coping. 1302: Coping with problems. 5440: Increase support systems. 1402: Self-control of anxiety. 5820: Decreased anxiety. 5880: Relaxation technique. (00017) Stress urinary incontinence r / c weakness of the pelvic muscles and structural supports m / p reports of involuntary loss of small amounts of urine when sneezing, coughing or laughing. NIC NOC 0610: Urinary incontinence care. 0502: Urinary continence. 0560: Pelvic floor exercise. 0503: Urinary elimination. (000132) Acute pain r / c surgical wound m / p verbal manifestation of intense pain. NIC 1400: Pain management. 2210: Administration of analgesics. NOC 1605: Pain control. 1843: Knowledge: pain management. PLANNING AND EXECUTION After listing the nursing diagnoses, we proceed to the planning and execution of the nursing care plan, which is designed to be carried out throughout the process. The application of care would be carried out from the first consultation with the woman, either in Primary Care or in the hospital, through the surveillance and control of existing problems and the prevention of complications. (00126) Deficient knowledge Hysterectomy is usually an elective procedure, so women have time to be adequately educated before the intervention. Despite this, there is a lack of knowledge on the part of the hysterectomized woman about the intervention and its consequences, as well as the physical and emotional care they will need. Family, friends and the media are the sources of information most used by patients, however they are not reliable in terms of the legitimacy of the information. Before surgery, we would give the woman a brochure with information on: what is a hysterectomy, what happens after, and advice on how to take care of herself. (ANNEX II) It is important to create a close and trusting atmosphere with the patient from the first consultation, to help her organize her ideas and emotions, and keep her well informed. We must incorporate the couple in the information process, to explore the negative connotations about hysterectomy, since this influences the delay in decision-making. Incorporating the partner is a necessary and frequently forgotten aspect, since an informed partner is a support resource for the woman, both in decision-making and during followup. Table 3: Interventions and results related to the nursing diagnosis of deficient knowledge. Own elaboration. Interventions (NIC) 5618: Teaching: procedure / treatment of the hysterectomized patient. Activities: Explain the purpose of the hysterectomy. Describe post-hysterectomy assessments / activities and the rationale for them. Reinforce information provided by other members of the care team, as appropriate. Determine the expectations of the hysterectomy by the patient. Correct unrealistic expectations of hysterectomy, as appropriate. Allow time for the patient to ask questions and raise concerns. 5606: Teaching: individual. Activities: Establish a relationship of trust. Determine the teaching needs of the patient. Assess the current level of knowledge and understanding of the patient's content. Select the appropriate educational materials. Provide educational brochures, videos, and online resources, where appropriate. Correct misinterpretations of information, as appropriate. Give the patient time to ask questions and discuss her concerns Include family, if appropriate. 5250: Support in decision making. Activities: Establish communication with the patient at the beginning of her admission. Help the patient to identify the advantages and disadvantages of each alternative. Provide the information requested by the patient. Results (NOC) 0906 Decision making. Indicators: 0906.03: Identify the possible consequences of each alternative. 0906.08: Compare alternatives. 0906.09: Choose between several alternatives. 1606 Participation in decisions about healthcare. Indicators: 1606.03: Search for information. 1606.02: Shows self-control in decision-making. (00120) Low situational self-esteem Among the negative aspects perceived by hysterectomized women is the inability to have children. After a hysterectomy the woman experiences fear, a feeling of emptiness, problems in the relationship with her partner, etc. All this contributes negatively to their self-esteem, so we must give emotional support and be attentive to the appearance of depressive symptoms. On the other hand, we must take into account the spiritual and religious values and beliefs of women, since having a uterus can be something perceived as important, and having to remove it can negatively affect expectations related to health and the perception of quality of life. We must help the patient to increase the personal judgment of her own worth Table 4: Interventions and results related to the nursing diagnosis of Low situational selfesteem. Own elaboration. 5270: Emotional support. Activities: Interventions (NIC) Comment on the emotional experience with the patient. Encourage the patient to express feelings of anxiety, anger, or sadness. Listen to expressions of feelings and beliefs. Provide help in decision making. 5400: Enhancement of self-esteem. Activities: Observe the patient's statements about her self-worth. Help the patient find self-acceptance. Help the patient reexamine negative self-perceptions. Help the patient identify important effects of her culture, religion, race, gender, and age on self-esteem. Check the frequency of negative manifestations about yourself. Results (NOC) 2002: Personal well-being. Indicators: 2002.12: Execution of habitual roles. 2002.10: satisfaction with the ability to express emotions. 1205: Self-esteem. Indicators: 1205.05: Description of the self. 1205.07: Open communication. 1205.01: Verbalization of self-acceptance. 