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Fibroids are non-cancerous growths in the muscle layer of your uterus (womb). Fibroids are very common. They are also known as myomas. Fibroids can vary in size, from being tiny to being the size of a melon.

Uterine Fibroids

FIBROIDS (FIBROMYOMAS)

Fibroids are benign / non-cancerous tumors that originates from the smooth muscle layer (myometrium) of the uterus.

Fibroids are non-cancerous growths in the muscle layer of the uterus (womb). Fibroids are very common. They are also known as myomas. Fibroids can vary in size, from being tiny to being the size of a melon.

This tumor is composed of smooth muscle and fibrous connective tissue. Other common names are: uterine leiomyoma, myoma, fibromyoma, fibroleiomyoma.

They occur usually after the age of 30 years and commonly in women who have not had children. It is predominantly an estrogen-dependent tumor.

Risk factors for uterine fibroids

Age: Uterine fibroids are more common in women between the ages of 30 to 40 years.
Parity: Women who have never given birth (nulliparous) or have had few pregnancies (low parity) are at a higher risk.
Race: Uterine fibroids are more prevalent in individuals of African descent (negro or black) compared to those of Caucasian (white) ethnicity.
Family History: If a woman has close relatives (such as mother, sister) with a history of uterine fibroids, her risk may be increased.
Hyper-estrogenemia: Elevated levels of estrogen, a female hormone, can promote the growth of fibroids.
Obesity: Being overweight or obese is associated with a higher risk of developing uterine fibroids.
Early Onset of Menarche: Starting menstruation at a young age may be linked to an increased likelihood of fibroid development.
Low Level of Vitamin D: Some studies suggest that insufficient vitamin D levels might be associated with a higher risk of uterine fibroids.
Drugs (Estrogen Replacement Therapy): Long-term use of estrogen replacement therapy, particularly without progesterone, can be a risk factor for uterine fibroids.

Classes or types of Uterine fibroids

Submucosal Fibroids: These fibroids grow into the uterine cavity. They are located just beneath the inner lining of the uterus (endometrium). Submucosal fibroids can cause various symptoms, including heavy menstrual bleeding and infertility.
Intramural Fibroids (Interstitial): Intramural fibroids are the most common type and grow within the muscular wall of the uterus, known as the myometrium. They may expand and distort the shape of the uterus, leading to pain, pressure, and other symptoms.
Subserosal Fibroids: These fibroids grow on the outside surface of the uterus. They can project outward and may become quite large. Subserosal fibroids can cause pelvic pain and pressure on nearby organs.
Cervical Fibroids: Located on the cervix, the lower part of the uterus, cervical fibroids are relatively rare. They may cause symptoms such as pain and discomfort, and in some cases, they can affect fertility or lead to difficulties during labor.
Pedunculated Fibroids: These fibroids are attached to the uterus by a narrow stalk or pedicel that contains blood vessels. Pedunculated fibroids can be either subserosal or submucous, depending on their location.
Fibroid of the Broad Ligament: This type of fibroid develops in the broad ligament, which is a supportive structure that helps hold the uterus in place within the pelvis. Broad ligament fibroids are relatively uncommon and may require specific management depending on their size and location.

Causes of Uterine Fibroids.

Causes of uterine fibroids are not fully understood, but research suggests that hormones and genetics play significant roles in their development.

Hormones: The hormones estrogen and progesterone, which regulate the menstrual cycle, have a close association with the growth and development of uterine fibroids. During each menstrual cycle, the lining of the uterus (endometrium) thickens under the influence of estrogen and progesterone. These hormones also seem to stimulate the growth of fibroids. As a result, fibroids often grow and enlarge during the reproductive years when hormone levels are at their highest. Conversely, as hormone production decreases during menopause, fibroids tend to shrink and become less symptomatic.
Genetics: There is evidence to suggest that genetics can play a role in the development of uterine fibroids. Women with a family history of fibroids are at a higher risk of developing them themselves. This suggests that certain genetic factors may predispose individuals to fibroid formation.
Other Factors: Although hormones and genetics are the main factors associated with uterine fibroids, some other factors may contribute to their development or growth. These factors include obesity, race (fibroids are more common in women of African descent), and dietary factors.

Clinical Presentation of Uterine Fibroids.

Painful and Prolonged Menstrual Periods: Fibroids can cause heavy and prolonged menstrual bleeding, leading to painful periods (dysmenorrhea).
Vaginal Bleeding after Menopause: Postmenopausal women with fibroids may experience vaginal bleeding, which is abnormal after menopause.
Difficulty with Urination and Constipation: Large fibroids or fibroids pressing on the bladder can cause frequent urination or difficulty emptying the bladder. Fibroids pressing on the rectum can lead to constipation.
Pressure in the Pelvic Area: Women with fibroids may feel pressure or heaviness in the lower abdomen or pelvis.
Fullness or Pressure in the Belly: Enlarged fibroids can cause the abdomen to appear distended and feel full.
Lower Back and Leg Pain: Some women may experience lower back pain or pain in the legs due to the pressure exerted by fibroids on surrounding structures.
Pain During Sex (Dyspareunia): Fibroids can cause pain or discomfort during sexual intercourse.
Difficulty in Getting Pregnant (Infertility): Depending on their size and location, fibroids can interfere with the implantation of a fertilized egg or lead to difficulties in conception.
Pressure Symptoms: Fibroids can create pressure on the bladder, leading to increased frequency of urination. They can also exert pressure on the rectum, causing constipation. Additionally, pelvic vein pressure can lead to hemorrhoids and varicose veins.
Acute Degeneration: In some cases, fibroids may undergo acute degeneration, which can cause severe pain.
Enlargement of the Abdomen: Large fibroids or multiple fibroids can cause the abdomen to become visibly enlarged due to their projection into the abdominal cavity.

