Davao Doctors College

Gen. Malvar St. Davao City

• In Partial Fulfillment of the Requirements in NCM 104

“Total Abdominal Hysterectomy and Bilateral Salpingo Oopherectomy”

Submitted by: Melinda R. Sundo BSN4 14C/ Group 28

Submitted to: Llewelyn I. Cortez,RN, MN

June 2010
Table of Contents

Definition of terms . .. ….......................................................................................1

Introduction............................................................................................................2-3

Review of Anatomy and Physiology of the Uterus and Cervix......................4-9

Pathophysiology.....................................................................................................10

Surgical Discussion................................................................................................11-12

Instrumentation......................................................................................................13

Nursing management.............................................................................................14-15

Drug Study…………………………………………………………………………….16-17

Reference...............................................................................................................18
Definition of Terms

hysterectomy - s a surgical procedure whereby the uterus (womb) is removed.

Salpingectomy - refers to the surgical removal of a Fallopian tube.

Oophorectomy (or ovariectomy) is the surgical removal of an ovary or ovaries. In

vetinary science, the procedure is called spaying and is a form of sterilization. Removal
of the ovaries in women is the biological equivalent of castration in males, and the term
is occasionally used in the medical literature instead of oophorectomy.

Endometriosis (from endo, "inside", and metra, "womb") is a

debilitating gynecological medical condition in females in which endometrial-
like cells appear and flourish in areas outside the uterine cavity, most commonly on the
ovaries.

uterus - s a major female hormone-responsive reproductive sex organ of

most mammals including humans.

Cervix- is the lower, narrow portion of the uterus where it joins with the top end of
the vagina. It is cylindrical or conical in shape and protrudes through the upper anterior
vaginal wall

Fallopian tubes- two very fine tubes lined with ciliatedepithelia, leading from
the ovaries of female mammals into the uterus, via the utero-tubal junction. In non-
mammalian vertebrates, the equivalent structures are the oviducts.

Supracervical hysterectomy- surgical technique that removes the uterus while leaving
the cervix intact, does not have clear benefits over total hysterectomy in women with
non-cancerous disease and should not be recommended as a superior technique

Fibroids — Fibroids (also known as leiomyoma) are noncancerous growths of uterine

muscle that occur in up to one-third of all women. Fibroids may become larger during
pregnancy, and typically shrink after menopause.

Endometrial hyperplasia — Endometrial hyperplasia is the term used to describe

excessive growth of the endometrium (the tissue that lines the uterus). It can sometimes
lead to endometrial cancer.
 Introduction

Total Abdominal Hysterectomy and Bilateral Salpingo Oopherectomy,this is the removal

of the uterus including the cervix as well as the tubes and ovaries using an incision in the
abdomen. Terectomy is the surgical removal of the uterus. Hysterectomy may be total,
as removing the body and cervix of the uterus or partial, also called supra-cervical.
Salpingo refers specifically to the fallopian tubes which connect the ovaries to the uterus.
Oophorectomy is the surgical removal of an ovary or ovaries. Hysterectomy is also
refered to as sugical menopause. Indications OF TAH-BSO Hysterectomy is often
performed on cancer patients or to relieve severe pelvic pain from things like,
endometriosis or adenomyosis..

A hysterectomy is a surgical procedure whereby the uterus (womb) is removed.

Hysterectomy is the most common non-obstetrical surgical procedure of women in the
United States. Approximately 300 out of every 100,000 women will undergo a
hysterectomy

A hysterectomy is also performed to treat uterine cancer or very severe pre-cancers

(called dysplasia, carcinoma in situ, or CIN III, or microinvasive carcinoma of the cervix).
A hysterectomy for endometrial cancer (uterine lining cancer) has an obvious purpose,
that of removal of the cancer from the body. This procedure is the foundation of
treatment for cancer of the uterus.

Therefore, a premenopausal (still having regular menstrual periods) woman whose

uterine fibroids are causing bleeding but no pain is generally first offered medical therapy
with hormones. Non-hormonal treatments are also available, such as tranexamic
acidand more moderate surgical procedures, such as ablations (removal of the lining of
the uterus). If she still has significant bleeding that causes major impairment to her daily
life, or the bleeding continues to cause anemia (low red blood cell count due to blood
loss), and she has no abnormality on endometrial sampling, she may be considered for
a hysterectomy.

