Tag: postoperative care

Gynaecological nursing focuses on diseases and disorders primarily or uniquely found in women.

Warning Signs

• Unusual Vaginal Discharge – yellow, green, or grey discharge accompanied by a foul odour
• Abnormal Vaginal Bleeding – possibly caused by pregnancy, hormonal imbalance, or fibroids
• Discomfort Whilst Urinating – damaged or weakened pelvic floor tissue
• Pelvic Pain – sharp pain may be an indication of infection, ruptured ovarian cyst, or an ectopic pregnancy, while constant pain may be caused by uterine fibroids
• Constant Fatigue – possibly caused by endometriosis, which is a condition in which tissue similar to the womb lining grows in other areas eg. the ovaries and the fallopian tubes
• Pain During Intercourse – may present as deep pelvic pain or soreness in the genital area, possibly due to vaginal dryness, uterine fibroids, or infections
• Unexplained Weight Loss – possible cancer sign
• Leg Pain – ovarian cancer causes swelling due to fluid build-up produced by the tumour

Treatment Indications

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Medical Management of certain Gynaecological Issues

• Uterine Bleeding can be managed medically by use of an IUD (Intrauterine Device), hormonal medications such as oestrogen, progesterone, and oral contraceptives, and non-hormonal medications such as NSAIDs.
• Pelvic Organ Prolapse can be medically managed by pelvic floor muscle training, vaginal pessaries, and adopting a healthy lifestyle which includes smoking cessation and maintaining an ideal body weight.
• Fibroids can be medically managed through watchful waiting – an ideal approach for asymptomatic women where they are required to track any symptoms and undergo regular pelvic exams to monitor fibroids, until the menopause period where these usually shrink.
• Endometriosis can be medically managed through over-the counter pain medications.

Gynaecological Procedures

Hysteroscopy

Hysteroscopy is a surgical procedure which allows the examination of the uterine cavity. A hysteroscope is inserted into the uterus through the vagina and cervix. Indications for a hysteroscopy include:

• Symptom Investigation – heavy periods, post-menopause bleeding, pelvic pain
• Diagnosis – to enable the diagnosis of polyps, fibroids and other possible issues
• Treatment – removal of polyps, displaced IUDs, intrauterine adhesions, and fibroids through a myomectomy.

UFE – Uterine Artery/Fibroid Embolisation

Uterine Fibroid Embolisation (UFE) is a minimally invasive procedure commonly performed by a radiologist, used to treat fibroid tumors of the uterus that may cause heavy menstrual bleeding, pain, and pressure on the bladder or on the bowels. UFE uses fluoroscopy to guide the delivery of embolic agents to the uterus and fibroids to block the arteries which provide blood to the fibroids. Lack of bloodflow to the fibroids causes them to shrink. It promotes preservation of the uterus.

Laparoscopy

Uterine Laparoscopy is a diagnostic method used in the case of unexplained pelvic pain, unexplained infertility, or a history of pelvic infection. Alternatively, Laparoscopy can also provide treatment through the removal of ovaries and ovarian cysts, adhesions, fibroids, and uterus. It can also provide endometrial tissue ablation to help lessen menstrual flow. Laparoscopy can be used to treat uterine prolapse, blood flow blocking in the case of fibroids, and ectopic pregnancies.

Pelvic Floor Surgery

In a vaginal prolapse, muscles supporting the organs in a woman’s pelvis weaken, causing the uterus, urethra, bladder or rectum to droop down into the vagina. In certain cases, organs may actually protrude out of the vagina. Physiotherapy may help in certain cases, however, sometimes surgery may be required so the pelvic organs are put back in place. This is done through the vagina or through laparoscopy.

Hysterectomy

A hysterectomy is a surgical procedure in which a woman’s uterus (or part of) is removed. Connected organs such as the fallopian tubes, ovaries, and cervix may also be removed during the same procedure. Hysterectomies are considered to be major surgeries and so are carried out electively through the abdomen, vagina, or laparoscopically.