Diagnosis and Investigations

History Taking: A comprehensive medical history is taken to understand the patient’s symptoms, menstrual patterns, reproductive history, and any relevant medical conditions. This helps in assessing the likelihood of uterine fibroids and guides further evaluation.
Physical Examination: A physical examination is conducted to assess general health and look for specific signs related to uterine fibroids. This may include checking for signs of chronic anemia (pallor) due to heavy menstrual bleeding.
Abdominal Examination: An abdominal examination is performed to detect any large pelvi-abdominal swelling, which can be associated with significant fibroid growth.
Pelvic Examination: During a pelvic examination, the healthcare provider assesses the size, shape, and position of the uterus. Uterine fibroids may cause the uterus to be symmetrically or asymmetrically enlarged. A speculum examination may also reveal the presence of fibroid polyps.
Investigations: Various diagnostic tests are used to confirm the presence of uterine fibroids and assess their characteristics. These investigations may include:

Pregnancy Test: To rule out pregnancy as a cause of symptoms.
Full Blood Count (FBC) and Iron Studies: To check for anemia, which can result from heavy menstrual bleeding caused by fibroids.
Pelvic Ultrasound (U/S): An ultrasound is a common imaging test used to visualize the uterus and detect fibroids. It is a non-invasive and relatively simple procedure.
Saline Hysterosonography: This procedure involves injecting saline into the uterus during an ultrasound to enhance visualization of the uterine cavity and identify submucous fibroids.
Hysterosalpingogram (HSG): An HSG is an X-ray procedure that uses contrast dye to visualize the uterine cavity and fallopian tubes. It can help detect intrauterine fibroids.
Transvaginal Ultrasound (TVUSS): This type of ultrasound involves inserting a small probe into the vagina for a clearer view of the pelvic organs, which can be especially useful in obese patients.
Hysteroscopy: A hysteroscope, a thin, lighted instrument, is used to directly visualize the uterine cavity, enabling the identification and removal of submucous fibroids.
Bimanual Examination: A two-handed examination of the pelvic organs to assess the size, shape, and mobility of the uterus and detect any abnormal masses.
MRI (Magnetic Resonance Imaging): Although not always necessary, MRI is highly accurate in providing detailed information about the size, location, and number of fibroids.

Management of Fibroids.

Most fibroids do not require treatment unless they are causing symptoms. After menopause, fibroids usually shrink, and it is unusual for fibroids to cause problems. The choice of management depends on several factors:

Age
Parity
Size and location of fibroids
Desire for uterine preservation
If need for more children

For example:

Multiple myomas and completed childbearing benefit from hysterectomy.
Nulliparous women may undergo myomectomy.
Submucosal myomas can be treated with hysteroscopic resection.
Subserosal pedunculated myomas can be removed through laparoscopic resection.

Emergency Treatment:

Blood transfusion is given to correct anemia.
Emergency surgery is indicated for infected myoma, acute torsion, and intestinal obstruction.

Medical Management:

The aim of medical management for fibroids is to;

Alleviate symptoms,
Reduce fibroid size,
Manage associated complications without the need for invasive surgical procedures.

This approach is particularly beneficial for women who wish to preserve fertility, avoid surgery, or are approaching menopause when fibroids naturally shrink.

1. Non-steroidal Anti-inflammatory Drugs (NSAIDs): Ibuprofen

NSAIDs help reduce pain and inflammation associated with fibroids. They are particularly useful in managing dysmenorrhea (painful periods).

2. Anti-fibrinolytic Agents: Tranexamic acid

Function: These agents reduce heavy menstrual bleeding (menorrhagia) by promoting blood clotting and stabilizing blood clots.

3. Hormonal Treatments

Low-dose Birth Control Pills and Intrauterine Devices (IUDs) with Hormones: Mirena (levonorgestrel-releasing IUD): These methods help control heavy menstrual bleeding by regulating hormonal levels, thinning the endometrial lining, and reducing menstrual flow.

4. Haematinics: Ferrous sulfate, folic acid

These supplements help improve hemoglobin levels and treat anemia caused by heavy menstrual bleeding.

5. Danazol

Danazol, with its anti-estrogenic effects, reduces fibroid size and controls symptoms by lowering estrogen levels, which fibroids depend on for growth. However, its use is limited due to significant side effects.