This is the most common type of hysterectomy. During a total abdominal hysterectomy,
the doctor removes the uterus, including the cervix. The scar may be horizontal or
vertical, depending on the reason the procedure is performed, and the size of the area
being treated. Cancer of the ovary(s) and uterus, endometriosis, and large uterine
fibroids are treated with total abdominal hysterectomy. Total abdominal hysterectomy
may also be done in some unusual cases of very severe pelvic pain, after a very
thorough evaluation to identify the cause of the pain, and only after several attempts at
non-surgical treatments. Clearly a woman cannot bear children herself after this
procedure, so it is not performed on women of childbearing age unless there is a serious
condition, such as cancer. Total abdominal hysterectomy allows the whole abdomen and
pelvis to be examined, which is an advantage in women with cancer or investigating
growths of unclear cause.
 Anatomy and Physiology of the Uterus and Cervix

Uterus

Human female internal reproductive anatomy

1. Round ligament

The uterus (from Latin2. Uterus3. "uterus" (womb, belly), plural uteruses or uteri)
or womb is a major female hormone-responsive reproductive sex organUterine
cavity4. of most mammalsIntestinal surface of Uterus5. Versical
surface(towa including humansrd bladder)6. Fundus of uterus7. . One end,
the cervixBody of uterus8. , opens into the vaginaPalmate folds of cervical canal9. ,
while the other is connected to one or both fallopian tubesCervical canal10. , depending
on the species. It is within the uterus that the fetusPosterior lip11. develops during ,
usually developing completely in placental mammalsgestationCervical
os (external)12. such as humans and partially in marsupialsIsthmus of
uterus13. Supravaginal portion of cervix1 such as kangaroos4. and opossumsVaginal
portion of cervix15. . Two uteruses usually form initially in a female fetus, and in
placental mammals they may partially or completely fuse into a single uterus depending
on the species. In many species with two uteruses, only one is functional. Humans and
other higherHYPERLINK "http://en.wikipedia.org/w/index.php?
title=Anterior_lip&action=edit&redlink=1" primatesAnterior lip16. such
as chimpanzeesCervix, along with horses, usually have a single completely fused
uterus, although in some individuals the uteruses may not have completely fused. The
term uterus is used consistently within the medical and related professions, while the
Germanic derived term womb is also common in everyday usage in
theEnglish language.

Most animals that lay eggs, such as birds and reptiles, have an oviduct instead of a
uterus. In monotremes, mammals which lay eggs and include the platypus, either the
term uterus oroviduct is used to describe the same organ, but the egg does not develop
a placenta within the mother and thus does not receive further nourishment after
formation and fertilization. Marsupials have two uteruses, each of which connect to a
lateral vagina and which both use a third, middle "vagina" which functions as the birth
canal. Marsupial embryos form achoriovitelline "placenta" (which can be thought of as
something between a monotreme egg and a "true" placenta), in which the egg's yolk sac
supplies a large part of the embryo's nutrition but also attaches to the uterine wall and
takes nutrients from the mother's bloodstream.

Function

The uterus provides structural integrity and support to the bladder, bowel, pelvic bones
and organs. The uterus helps separate and keep the bladder in its natural position above
the pubic bone and the bowel in its natural configuration behind the uterus. The uterus is
continuous with the cervix, which is continuous with the vagina, much in the way that the
head is continuous with the neck, which is continuous with the shoulders. It is attached
to bundles of nerves, and networks of arteries and veins, and broad bands of ligaments
such as round ligaments, cardinal ligaments, broad ligaments, and uterosacral
[1]
ligaments.

The uterus is essential in sexual response by directing blood flow to the pelvis and to the
external genitalia, including the ovaries, vagina, labia, and clitoris. The uterus is needed
for uterine orgasm to occur.

