Total hysterectomy denotes the surgical excision of the entire uterus, followed by repair of the vaginal vault. It can be done abdominally or vaginally, hence termed total abdominal and vaginal hysterectomy, respectively. Indications include benign lesions such as leiomyomas greater than 12-week size and endometriosis, as well as malignancy such as endometrial carcinoma. Trauma and obstetric factors such as post-partum hemorrhage such as that caused by an atonic uterus that doesn’t respond to a B-Lynch suture could also indicate hysterectomy.
In the event of a total hysterectomy, a nursing care plan serves both pathophysiological and psychosocial interventions (Calderon, Pasic & Castorena, 2012). Besides, nursing care takes into account the patient’s grieving aspect due to losing of vital body parts as well as the inability to sire children following total hysterectomy. The subsequent discussion is a case study analysis of the nursing care plan for a patient admitted to a health facility having undergone a total hysterectomy. The patient complains of abdominal pain.
Chosen Pathophysiological/Psychosocial Priority
The nursing priorities for the patient will be to prevent complications arising due to the surgery. Pain is a cardinal sign of inflammation, alongside rubor, calor and functio laesa. Postoperative infection could occur as a result of breakdown of local and systemic host defenses caused by organisms such as Staphylococcus aureus and Clostridium perfringens. This patient, by virtue of being hypertensive, diabetic, and with a history of malignancy, is therefore at higher risk of infection owing to delayed wound healing and immunosuppression.
While there has been relatively few number of deaths related to hysterectomy, as indicated by Maresh et al, studies on complication rates, specifically related to surgery types have been encourage due to the growing concern for high complication rates. (Maresh et al., 2002)
At the same time, due to the popularity of the procedure as a treatment to cervical cancer, (Steed et al., 2004) the increasing rates of complications related to one or both types of hysterectomy warrants further attention especially after the procedure. This informs not only individual prognosis but also can open more opportunities of improvement regarding the surgical procedure.
Various clinical manifestations could present due to total hysterectomy. These include;
ü Hematuria and urinary retention. She needs to be examined for signs of urinary retention and bloody urine (Carpenito, 2009). A catheter should be put into place to monitor hematuria as there could be trauma to the bladder or ureter, considering her bladder is already weak following the bladder cancer.
Rationale: Iatrogenic injury to associated structures such as the bladder and ureter should be factored in due to the close relation of the same to the uterus.
ü Absent or reduced bowel sounds upon auscultation (Konar, 2013). Post-operative bowel dysfunction is very common; hence the abdomen needs auscultation for bowel sounds, thrills and bruits.
Rationale: Absent or extremely reduced bowel sounds confirms the presence of ileus hence these influence the interventions made.
ü Ascites. This is manifested by abdominal distention and occurrence of pain (Lewis et al., 2010). Percuss for shifting dullness. The patient rates abdominal pain 5 out 10 on the intensity scale.
Rationale: Fluid from the serous exudate accumulates within the peritoneum, causing pain through distention. Shifting dullness upon percussion confirms presence of liquid within the abdomen.
Intervention 1: Perform pain assessments (PQRSTU) to identify the source, the quality, and the duration of the pain, and the patient’s understanding of pain and her anticipation for pain relief.
Rationale: This technique lessens the sensitivity of the scale but retains other features similar to PQRST with some minor alterations. (Chalkley & Mulhall, 1991) The assessment of pain that results to better diagnosis hence enabling the most efficient treatment for the patient, is crucial at this stage especially that the patient is taken in after a major surgery.
Intervention 2: Introduce strategies that help to decrease the pain experience such as distraction, relaxation, imagery, breathing exercise and music therapy.
Rationale: Due to the moderate to severe pain after the surgical procedure, there are many ways on how to help the patient cope. Some prefer morphine and pain-killers but many studies have also considered music and positive suggestion. (Gupta et al., 2004)
Intervention 3: Reduce external stressors or any sources of discomfort whenever possible and provide calm and relax environment for the patient to rest
Rationale: This is for humanitarian reasons at the same time to avoid further complications due to the discomfort of the pain. This also helps prevent psychosomatic symptoms that may intervene with actual pain felt that may demonstrate infection or complication.
Intervention 4: Administer analgesics as ordered, evaluating the effectiveness and inspecting any signs and symptoms of adverse effects
Rationale: This is done to relieve the patient of the discomfort such as nociception-induced responses like endocrinal metabolic response to surgery. (Kehlet & Dahl, 1993) At the same time, the observation of the occurrence of any reactions to the administered drugs may reveal more of the nature of the pain experienced.
Intervention 5: Use RICE method to help relieve the abdominal pain (Rest, Ice, and compression in this case)
Rationale: RICE method denotes rest, ice, compression, and elevation. The approach promotes rest to the body muscle. Ice relieves pain by reducing swelling of the wounds. Nevertheless, compression is undertaken to reduce blisters (Calderon, Pasic & Castorena, 2012). Moreover, elevation of the injured body parts is conducted as one applies to ice as a way to reduce swelling.
As indicated in the preceding discussion, nursing care is an important aspect for the patients who have undergone a total hysterectomy (Lewis et al., 2010). The care process aims to minimize as well as prevent pain and complications arising after surgery. As highlighted in the case study, the patient encounter abdominal pain after surgery. The priority was, therefore, to manage the pain and reduce hospital stay (Carpenito, 2009). Moreover, the nursing care focused on identifying therapy options that the patient can adopt after discharge. Therefore, the RICE method was illustrated to the patient.