6. Gonadotropin-Releasing Hormone (GnRH) Agonists: Lupron, Synarel

GnRH agonists reduce estrogen and progesterone production, leading to a temporary menopausal state. This significantly shrinks fibroids and alleviates symptoms. These are usually used short-term due to their side effects and are often given before surgery to reduce fibroid size.

7. Anti Progesterones: Mifepristone (25-50 mg twice weekly)

As a progesterone receptor inhibitor, mifepristone reduces the size of fibroids and decreases bleeding by blocking the hormone progesterone, which is essential for fibroid growth.

Surgical Management:

Myomectomy: Surgery to remove one or more fibroids. Indicated when conservative treatments fail and the woman desires to preserve fertility or retain the uterus. Indications:

Young women needing more children
Small or few fibroids
Heavy or prolonged bleeding

Hysterectomy: Removal of the uterus. Indications:

Possible malignant changes
Large fibroids or numerous small fibroids
Completed family or approaching menopause

Endometrial ablation: Removing the lining of the uterine wall

Uterine artery embolization: Limiting blood supply to the myoma

Minimally Invasive Treatments

Radiofrequency Ablation: Shrinks fibroids by inserting a needle-like device into the fibroid through the abdomen and heating it with radio-frequency (RF).
Uterine Artery Embolism: Catheterization via the femoral artery with the injection of polyvinyl particles to reduce blood supply to the uterus, causing fibroids to shrink due to ischemia.

Pre and Post Operative Care/Management

This involves providing care for patients undergoing surgery of gynecological procedures.

1. Admission and History Taking:

Obtain personal, medical, social, and gynecological history.
Conduct a physical examination, including vital signs (temperature, respirations, blood pressure, and pulse), head-to-toe examination to rule out anemia, dehydration, jaundice, and vaginal examination to assess any abnormalities.
General assessment by the gynecologist.

2. Informed Consent: Explain the reasons for the operation, its benefits, risks, and expected results to the patient and involve the partner if necessary.

3. Investigations: Conduct various tests, including urinalysis, hemoglobin (HB) level, blood grouping and cross-match, abdominal ultrasound scan, urea and electrolytes, INR/PT (International Normalized Ratio/Prothrombin Time), and ECG/ECHO if required.

4. Patient Education: Educate the patient about the surgery, its purpose, potential complications, and side effects of anesthesia. Provide reassurance and counseling to relieve anxiety.

5. Preparing for Surgery:

Ensure the patient fasts from food and drinks on the day of the operation.
Arrange for IV line insertion, blood booking in the laboratory, and catheterization of the patient.
Administer pre-medications as prescribed.

6. Assisting with Theatre Preparation:

Help the patient change into a theater gown.
Continue providing counseling and emotional support.

Post-Operative Management:

After the operation, prepare the post-operative bed for the patient.
Obtain reports from the surgeon, recovery room nurses, and anesthetists.
Wheel the patient to the ward.
Receive the patient in a warm bed, keeping her in a flat position, or turning her to one side depending on the surgery type (supine for abdominal surgery or a comfortable position for vaginal surgery).

Observation:

Monitor the patient closely, taking vital signs regularly (every ¼ hr for the first hour and every ½ hr for the next hour until discharge).
Observe temperature, pulse, respiration, blood pressure, and signs of bleeding or edema at the surgical site.
Check the IV line and blood transfusion line if applicable.

Upon Consciousness:

Gently welcome the patient from the theater, explain the surgery, and assist with face sponging.
Provide a mouthwash and change the gown.

Medical Treatment:

Administer analgesics, such as Pethidine 100mg every 8 hours for 3 doses, and switch to Panadol to complete 5 days.
Prescribe antibiotics, such as ampicillin or gentamicin, as ordered.
Offer supportive care with vitamins like vitamin C, iron, and folic acid.
Monitor and care for the wound in case of abdominal surgery, leaving the wounds untouched if bleeding occurs and re-bandaging if necessary.

Nursing Care:

Assist the patient with hygiene, including bed baths and oral care.
Allow the patient to feed herself as soon as she is able and provide plenty of fluids.
Encourage regular bowel and bladder emptying, offering assistance as needed.
Initiate chest and leg exercises to avoid swelling and bleeding in the wound.
Gradually increase the exercise routine to prevent deformities and contractures.

Vaginal Surgery Management:

Insert a vaginal pack to control hemorrhage and inspect it frequently for severe bleeding.
Apply vulval padding after pack removal until bleeding stops, changing it when necessary to prevent infections.
Swab or clean the vulva at least every 8 hours to prevent infection.

Advice on Discharge:

For Myomectomy patients, advise avoiding conception for 2 years following the operation and delivering via cesarean section.
For hysterectomy patients, inform them that they will not conceive again or have periods.
Recommend abstaining from sexual intercourse for about 6 weeks and avoiding douching. Vaginal bleeding may persist for up to 6 weeks.