The reproductive function of the uterus is to accept a fertilized ovum which passes
through the utero-tubal junction from the fallopian tube. It then becomes implanted into
theendometrium, and derives nourishment from blood vessels which develop exclusively
for this purpose. The fertilized ovum becomes an embryo, attaches to a wall of the
uterus, creates a placenta, and develops into a fetus (gestates) until childbirth. Due to
anatomical barriers such as the pelvis, the uterus is pushed partially into the abdomen
due to its expansion during pregnancy. Even during pregnancy the mass of a human
uterus amounts to only about a kilogram (2.2 pounds).

Anatomy

The uterus is located inside the pelvis immediately dorsal (and usually somewhat rostral)
to the urinary bladder and ventral to the rectum. The human uterus is pear-shaped and
about 3 in. (7.6 cm) long. A female's uterus can be divided anatomically into four
segments: The fundus, corpus, cervix and the internal os.

Regions

From outside to inside, the path to the uterus is as follows:

• Cervix uteri - "neck of uterus"

• External orifice of the uterus

• Canal of the cervix

• Internal orifice of the uterus

• corpus uteri - "Body of uterus"

• Cavity of the body of the uterus

• Fundus (uterus)
The cervix is the lower most part of the uterus and is made up of strong muscles. It also
provides support to the uterus due to attachment of muscles from the pelvic bone. The
cervix protrudes and opens through a canal into the vagina. The function of the cervix is
to allow flow of menstrual blood from the uterus into the vagina, and direct the sperms
into the uterus during intercourse.

The opening of the cervical canal is normally very narrow. However under the influence
of the body hormones and the pressure from the fetal head, this opening widens to
about 4 inches (10 cm.) during labor, to allow the birth of a baby. If the opening is loose,
as observed in some women, it can lead to miscarriages during pregnancy.

I. Columnar Epithelium Landmarks (Uterus)

• Endocervical canal

• Columnar epithelium villi

• Ectropion

• Eversion of columnar epithelium onto ectocervix

• Appears like an Erosion

II. Transitional Landmarks (Squamous Metaplasia)

Transformation Zone
• From True (proximal) to Original (distal) SCJ
• Where premalignant changes and neoplasia occur
• Encompasses Immature and mature squamous metaplasia
•
• True Squamocolumnar junction
• Upper or proximal limit of squamous metaplasia
• Usually not visualized
• Within endocervical canal
• Approximately 3 cm from observed SCJ
• Immature Squamous metaplasia
 • Observed Squamocolumnar Junction
•
•
I. Squamous Epithelium Landmarks (Vagina)
• Mature squamous metaplasia
• Nabothian cysts/follicles are in this area
•
• Original Squamocolumnar Junction
• Squamous epithelium
• Ectocervix

PATHOPHYSIOLOGY

ABNORMAL UTERINE BLEEDING

abnormal uterine bleeding

pregnant not
pregnant

first trimester 2nd and 3rd

normal pregnancy abnormal pregnancy

• implantation bleed
• abortion intrauterine
extrauterine
• trophoblastic •
ectopic
 Surgical Discussion

Abdominal hysterectomy is performed in a hospital setting, and generally requires one to

two hours in the operating room. Patients are given general or spinal anesthesia plus
sedation so that they feel no pain. Heart rate, blood pressure, blood loss, and respiration
are closely observed throughout the procedure. After surgery, patients are transferred to
the recovery room (also known as the post-anesthesia care unit) so that they can be
monitored while waking up. Most patients will then be transferred to a hospital room,
where they will spend one to two nights.

Reasons for Abdominal Hysterectomy

A hysterectomy may be recommended for a number of conditions. For some of these

conditions, there may be an alternative to hysterectomy, described below.

Abnormal uterine bleeding — Excessive uterine bleeding, called menorrhagia, can lead
to anemia (low blood iron count), fatigue, and contribute to missed days at work or
school. Menorrhagia is generally defined as bleeding that lasts longer than seven days
or saturates more than one pad per hour for several hours.

Heavy or irregular bleeding are generally treated first with medication or other surgical
alternatives to hysterectomy. (See "Patient information: Menorrhagia (excessive
menstrual bleeding)".) However, abnormal uterine bleeding that does not improve with
conservative treatments may require hysterectomy.

Fibroids — Fibroids (also known as leiomyoma) are noncancerous growths of uterine

muscle that occur in up to one-third of all women. Fibroids may become larger during
pregnancy, and typically shrink after menopause. They may cause excessive bleeding
and pelvic pain or pressure. (See "Patient information: Fibroids".)