Perioperative Gynaecological Nursing Care

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Preoperative care

GOALS

Preoperative care should aim to:

• reduce surgical morbidity
• minimise delays and cancellations
• assess and optimise the patient’s health and fitness status
• anticipate possible complications and prepare for their eventuality
• facilitate anaesthesia planning
• reduce patient anxiety by providing related information, answering any related questions, and address any concerns that the patient may have about perioperative care

PATIENT HISTORY

• compile the patient’s medical history, including personal and family diseases, allergies, health-related habits, socioeconomic status, and past hospitalisation experiences
• compile the patient’s surgical history, including information about previous operations and anaesthetic tolerance
• compile gynaecologic and obstetric history, including current issue complaints, information about the menstrual cycle, past pregnancies, use of birth control, sexual history, smear test, infections, and breast diseases

EXAMINATION

Physical examination of the patient in the preoperative period helps to establish whether the current disease or issue is causing the patient to be instable or experience exacerbations. A preoperative physical examination should include:

• vital signs
• physical observation
• airway and lung auscultation
• cardiac auscultation (including rhythm determination)
• neurologic condition
• abdominal and pelvic examination

GYNAECOLOGIC EXAMINATION

• breast, abdomen and pelvic organ examination, all of which can be supplemented by detailed assessment of the uterus via an ultrasound scan
• endometrial sampling in women with abnormal uterine bleeding or abnormal endometrial imaging
• cervical cancer screening
• pregnancy test for women in childbearing age

PSYCHOLOGIC CONSIDERATIONS

• feeling vulnerable may cause women to experience negative feelings which include fear of the unknown, fear of pain, and fear of the illness itself
• provide a relaxed and private setting
• ask open-ended questions in a non-judgemental way
• do not make assumptions about the patient, including assumptions related to patient sexuality
• ensure all questions the patient may have are answered clearly and understood well

INVESTIGATIONS

• blood tests should include CBC, fasting and blood glucose, kidney function, serum electrolytes, blood group, liver function test, INR
• ECG and stress test
• chest x-ray
• ultrasound
• CT scan
• MRI

PREOPERATIVE GYNAECOLOGICAL NURSING CARE

• gain informed consent
• review pre-op physical preparation eg. skin, bowels, NBM, cessation of medications, use of drugs, alcohol and smoking
• explain what happens in the operating theatre
• discuss post-operative routines such as routines related to respiratory care (coughing exercises), leg exercises (promoting venous return), early ambulation, pain control, fluids and nutrition
• ensure patient has allergy and ID bracelets on
• record baseline vital signs prior to transfer to the operating theatre
• ensure jewellery and valuables are removed prior to transfer
• ensure nail polish and makeup are removed prior to transfer
• ask about any dentures and loose teeth, hearing aids etc – ensure their safety prior to transfer
• ensure patient is put NBM at the right time
• administer thromboprophylactic treatment
• ensure patient has a bath or shower with antimicrobial soap
• ensure hair removal is done – avoid abrasions by using hair clipping rather than shaving
• ensure patient relatives know about the approximate length of surgery waiting time
• ensure administration of prophylactic antibiotic 30 minutes prior to surgery

Intraoperative Care

The intraoperative period covers the time from when a patient is transferred to the operating room until being admitted to the post-anaesthesia care unit. During this period, the nurse acts as the patient’s main advocate.

In intraoperative care, the following should be ensured:

• safe patient care
• safe environment
• limited traffic in and out of the operating theatre
• correct use of surgical attire to promote staff safety, maintain sterility and cleanliness
• correct patient positioning to reduce unnecessary injury due to prolonged surgery time
• adherence to surgical count policy
• adherence to sterility so as to reduce the risk of wound contamination and possible post-op surgical site infections
• bladder catheterisation through the use of an intermittent stainless steel catheter may be needed (based on surgeon’s preference); catheterisation is carried out when the patient is asleep but before the first incision is made
• draping serves as a barrier to endogenous and exogenous sources of contamination, thus reducing the risk of SSIs, as well as extends the sterile field for the placing of sterile instruments and supplies

WHO SURGICAL SAFETY CHECKLIST

PATIENT POSITIONING

Lithotomy positioning allows optimum exposure and surgical access to the perineum for vaginal surgeries. Potential issues with Lithotomy positioning include skin breakdown, nerve damage, musculoskeletal injury, and circulatory compromise.