Complications of Uterine Fibroids:

Menorrhagia (heavy menstrual bleeding)
Premature birth, labor problems, and miscarriage
Infertility
Twisting of the fibroids
Anemia
Urinary tract diseases
Postpartum hemorrhage

Complications during pregnancy and labor may include:

Antepartum hemorrhage (placenta previa, placental abruption)
Abortion
Fetal restricted growth
Malpresentation
Cesarean section
Labor dystocia
Premature labor
Uterine inertia leading to postpartum hemorrhage
Obstructed labor
Subinvolution of the uterus with increased lochia.

Uterine Fibroids Read More »

Post-Operative Nursing Care

Post-operative nursing care refers to the specialized care provided to patients following a surgical procedure. This care focuses on monitoring, managing, and supporting the patient’s recovery through a variety of interventions and assessments.

Aims or principles of post-operative care

Prevent, Recognize, and Treat Complications: Through skillful observation and application of knowledge, proactively identify and manage potential complications throughout the recovery period, from unconsciousness to discharge.
Ensure Patient Comfort: Prioritize pain management, provide emotional support, and create a comfortable and safe environment to promote healing and well-being.
Restore Maximum Health and Independence: Guide the patient towards optimal physical and functional recovery, enabling them to regain their independence and return to their desired lifestyle.

Immediate care of a patient recovering from anesthesia

Transporting the patient from the operating room to the recovery room

Following the completion of the operation, the operating room staff generally dresses the patient in a clean gown and moves the patient to the stretcher. Care is taken to avoid:

Exposing the patient, which predisposes them to respiratory infections and shock.
Rough handling, which may place a strain on the sutures.
Hurried movements and rapid position changes, which predispose the patient to hypotension.

Recovery Room Care

After arriving, the patient is either transferred to a bed from a stretcher or left on the couch. The patient is positioned supine with the head turned to one side and the chin extended forward. This is done because the patient is unconscious or semi-conscious from anesthesia, and this position helps to avoid respiratory obstruction from a relaxed tongue falling back into the throat, or by aspiration of mucus, blood, and/or vomitus. This positioning also allows secretions to flow out or for easy suctioning.

Baseline assessment of the patient is done, including:

Vital signs: blood pressure, pulse, respiratory rate, airway patency, depth of respirations, chest expansion, and the color of the skin.
Visual assessment of the patient, presence of IV infusions, drains, or special equipment.
The time of admission to the recovery room.
The absence of reflexes, e.g., pharyngeal or swallowing reflex, to ensure proper positioning of the head (lateral head position with the neck extended forward until the patient is swallowing).
The patient’s level of responsiveness upon admission (e.g., touch, pain, sound, movement, etc.).
The temperature and vital signs, which are taken every 15 minutes until stable, then every 30 minutes for the next 2-3 hours. Temperature is taken every 2-4 hours, depending on recovery policy.
The quality and rate of respirations. If in distress, oxygen is given, and the anesthetist is informed of respiratory depression or change in ventilatory pattern. Arterial blood gas is determined, and mechanical breathing aids are employed to resuscitate the patient (e.g., intubation, tracheostomy, ambu-ventilation, suctioning, etc.).
The presence of an airway/mouthpiece meant to keep the tongue from falling back. Sometimes the patient may push this away as they regain consciousness.
Skin color and dryness. A pale, cold, sweating skin is one sign of shock. Also, observe the lips and nail beds for pallor and cyanosis. Run the fluids as prescribed.
The condition of the dressing: if soiled, note the color, type, and amount of drainage.
The presence of drainage tubes (e.g., thoracic, abdominal, gastric catheters). Check if the patent, clamped, whether to be connected to suction apparatus, and whether they are draining.
The IV infusions: note the type of IV infusion solutions, amount left in the bottle, the rate of the drip, infiltrations, and orders for any other fluid to follow. Check if medications have to be added to the IV or if there are orders for any to be added.
The presence of a blood transfusion: note if BT is running or if one is ordered. Watch the rate of the drip and carefully for signs of a reaction.
Any unusual symptoms like airway obstruction, arrhythmias, signs of shock, hemorrhage, marked temperature elevation, and signs of circulatory overload from excess IV fluids.

After the patient stabilizes (i.e., in 2-3 hours) and recovers from anesthesia, they are discharged from the recovery room by the anesthetist or surgeon. The ward nursing staff is informed to come and collect the patient.

Patient is Collected from the Recovery Room Back to the Ward

The ward nurses are informed about the patient to be collected from the recovery room after stabilizing.
A verbal report is given by the recovery room nurse to the two nurses who have come to collect the patient. This report covers the type of operation done, vital signs, the level of consciousness, wound status and drainages, infusions and blood transfusions, resuscitation done, anesthesia, problems the patient had during surgery (such as vomiting or stoppage of breathing), urinary drainage, and other post-operative instructions.
Brief taking of vital parameters is done by the ward nurses to confirm the report from the theater and to prove that the patient is alive.
The patient is rolled back to the ward with the legs in front and the head behind for easy resuscitation by the nurse behind should there be any problem.
The patient is gently lifted from the stretcher to the bed prepared before, and care of the anesthetized patient is instituted immediately.

Immediate Post-Operative Care in the Ward

Care of Anesthetized Patient in the Ward:

The patient should not be left alone during this period because of the danger of asphyxiation, shock, falls, and hemorrhage.