Pelvic organ prolapse — Pelvic organ prolapse occurs due to stretching and weakening
of the pelvic muscles and ligaments. This allows the uterus to fall (or prolapse) into the
vagina. Prolapse is more common in women who have been pregnant, had vaginal
childbirth, and in those with certain genetic factors, lifestyle factors (repeated heavy
lifting over the lifetime), or chronic constipation.

Cervical abnormalities — Hysterectomy is rarely needed for carcinoma in situ (CIN 3)

that does not resolve after other procedures (such as cone biopsy, laser or cryosurgery).
(See "Patient information: Management of atypical squamous cells (ASC-US and ASC-
H) and low grade cervical squamous intraepithelial lesions (LSIL)" and "Patient
information: Management of high grade cervical squamous intraepithelial lesions (HSIL)
and glandular abnormalities (AGC)".)

Endometrial hyperplasia — Endometrial hyperplasia is the term used to describe

excessive growth of the endometrium (the tissue that lines the uterus). It can sometimes
lead to endometrial cancer. Although endometrial hyperplasia can often be treated with
medication, a hysterectomy is sometimes needed or preferred to medical therapy.

Cancer — Cancer of the uterus (endometrium), cervix, or ovaries may require

hysterectomy. (See "Patient information: Cervical cancer treatment; early stage
cancer" and "Patient information: Endometrial cancer treatment" and "Patient
information: Ovarian cancer treatment".)

Severe bleeding after childbirth — Hysterectomy may rarely be required in women who
have uncontrollable bleeding after childbirth.
Chronic pelvic pain — Chronic pelvic pain can be due to the effects of endometriosis or
scarring (adhesions) in the pelvis and between pelvic organs. However, pelvic pain can
also be caused by other sources, including the gastrointestinal and urinary systems.
(See "Patient information: Chronic pelvic pain in women".) It is important for a woman
with pelvic pain to ask about the probability that her pain will improve after hysterectomy.

Instrumentation

• 2 - 46118P Malleable 1” x 4”

• 2 - 46118 Malleable 1” x 8”

• 2 - 46118A Malleable 1” x 10”

• 2 - 46122 Malleable 2” x 8”

• 1 - 46174 Deaver 2” x 5”

• 1 - 46180 Heany 1” x 4”

• 1 - 46160 Harrington 2” x 6”
 • 2 - 46663 Double Angled 1/2” x 2”

• 2 - 46660 Double Angled 1” x 3”

• 1 - 46135 Fence 4” x 5”

• 1 - 46150 Richardson 2” x 4”

• 2 - 46143 Fenestrated 1” x 3”

• 1 - 41929 Rail Extender Long

• 1 - 41933 Hysterectomy Tray

• 1 - 44118C 18” Straight Arm with Cam Joint 2

Nursing Management

• Assess perception of change in structure or function of body part (also

proposed change). The extent of the response is more related to the value or
importance the patient places on the part or function than the actual value or
importance. Even when an alteration improves the overall health of the individual
(e.g., an ileostomy for an individual with precancerous colon polyps), the
alteration results in a body image disturbance.

• Assess perceived impact of change on activities of daily living (ADLs), social behavior,
personal relationships, and occupational activities.

• Assess impact of body image disturbance in relation to patient’s developmental

stage. Adolescents and young adults may be particularly affected by changes in the
structure or function of their bodies at a time when developmental changes are normally
rapid, and at a time when developing social and intimate relationships is particularly
important.

• Note patient’s behavior regarding actual or perceived changed body part or

function. There is a broad range of behaviors associated with body image disturbance,
ranging from totally ignoring the altered structure or function to preoccupation with it.

• Note frequency of self-critical remarks

• Acknowledge normalcy of emotional response to actual or perceived change in body

structure or function. Stages of grief over loss of a body part or function is normal, and
 typically involves a period of denial, the length of which varies from individual to
individual.

• Help patient identify actual changes. Patients may perceive changes that are not present
or real, or they may be placing unrealistic value on a body structure or function.

• Encourage verbalization of positive or negative feelings about actual or perceived

change. It is worthwhile to encourage the patient to separate feelings about changes in
body structure and/or function from feelings about self-worth.