1208: Depression level. Indicators: 1208.19: Low self-esteem. 1208.07: Expression of feelings. 1208.01: Depressed mood. 1409: Self-control of depression. Indicators: 1409.08: Refers absence of physical manifestations of depression. 1409.09: Refers improvement in mood. (00059) Sexual dysfunction Hysterectomy has side effects on sexuality. Women may suffer from dyspareunia or coitalgia, due to vaginal shortening and scar retraction after the uterus and cervix are removed. Sexual well-being is one of the most important factors in a woman's feeling of pleasure, since it manages to unify physical and emotional satisfaction, and her sense of femininity, key elements in the perception of quality of life. After a hysterectomy, the woman's self-perception is altered, which affects the couple's relationship. Although the removal of the uterus does not prevent sexual practice and satisfaction, there is an alteration in the reproductive pattern; the woman feels that she has lost sexual attractiveness due to her loss of fertility. It is important to assess the quality of sexuality before and after hysterectomy. They are given a sexual satisfaction index (ISS) before and after the intervention, consisting of 25 items that assess the degree of sexual satisfaction with the partner within a relationship and are scored on a Likerttype scale. Table 5: Interventions and results related to the nursing diagnosis of Sexual Dysfunction. Own elaboration. Interventions (NIC) 7110: Encourage family involvement. Activities: Facilitate the understanding of the medical aspects of the patient to family members. Identify the perception by family members of the situation and the triggering events, the patient's feelings and behaviors. Identify other stressors for family members. 5220: Improved body image. Activities: Help the patient determine the extent of the actual changes in the body or its level of functioning. Identify the influence of the patient's culture, religion, race, sex, and age on body image. To determine the perceptions of the patient and the family about the alteration of the body image in the face of reality. 5248: Sex counseling. Activities: Establish a therapeutic relationship based on trust and respect. Provide privacy and ensure confidentiality. Encourage the patient to verbalize her fears and ask questions about sexual functioning. Evaluate the presence of stress, anxiety and depression as possible causes of sexual dysfunction. Provide concrete information about sexual myths and bad information that the patient can express verbally. Include sexual partner or partner in counseling as much as possible, if applicable. Provide referral / consultation with other members of the care team, as appropriate. 5426: Facilitate spiritual growth. Activities: Encourage conversation that helps the patient organize interests spiritual. Help the patient explore beliefs regarding healing of body, mind, and spirit. Results (NOC) 1200: Body image. Indicators: 1200.01: Internal image of himself. 1207: Sexual identity. Indicators: 1207.09: Refers to healthy intimate relationships. 2001: Spiritual health. Indicators: 2001,16: Relationship with the inner self 2609: Family support during treatment. Indicators: 2609.01: Members express wishes to support the sick member. 2609.02: Members express feelings and emotions of concern regarding the sick member. (00069) Ineffective coping It is important to take into account the psychological state that the woman experiences before and after the surgery. If the patient has depression, anxiety, alterations in self-esteem or other mood disorders, it can negatively affect her coping with the intervention and her subsequent recovery. To increase a woman's coping with her new health situation, we must act on a physiological, cognitive and behavioral level. Table 6: Interventions and results related to the nursing diagnosis of Ineffective Coping. Own elaboration. Interventions (NIC) 5230: Increase coping. Activities: Assess the impact of the patient's life situation on roles and relationships. Encourage the patient to find a realistic description of the role change. Encourage the patient to identify her strengths and abilities. Provide objective information regarding diagnosis, treatment and prognosis. Encourage the manifestation of feelings and fears. Encourage a gradual mastery of the situation. Help you identify suitable short-term and long-term goals. 5440: Increase support systems. Activities: Calculate the psychological response to the situation and the availability of the support system. Determine the degree of family and financial support, as well as other resources. Observe the current family situation and the support network. Refer to a self-help group, or an internet-based resource if deemed appropriate. Explain to the others involved how they can help. 5820: Decreased anxiety. Activities: Make a calm approach so that you feel more secure. Try to understand the patient's perspective in a stressful situation. Stay with her, to give her security. 5880: Relaxation technique. Activities: Maintain eye contact. Sit down and talk to the patient. Encourage slow and deep breathing. Reaffirm the patient in her personal safety. Stay with the patient. Instruct on methods that reduce anxiety Results (NOC) 1302: Coping with problems. Indicators: 1302.03: Verbalizes a sense of control. 1302.04: Refers to decrease in stress. 1302.05: Verbalizes acceptance of the situation. 1302.08: It adapts to changes in development. 1302.22: Use the personal support system. 1302.17: Refers to decrease in negative feelings. 1402: Self-control of anxiety. Indicators: 1402.04: Seeks information to reduce anxiety. 1402,14: Refers to sleep adequately. 