Position:

This varies with the type of surgery. It can be supine with the head turned to one side to prevent the bulky tongue from falling back by gravity over the pharynx and blocking the airway, and to promote drainage of saliva from the mouth.
The head can be made lower than the shoulders to prevent the flow of fluids into the trachea, allowing secretions to pool in the cheek, making removal easier, and preventing obstruction and pneumonia. The usual position is modified Sims.

Respiratory Status: Assess the quality, depth, and rate of respirations, as well as the skin color and temperature, which indicate adequate oxygen exchange.

Neurologic Status/Level of Responsiveness: Determine whether the patient is alert and oriented, unconscious, confused, restless, etc.

Cardiovascular Status: Obtain vital signs, and check the color and temperature of the skin.

Wound:

Check for drainage and bleeding, and connect any drainage tubes to the suction machine or collection bag.
See if the dressings are soiled, and look and feel under the patient to detect pooling of blood.

Tubes: Ensure catheters, NGTs, and infusion lines are patent, check the rate and amount, look for drainage or blockage, and verify proper attachment to drainage systems.

Discharge Advice/Health Education on Home Care of the Patient:

The length of time needed for a patient to recover from surgery depends on the patient’s physical and mental condition prior to surgery, the magnitude of the surgery, and the development of any post-operative complications.
Assess the knowledge and understanding of the patient about the surgery and the preventive measures.
Look for learning readiness and the ability of the patient and/or family members to provide care and skills needed to perform procedures at home.
Teach the patient to report pain in any area, temperature elevation, cough and sputum of abnormal color, loss of energy, nausea and vomiting, change in urine characteristics, difficulty in breathing, abnormal drainage, and sudden weight loss. These are signs of complications.
Emphasize the importance of hand washing prior to meals, performing any procedure of care, and toileting.
Practice together with the patient coughing, breathing, and exercises to prevent pulmonary complications.
Advise the patient to avoid smoking or contact with people with RTIs.
Encourage the patient to continue with physical exercises, increase activity when necessary, and stop when tired. Exercises promote activity to maintain circulation and normal functioning of the systems.
Inform the patient to take plenty of fluids, vitamins, and electrolytes to maintain fluid/nutritional status for health (wound healing, skin integrity, elimination, liquefy secretions).
Teach the patient how to care for the wound: dressing change, cleansing, and skin care. Allow practicing aseptic technique in wound care and protection of the wound when bathing to maintain a clean, dry, healing wound.
Educate the patient on how to take drugs: checking their actions, dose, route, frequency, side effects, and food and drug interactions to ensure compliance.
Instruct the patient to modify their home environment to clear pathways of rugs, provide good lighting, and use articles to hold onto when walking, wearing firm and good-fitting shoes to ensure safety and prevent accidents.
Discuss the care of appliances such as fixators, plaster of Paris, and prostheses for the purpose of safe usage and optimal effect of supportive aids.
Provide information on where to find supplies and equipment for home care.
Give the patient contact information and the phone number of the doctor or other staff for easy follow-up or emergency calls.

POST OPERATIVE CARE

Requirement

As for Postoperative bed

Procedure

Steps	Action	Rationale
1	Two ward nurses (Senior and Junior) collect the patient from the theatre.	To ensure the patient’s safety.
2	Receive full report of the patient’s condition from Surgeon, anaesthetist and theatre nurse.	To promote continuity of quality care and legal purpose.
3	Take the patient to the ward while observing consciousness, color of the patient and maintain a clear airway.	–
4	Screen the patient bed.	To ensure privacy.
5	Pull the prepared bed away from the wall and push the theatre trolley up against the bed. Roll the patient from trolley to bed.	This enables safe lifting of the patient.
6	Position the patient in an appropriate position depending on the surgery done and making sure the airway is maintained clear.	To maintain patient airway and aid free drainage of secretions.
7	Leave the airway piece in position until the patient regains consciousness.	To prevent the tongue from falling back and causing obstruction.
8	Check the surgeon’s post-operative instructions regarding operation and care i.e. intravenous fluid therapy, medicines, nutrition, and positioning.	To promote continuity of quality care.
9	Stay with the patient until the patient is conscious. Take vital observations as prescribed or at intervals ¼ to ½ hourly depending on the patient’s condition.	Monitor and evaluate patient’s conditions and timely interventions.
10	Observe the incision site for bleeding and drainage tubes for functionality.	–
11	Carry out special nursing procedures as prescribed i.e. suction, intravenous fluids.	–
12	Provide warmth to the patient.	To prevent hypothermia.
13	Document all the care provided and report accordingly.	Monitor progress and provide appropriate interventions.
14	Give a pillow to the patient when fully conscious, and more pillows as required.	To aid comfort.
15	Observe fluid intake; give Intravenous fluids as prescribed and encourage oral fluid as indicated; measure and record in fluid balance chart.	Monitor fluid balance.
16	Observe fluid output: Encourage the patient to pass urine or empty the drainage bag, measure and record the amount passed.	–
17	Administer post-operative medicine as prescribed by the doctor.	Promote healing or treat pain.
18	Assist the patient to perform different exercises as taught before operation.	Prevent post-operative complications.
19	Offer general nursing care to postoperative patient.	–

Points to Remember:

Take note of the irregularities in vital observations:
- A rising pulse rate and/or decreasing pulse volume.
- A falling or inaudible blood pressure recording.
- Slowing, rapid, or noisy respirations.
For the skin note; the color, feel of the skin, i.e. cold or clammy.
Dressing; note, any oozing or bleeding from the incision site. In case of bleeding is present add more sterile dressing and bandage in position, and report immediately to the nurse in charge or the doctor.
Special nursing care is given to patients as per operation and condition.

