ADVANCING YOUR PRACTICE

Care of the patient undergoing a hysterectomy

Hysterectomy is the surgical removal of the uterus to treat cancer, dysfunctional uterine bleeding, endometriosis, nonmalignant growths, persistent pain, pelvic relaxation and prolapse, and previous injury to the uterus. The number of hysterectomies in the United States per year has stabilized at 600,000, despite an increase in the number of women who have reached the age at which this procedure is likely to be performed. The number is thought to be stabilizing because women often seek second opinions, and the number of other therapeutic options (laser therapy, endometrial ablation, and medications to shrink fibroid tumors) has increased.

Hysterectomy can be performed using a variety of surgical approaches. A total hysterectomy involves removal of the uterus and the cervix. Hysterectomy can be supracervical or subtotal, in which the uterus is removed but the cervix is spared. Malignant conditions usually require a total abdominal hysterectomy and bilateral salpingo-oophorectomy (removal of fallopian tubes and ovaries). In radical hysterectomy, the uterus and surrounding tissue are removed, including the upper third of the vagina and pelvic lymph nodes. Hysterectomy can be performed through the vagina, through an abdominal incision, or laparoscopically (in which the uterus is removed in sections through small incisions using a laparoscope).

A laparoscopically-assisted approach can also be used for vaginal hysterectomy, with excellent results and rapid recovery. This procedure is performed as a short-stay procedure or ambulatory surgery in carefully selected patients. It can also be used effectively in patients who are obese.

Preoperative management
The physical preparation of a patient undergoing a hysterectomy is similar to that of a patient undergoing a laparotomy. The lower half of the abdomen and the pubic and perineal regions may be shaved, and these areas are cleaned with soap and water (some surgeons don’t require that patients be shaved). To prevent contamination and injury to the bladder or intestinal tract, the intestinal tract and the bladder need to be empty before the patient is taken to the operating room. An enema and antiseptic douche may be prescribed the evening before surgery, and the patient may be instructed to administer these treatments at home. Preoperative medications may be administered before surgery to help the patient relax.

Postoperative management
The principles of general postoperative care for abdominal surgery apply, with particular attention given to peripheral circulation to prevent thrombophlebitis and deep vein thrombosis (DVT): noting varicosities, promoting circulation with leg exercises, and using elastic compression stockings. Major risks are infection and hemorrhage. In addition, because the surgical site is close to the bladder, voiding problems may occur, particularly after a vaginal hysterectomy.

Edema or nerve trauma may cause temporary loss of bladder tone (bladder atony), and an indwelling catheter may be inserted. During surgery, the handling of the bowel may cause paralytic ileus and interfere with bowel functioning.

The patient may have strong emotional reactions to having a hysterectomy and strong personal feelings related to the diagnosis, views of significant others who may be involved (family, partner), religious beliefs, and fears about prognosis. Concerns such as the inability to have children and the effect on femininity may surface, as may questions about the effects of surgery on sexual relationships, function, and satisfaction. The patient needs reassurance that she will still have a vagina and that she can experience sexual intercourse after temporary postoperative abstinence while tissues heal. Information that sexual satisfaction and orgasm arise from clitoral stimulation rather than from the uterus reassures many women. Most women note some change in sexual feelings after hysterectomy, but they vary in intensity. In some cases, the vagina is shortened by surgery, and this may affect sensitivity or comfort.

When hormonal balance is upset, as usually occurs in reproductive system disturbances, the patient may experience depression and heightened emotional sensitivity to people and situations. The nurse needs to approach and evaluate each patient individually in light of these factors. A nurse who exhibits interest, concern, and willingness to listen to the patient’s fears will help the patient progress through the surgical experience.

Postoperative pain and discomfort are common. Therefore, the nurse assesses the intensity of the patient’s pain and administers analgesia as prescribed. In some circumstances, a nasogastric tube may be inserted before the patient leaves the operating room to prevent discomfort from abdominal distention, especially if excessive handling of the viscera was required or if a large tumor was removed. Excision of a large tumor could cause edema because of the sudden release of pressure. In the postoperative period, fluids and food may be restricted for 1 or 2 days. If the patient has abdominal distention or flatus, a rectal tube and application of heat to the abdomen may be prescribed. When abdominal auscultation reveals return of bowel sounds and peristalsis, additional fluids and a soft diet are permitted. Early ambulation facilitates the return of normal peristalsis.