• Assist patient in incorporating actual changes into ADLs, social life, interpersonal
relationships, and occupational activities. Opportunities for positive feedback and
success in social situations may hasten adaptation.

• Demonstrate positive caring in routine activities. Professional caregivers represent a

microcosm of society, and their actions and behaviors are scrutinized as the patient plans
to return to home, to work, and to other activities.

• Teach patient about the normalcy of body image disturbance and the grief process.

• Teach patient adaptive behavior (e.g., use of adaptive equipment, wigs, cosmetics,
clothing that conceals altered body part or enhances remaining part or function, use of
deodorants). This compensates for actual changed body structure and function.

• Help patient identify ways of coping that have been useful in the past. Asking patients to
remember other body image issues (e.g., getting glasses, wearing orthodontics, being
pregnant, having a leg cast) and how they were managed may help patient adjust to the
current issue.

• Refer patient and caregivers to support groups composed of individuals with similar
alterations.
 DRUG STUDY

NIFEDIPINE

CLASSIFICATION: Antianginals
INDICATION: Vasopastic angina, classic chronic stable angina pectoris
CONTRAINDICATION: contraindicated in patients hypertensive to drugs
ADVERSE EFFECTS: dizziness, light- headedness, somnolence, headache, weakness,
syncope, nervousness
MODE OF ACTION: thought to inhibit calcium ion influx across cardiac and smooth
muscle cells, decreasing contractility and oxygen demand. Also may dilate coronary
arteries and arterioles.
PATIENT TEACHING:
-tell patient that chest pain may occur or may worsen briefly when beginning drug or
when dosage increased
-instruct patient to swallow extended release tablets without breaking, crushing, or
chewing them
-advise patient to avoid taking drug with grape fruit juice

VITAMIN K

CLASSIFICATION: vitamins and minerals

INDICATION: RDA, HYPOPROTHROMBONEMIA caused by effect of oral
anticoagulants
CONTRAINDICATION: contraindicated to patients hypertensive to drugs
ADVERSE EFFECTS: dizziness, flushing, transient hypotension after IV administration,
rapid and weak pulse
MODE OF ACTION: An antihemorraghic factor that promotes hepatic formation of
active coagulation factors.
PATIENT TEACHING:
-explain purpose of drugs
- tell the patient to avoid hazardous activities if dizziness occurs
- tell patient that foods that provide vitamin K include cabbage, cauliflower, spinach, fish,
liver, eggs, meats, and dairy products

KETOROLAC

CLASSIFICATION: NSAID
INDICATION: short term management of moderately severe acute pain for single dose
treatment
CONTRAINDICATION: contraindicated as prophylactic analgesic before surgery or
intraoperatively when homeostasis is critical and in patients currently recieing aspirin,
NSAID or probenecid.
ADVERSE EFFECTS: drowsiness, sedation, dizziness, headache
MODE OF ACTION: may inhibit prostaglandin synthesis to produce anti- inflammatory,
analgesic, and anti pyretic effects
PATIENT TEACHING:
-correct hypovolemia before giving
-carefully observe patients with coagulopathies and those taking anticoagulants
-NSAID may mask signs and anti inflammatory actions

TRAMADOL HCl

CLASSIFICATION: opiod analghesic

INDICATION: moderate to moderately severe pain
CONTRAINDICATION: contraindicated in patients with acute intoxication from alcohol,
hypnotics, centrally acting analgesics, opiods or psychotropic drugs
ADVERSE EFFECTS: dizziness, vertigo, headache, somnolence, CNS stimulation,
asthma, anxiety, confusion, coordination disturbance, euphoria, nervousness, sleep
disorder, seizures
MODE OF ACTION: A centrally acting synthetic analgesic compound not chemically
related to opiods. Thought to bind to opiate receptors and inhibit reuptake of
norepinephrine AND SEROTONIN
PATIENT TEACHING:
-tell patient to take drug as prescribed and not to increase dose or dosage interval
unless ordered by physician
-advise patient to check with prescriber before taking OTC drugs because interactions
can occur

Reference:

Medical- Surgical Nursing, Smeltzer et all. Volume 1.

Website:

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