PERI-OPERATIVE CARE (Summary)

PRE-OPERATIVE:

Admission
Explanation to the patient about the nature of the surgery and the possible outcomes.
Informed Consent for admission and surgery.
Vital observations and other lab investigations, radiological investigations to get a baseline.
Preparation of the body and mind through counseling and continuous reassurance. This helps to allay anxiety as well.
Talk to the patient and answer questions of their concerns to reduce fear/anxiety.
Spiritual care if one so wishes; respective church leaders are allowed to come and see the patient.
A baseline Physical examination, e.g., weight, height, nutritional status, needs to be assessed prior.
Site preparation: involves marking/labeling, 48 hours shaving if hairy.
Removal of jewelry and rings.
Removal of dentures and prostheses.
Inserting an IV line.
Rehydration with IV fluids.
Administration of premedication drugs.
Perform required procedures like inserting NGT, catheterization, bowel irrigation.
Ensure enough rest and sleep.
Educate on anticipated activity post-operatively.
Starve the patient prior as per order (nil per os).
Make a post-op bed with all the necessary accessories required, e.g., oxygen, suction apparatus.

POST-OPERATIVE CARE:

Reception from theatre with all the necessary instructions.
Vital parameters monitoring.
Monitoring for bleeding, and signs of shock.
Admission to a warm postoperative bed from the theatre.
Intravenous infusion with fluids and prescribed drugs.
Fluid balance chart recording and monitoring.
Ongoing post-op medication.
Bowel and bladder care.
Rest and sleep.
Proper management of drainages, e.g., abdominals, etc.
Proper positioning to relieve pain.
Diet/nutrition.
Wound care.
Pain management.
Bed hygiene.
Body/skin hygiene.
Physiotherapy, e.g., breathing exercises.
Psychological care.

POST-OPERATIVE COMPLICATIONS:

Hemorrhage; can be primary or secondary.
Pain.
Shock.
Wound infection/sepsis.
Hypostatic pneumonia due to constant lying on the bed.
Delayed healing.
Paralytic ileus.
Adhesions.

Post-Operative Nursing Care Read More »

CARE OF THE PATIENT’S EYES

CARE OF THE PATIENT’S EYES.

Care of the patient’s eyes includes a range of procedures and practices aimed at maintaining the cleanliness, comfort, and health of the eyes.

It Involves:

Cleaning of the Eye: This includes removing debris, discharge, and crusting from the eyelids and eyelashes. It’s done gently using sterile wipes or cotton balls moistened with warm water.
Instillation of Eye Drops/Ointment: This is done to deliver medication directly to the eye, treating various conditions like infection, inflammation, dryness, or glaucoma.
Cold and Warm Compresses: These are used to reduce inflammation, calm irritation, or promote relaxation. Cold compresses are applied for injuries or swelling, while warm compresses are beneficial for dry eye or clogged tear ducts.
Eye Irrigation: This involves flushing the eye with a sterile solution to remove foreign objects, irritants, or excessive discharge.

Indications of Cleaning the eye

Patients with Eye Discharge: This can be a sign of infection, inflammation, or irritation. Cleaning the eye, instilling appropriate drops, and sometimes irrigation can help manage the discharge and promote healing.
Postoperative Care for Patients Following a Cataract Operation: This includes gentle cleaning of the eye, instillation of prescribed eye drops, and monitoring for signs of infection or complications.
Eye Care for the Unconscious Patient: This is crucial for preventing infections and maintaining eye health. It includes cleaning the eye, keeping the eyelids closed, and ensuring the eyes are protected from injury.
To Be Performed Prior to Instilling Eye Drops or Ointment: Cleaning the eye beforehand helps ensure that the medication is delivered effectively and avoids contamination.
Patients with Dry Eye Syndrome: Eye care practices can help manage symptoms by promoting tear production, lubricating the eye, and protecting the cornea.
Patients with Eye Allergies: Cleaning the eye and instilling antihistamine drops can help manage the symptoms of itching, redness, and watery eyes.
Patients with Foreign Body in the Eye: Eye irrigation with a sterile solution is essential to remove the foreign object and prevent damage to the cornea.