Supine positioning is ideal for pelvic surgeries such as in open hysterectomy. Potential issues with Supine Positioning include skin breakdown, lumbar strain, nerve injury, and circulatory compromise.

NOTE: If the patient is put in the Trendelenburg Position, the patient may also be at risk of respiratory compromise.

ELECTROCAUTERY

Electrocautery is a procedure which uses heat from an electric current to destroy abnormal tissue eg. tumors or lesions. It may also be used to control bleeding during surgery or after an injury.

DIATHERMY BURN

Diathermy is a surgical technique which uses heat generated by an electrical current to cut tissue or seal blood vessels. Accidental diathermy burns can cause unsightly scarring which may limit motion in affected joints or function of other tissues.

INTRAOPERATIVE HYPOTHERMIA PREVENTION

Under surgical conditions, the body becomes at risk of hypothermia due to exposure and impairment of the body’s normal thermoregulatory response. This results in accelerated heat loss.

An individual with hypothermia experiences drug metabolism impairment, coagulation, increased bleeding, and wound infection.

Methods to maintain normothermia under intraoperative circumstances include warming through forced air blanket, and administration of warmed IV fluids.

OPEN SURGERY VS LAPAROSCOPY

Type of surgery and incision made for gynaecological issues depend on:

• uterine size
• possible required exploration of the upper abdomen
• past incisions
• cosmetic considerations

Open Surgery Approach

Advantages	Disadvantages
uterine size, fibroid size and extensive adhesions do not pose any limiting issues	longer recovery and rehabilitation period
promotes prolapse repair if required	increased risk of bleeding and infection
enables extensive exploration if needed	usually more painful

Laparoscopic Approach

Advantages	Disadvantages
shorter inpatient treatment duration	increased length of surgery
quicker return to normal activities	increased risk of bladder or ureter injury
associated with long term better quality of life	requires high laparoscopic surgical skills
enables diagnosis and treatment of additional pelvic diseases	use of carbon dioxide gas for abdomen inflation causes pain in the lower chest and up into the shoulder area post-op
reduced bleeding and infection risk

Vaginal Approach

Advantages	Disadvantages
shortest operation time	limited by uterine size, presence of pelvic adhesions, and previous surgeries
short recovery period and quicker discharge from hospital	limited ability to examine the fallopian tubes and ovaries
lowest cost
no scarring
reduced need for pain medication

Postoperative Care

Postoperative care is the management of a patient following a surgical intervention. Postoperative care extends from the immediate postoperative period in the operating room and post-anasthaesia care unit, to the days following surgery.

Postoperative care aims to prevent complications eg. infection, promote healing, and rehabilitation of the patient towards better quality of life. Postoperative care should be managed through the use of the nursing process. The extent of this period depends on the patient’s pre-surgical health status, type of surgery performed, and whether the surgical procedure was performed in a day-surgery setting or in the hospital.

Discharge Criteria

PATIENT CONDITION

• stable vital signs
• conscious state (same as pre-anaesthesia)
• pain control
• mobility (same as pre-anaesthesia)
• manageable nausea, vomiting or dizziness
• oral food and drink tolerance
• passing of urine / urinary catheter in situ
• discharge authorised by a member of the medical team
• responsible adult availability to transport patient and accompany home in a suitable vehicle

PATIENT MONITORING & EDUCATION

• vaginal flow monitoring – brownish discharge may be present for a few weeks
• incision should be kept clean and dry to avoid it becoming infected
• soft loose-fitting clothes should be worn due to incision tenderness
• deep breathing exercises
• leg exercises
• flatus should be tackled with walking and warm fluid intake
• prevention of constipation through dietary fibre intake
• straining avoidance (including for bowel movement purposes)
• avoidance of sexual intercourse for 4-6 weeks
• avoid inserting items in the vagina

HOSPITAL DISCHARGE REQUIREMENTS

• provide the patient with written and verbal instructions about post-op care
• provide the patient with advice on resumption of regular medication
• provide the patient with information on when to resume normal daily activities
• provide the patient with a contact place and telephone number in the case of emergency care need

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