1402.15: Refers to the absence of physical manifestations of anxiety. (00017) Stress urinary incontinence Hysterectomy can alter the anatomy of the pelvic floor, causing stress urinary incontinence. This is because removal of the uterus can lead to prolapse of the bladder or rectum and there is a connection between the muscles, connective tissue and support between these three organs. It is important to prevent stress urinary incontinence in hysterectomized women by strengthening these muscles. We must perform an assessment of the pelvic floor post-hysterectomy, as well as teach strengthening exercises. Table 7: Interventions and results related to the nursing diagnosis of Stress Urinary Incontinence. Own elaboration. Interventions (NIC) 0610: Urinary incontinence care. Activities: Explain the etiology of the problem and the basis for the actions. Discuss the procedures and expected results with the patient. Limit the ingestion of bladder irritants (cola, coffee, tea and chocolate). 0560: Pelvic floor exercise. Activities: Teach the patient to tighten and then relax the muscle ring around the urethra and anus, as if trying to avoid urination or defecation. Teach the patient to avoid contracting the abdominal muscles, thighs and buttocks, to hold their breath or to exert themselves while performing the exercises. Teach the patient to perform exercises to tighten the muscles, practicing 300 contractions each day, holding the contractions for 10 seconds each time and resting for at least 10 seconds between contractions, according to the center's protocol. Explain to the patient that the effectiveness of the exercises is achieved at 6-12 weeks. Results (NOC) 0502: Urinary continence. Indicators: 0502.11: Absence of urine leakage when abdominal pressure increases. 0503: Urinary elimination. Indicators: 0503.34: Urinary continence. (00132) Acute pain r / c surgical wound m / p verbal manifestation of intense pain. In the postoperative period of hysterectomy, analgesia is scarce, and in many cases analgesia applied in the surgical unit is sufficient, and only the prophylactic dose of antibiotics is administered. However, postoperative pain will depend on the technique used, as well as the woman's pain threshold. Pain is greater in the abdominal approach, as well as the need for intravenous analgesia for more than 24 hours. For the measurement of postoperative pain we will use the visual analog scale (VAS). The pain perceived by the patient can be dealt with better if, in addition to medication, distraction strategies related to breathing, relaxation and visualizations are taught. Table 8: Interventions and results related to the nursing diagnosis of acute pain. Own elaboration. Interventions (NIC) 1400: Pain management. Activities: Provide information about the pain, such as causes of pain, how long it will last, and expected discomfort from the procedures. Reduce or eliminate factors that precipitate or increase the experience of pain (fear, fatigue, monotony and lack of knowledge) Provide the person with optimal pain relief through prescribed pain relievers. Carry out a comprehensive pain assessment (subjective and objective information). Use EVA scales. Code protocol. DEN-PG-001D. Determine the impact of the painful experience on the quality of life (sleep, appetite, relationships, humor, work) Explore with the patient the factors that ease and / or worsen pain. Encourage rest, avoid unnecessary procedures. Notify if pain is not controlled to adjust or change treatment (rule out complication) 2210: Administration of analgesics. Activities: Assess pain intensity and record. Administer pain relievers at the appropriate time. Take actions that reduce adverse effects (constipation, gastric irritation). Avoid administering pain relievers on demand. Results (NOC) 1605: Pain control. Indicators: 1605.01: Recognize causal factors. 1605.03: Use preventive measures. 1605.11: He refers to controlled pain. 1843: Knowledge: pain management. Indicators: 1843.06: Correct use of prescribed medication. 1843,21: Precautions in the activity. EVALUATION At the time of discharge, the patient will know the necessary care and will find herself adapted to her new situation. We must evaluate the hysterectomized woman physically and psychologically. We will perform an evaluation of the pelvic floor to rule out possible stress urinary incontinence problems. To measure the postoperative pain of the patient, the Visual Analogue Scale (VAS) will be used. (ANNEX III) Before the intervention, the woman will perform a test to measure her Sexual Satisfaction Index (ISS), which will be repeated after the hysterectomy. (ANNEX IV) The presence of anxiety or depression before and after the intervention will also be assessed using the Goldberg Scale. If the result is positive, the full scale would be delivered to assess the degree of anxiety or depression. (ANNEX V) The subsequent evaluation will be carried out in the Health Center by the Primary Care nurse, where a new assessment of the patient will be carried out to assess her health status at that time, so that, in this way, a plan is carried out care. CONCLUSIONS  Through the proposed Nursing care plan, we want to ensure that the woman who is going to be hysterectomized has all the necessary information, in a way that reduces anxiety and fear and increases coping with the intervention.  It is also intended to achieve a reduction in postoperative pain and the absence of physical complications or psychological alterations and an improvement in sexual function after discharge.  It is thus concluded that the role of nursing in the care of the hysterectomized patient is fundamental; with regard to clinical surveillance and care, and also at the educational and emotional support level