Aims/Purposes of Eye Care:

To prevent and treat infections: Cleaning and disinfecting the eye area helps reduce the risk of infections.
To alleviate symptoms and discomfort: Procedures like cold compressions, warm compresses, and eye irrigation can provide relief from pain, itching, and dryness.
To promote healing and recovery: Appropriate cleaning and medication can help facilitate healing after eye surgery or trauma.
To maintain optimal eye health: Regular eye care can help prevent eye diseases and preserve vision.

Cleaning of the Eye

Objectives

Identify the requirements for cleaning the eyes.
Prepare the requirements for cleaning the eyes.
Demonstrate the ability to clean the eyes.

Requirement

Tray containing:

Gallipot of cotton balls
Receiver
Clean/disposable gloves
Mackintosh and towel
Plastic apron
Gallipot of normal saline 0.9% or cooled boiled water

At the bedside:

Hand washing equipment
Screen

Procedure

Steps	Action	Rationale
1.	Observe general rules.	Promotes adherence to standards.
2.	Put the patient in a sitting up position.	To prevent the flow of solution to the healthy eye.
3.	Place protective mackintosh and towel in place.	To prevent soiling/wetting the patient’s clothes.
4.	Wash and dry hands and put on gloves.	To prevent cross infection.
5.	Stand at the right-hand side of the patient.
6.	Dip the swabs/cotton balls in the solution and bathe the eye in the following sequence: – Start from the healthy eye – Swab from the nasal to the temporal aspect, using the swab once and discard. – Use the dry swabs to dry the eye – Do the same for the other eye – Repeat the swabbing until the eye is cleared of all discharge.	Prevents contamination from entering the other eye. Prevent the spread of infection.
7.	Dry excess fluid with a dry swab.	Prevent the spread of infection.
8.	Thank and leave the patient comfortable.	Promotes a sense of well-being.
9.	Clear away.	Maintain the cleanliness of the environment.
10.	Document the procedure.

INSTILLATION OF EYE DROPS/ OINTMENT.

Instillation Of Eye Drops/ Ointment is the process of application of medication into the patients’ eyes.

Objectives

Identify the requirements for instilling eye drops/ointment.
Prepare the requirements for instilling eye drops/ointment.
Instill the eye drops/ointment to the eyes.

Indications:

For Eye Drops:

To treat infections: Antibiotic eye drops are commonly used to combat bacterial infections like conjunctivitis (pink eye).
To keep eyes moist: Artificial tears or normal saline drops are used to lubricate the eye and relieve dryness, often prescribed after cataract surgery.
To anaesthetize the eye: Anaesthetic drops numb the eye surface, used for procedures like cataract surgery or foreign body removal.
To dilate the pupil: Mydriatic drops widen the pupil, facilitating eye exams or helping treat certain eye conditions.
To reduce inflammation: Steroid eye drops are used to reduce inflammation in the eye, often prescribed after eye injury or surgery.
To lower intraocular pressure: Glaucoma medications are often administered as eye drops to control eye pressure and prevent further damage.

For Eye Ointment:

To protect the vision of neonates: Prophylactic antibiotic ointment is routinely applied to newborns’ eyes to prevent infections.
To treat infections: Antibiotic ointments can be used to treat bacterial eye infections, often preferred for overnight treatment due to their longer-lasting effect.
To lubricate and soothe dry eyes: Ointments can provide a longer-lasting lubricating effect than drops, especially helpful for severe dryness.
To treat certain eye allergies: Steroid ointments can be used to reduce allergic inflammation.

Requirements

Patient’s medication chart.

Tray:

Prescribed eye drops/eye ointment
Gallipot of cotton balls
Receiver
Gloves
Eye pad in a sterile bowl
Strapping

At the Bedside:

Hand washing equipment
Screen

Procedure for eye drop

Steps	Action	Rationale
1.	Refer to general rules.	Promotes adherence to standards.
2.	Check the prescription.	Ensures correct administration of medicine.
3.	The patient may be seated or lying down for this procedure.	Provides easy access to the eye for instillation.
4.	Wash hands and put on gloves.	Prevents the spread of microorganisms.
5.	Clean the eyes as before.	Prevents entrance of microorganisms to the lacrimal duct.
6.	Place a folded swab on the lower lid up to the lash margin.	Absorbs medication that escapes from the eye.
7.	Instilling eye drops: Gently pull down the eyelid of the affected eye.	Exposes lower conjunctival sac.
8.	Request the patient to look up; hold the dropper close to the eye and drop the medicine according to the dose into the lower conjunctival sac.	To reduce stimulation of the blink reflex.
9.	Release the lower eyelid after the eye drops are installed.
10.	Request the patient to gently close the eye.
11.	Apply gentle pressure over the inner Canthus.	To prevent eye drops from falling over the inner Canthus to prevent systemic effects from the medicine.
12	Administering eye ointment: – Gently pull down the lid	To expose the inner surface of the lid and conjunctival sac.
13	Squeeze a small amount (1.25cm) of ointment along the exposed sac from in outwards.	Promotes comfort and prevents trauma to the eye.
14	Instruct the patient to close the eyes.	The warmth helps to liquefy the ointment Prevents contamination and entrance of micro-organism into the eye.
15	Instruct the patient to roll the eyeball Patient should keep the eye closed for a few minutes.	Allows even distribution of medication over the eye.
16	Thank and leave the patient comfortable.	Ensures patient’s comfort.
17	Clear away.	Ensures a clean environment.
18	Record treatment given on the chart.	Continuity of care and follow up.