Monitoring and managing potential complications
Hemorrhage
Vaginal bleeding and hemorrhage may occur after hysterectomy. To detect these complications early, the nurse counts the perineal pads used, assesses the extent of saturation with blood, and monitors vital signs. Abdominal dressings are monitored for drainage if an abdominal surgical approach was used. In preparation for hospital discharge, the nurse gives prescribed guidelines for activity restrictions to promote healing and to prevent postoperative bleeding. Because many women may go home the day of surgery or within a day or two, they’re instructed to contact the nurse or surgeon if bleeding is excessive.

DVT
Because of positioning during surgery, postoperative edema, and decreased activity postoperatively, the patient is at risk for DVT and pulmonary embolism (PE). To minimize the risk, elastic compression stockings are applied. In addition, the patient is encouraged and assisted to change positions frequently, although pressure under the knees is avoided, and to exercise her legs and feet while in bed. The nurse helps the patient ambulate early in the postoperative period. In addition, the nurse assesses for DVT or phlebitis (leg pain, redness, warmth, edema) and PE (chest pain, tachycardia, dyspnea). If the patient is being discharged home soon after surgery, she’s instructed to avoid prolonged sitting in a chair with pressure at the knees, sitting with crossed legs, and inactivity. Furthermore, she’s instructed to contact her health care provider if symptoms of DVT or PE occur.

Bladder dysfunction
Because of possible difficulty in voiding postoperatively, occasionally an indwelling catheter may be inserted before or during surgery and is left in place in the immediate postoperative period. If a catheter is in place, it’s usually removed shortly after the patient begins to ambulate. After the catheter is removed, urinary output is monitored; additionally, the abdomen is assessed for distention. If the patient doesn’t void within a prescribed time, measures are initiated to encourage voiding (assisting the patient to the bathroom, pouring warm water over the perineum). If the patient can’t void, catheterization may be necessary. Occasionally, the patient may be discharged home with the catheter in place and needs to be instructed in its management.

Patient teaching
The information provided to the patient is tailored to her needs. She must know what limitations or restrictions, if any, to expect. She’s instructed to check the surgical incision daily and to contact her primary health care provider if redness or purulent drainage or discharge occurs. She’s informed that her periods are now over but that she may have a slightly bloody discharge for a few days; if bleeding recurs after this time, it should be reported immediately. The patient is instructed about the importance of an adequate oral intake and of maintaining bowel and urinary tract function. The patient is informed that she’s likely to recover quickly; however, postoperative fatigue, which may occur following any surgical procedure, isn’t unusual.

The patient should resume activities gradually. This doesn’t mean sitting for long periods, because doing so may cause blood to pool in the pelvis, increasing the risk of thromboembolism. The nurse explains that showers are preferable to tub baths to reduce the possibility of infection and to avoid the dangers of injury that may occur when getting in and out of the bathtub. The patient is instructed to avoid straining, lifting, having sexual intercourse, or driving until her surgeon permits her to resume these activities. Vaginal discharge, foul odor, excessive bleeding, any leg redness or pain, or an elevated temperature should be reported to the primary health care provider promptly. The nurse should be familiar with information given to patients by their surgeons regarding all activities and restrictions to reinforce them and prevent confusion.

Continuing care
Follow-up telephone contact provides the nurse with the opportunity to determine whether the patient is recovering without problems and to answer any questions that may have arisen. The patient is reminded about postoperative follow-up appointments. If the patient’s ovaries were removed, hormone therapy (HT, previously referred to as hormone replacement therapy or HRT) may be considered. Providing information about the findings of the Women’s Health Initiative (2002) study about the benefits and risks of HT promotes informed decision making about its use. The patient is reminded to discuss HT and alternative therapies with her primary care provider.

Source: Smeltzer SC, et al. Brunner and Suddarth’s Textbook of Medical-Surgical Nursing, 11th edition. Philadelphia, Pa., Lippincott Williams & Wilkins, 2007:1691-1694.