General Principles – Application of Eye Ointment

Ointment may be prescribed in addition to drops. If both are prescribed, drops should be instilled first, followed by ointment after a 3-minute interval.
Ointment may be prescribed for structures other than the eye. This could include wounds on the lids, face, or eye socket.
Ointment may be prescribed for use after the first dressing. This might not happen for up to a week in some oculoplastic surgery cases.
If requested, visual acuity should be recorded before ointment is applied. This is because ointment clouds vision. Any existing ointment excess should be removed before taking the measurement.
A 5-mm strip of ointment should be applied to the inner edge of the lower fornix of the appropriate eye.
The patient should close his eye and remove excess ointment with a swab.
The patient should be advised that the ointment is likely to cause blurring of vision due to its viscous nature.
In the case of wounds on the lids, face, or eye socket, ointment should be squeezed directly onto the wound. It can be dispersed using a moistened swab. If the ophthalmic surgeon requests it, the wound or scar should be massaged using the ointment.

Procedure of Instillation of Eye Ointment

Steps	Action	Rationale
1.	Wash hands and prepare trolley and equipment in accordance with ANTT (Aseptic Non Touch Technique) principles.	Promotes adherence to standards.
2.	Check the patient identification band against the eye-drop medication chart.	Ensures correct patient identification and medication administration.
3.	Prepare the patient for the procedure and obtain consent, giving an explanation of the procedure including any side-effects of the medication.	Informed consent and patient understanding of the procedure.
4.	Assess the patient as before, including ensuring that the drops are not contra-indicated.	Ensures the medication is safe and appropriate for the patient.
5.	The patient should be seated.	Provides easy access to the eye for instillation.
6.	Wash hands or use alcogel.	Prevents the spread of microorganisms.
7.	Prepare equipment and place it in the tray, identifying key parts to be protected during the procedure; in this case, the tips of bottles.	Maintains aseptic technique.
8.	Check drops/ointment against the prescription.	Ensures correct medication is administered.
9.	Check the correct strength (%) of the drops against prescription.	Ensures correct dosage.
10.	Check drops/ointment have not expired. Check clarity of drops, i.e., the fluid in the bottle/minim must be clear and not discoloured.	Ensures medication is safe and effective.
11.	Check packaging/bottle seal is intact when first used.	Ensures sterility and safety of the medication.
12.	Identify any current allergy to the topical medications.	Prevents adverse allergic reactions.
13.	Ensure that the drops are instilled into the correct eye.	Ensures correct administration site.
14.	Examine the eye to be treated for the following: Redness not attributed to surgery or other known causes. No stickiness or pain. No deterioration of vision. Allergies to the prescribed eye drops.	Assesses the condition of the eye to avoid complications.
15.	Check no contact lens in situ unless advised to the contrary by the doctor.	Prevents interference with medication absorption and eye health.
16.	Remove gloves, clean hands with alcohol gel and reapply non-sterile gloves.	Prevents contamination and maintains hygiene.
17.	Open packaging, ensuring key parts remain protected. NB: You may need to open additional packaging if the eye needs cleaning prior to drop instillation, in which case you should proceed to eye cleaning first.	Maintains aseptic technique.
18.	Instruct the patient to slightly tilt the head back and ask the patient to look up. NB: Before using any bottle of eye drops, shake the bottle first.	Facilitates easy access to the eye and proper medication distribution.
19.	Instill only one drop into the lower fornix towards the outer canthus or squeeze 5 mm of ointment along the lower fornix towards the outer canthus. NB: Ointment must only be applied after prescribed eye drops.	Ensures correct medication application.
20.	Ask the patient to gently close his eyes, counting slowly to 60. This helps to minimize systemic absorption.	Promotes proper absorption and effectiveness of the medication.
21.	Wipe away any excess drops/ointment, taking care not to wick away drops from the eye.	Maintains patient comfort and ensures proper dosage remains in the eye.
22.	If further drops are prescribed, wait an interval of 3 minutes before carrying out the procedure. Apply alcogel to hands before instilling the next eye drop.	Prevents contamination and ensures effectiveness of multiple medications.
23.	Make the patient comfortable; patients usually appreciate being given a tissue to dab their cheeks.	Ensures patient comfort and cleanliness.
24.	Dispose of clinical waste, cleanse hands, and then clean the tray.	Maintains a clean and safe environment.
25.	Cleanse hands and document the procedure in the case notes and/or drop chart.	Ensures proper record-keeping and patient safety.

WARM EYE COMPRESS.

A warm eye compress involves applying a warm, moist cloth or compress to the eye area.

Soothe and relax the eye muscles: The warmth helps to relax the eye muscles, which can be helpful for reducing eye strain and fatigue.
Increase blood flow to the area: The warmth dilates blood vessels, increasing blood flow to the eye area, which can promote healing and reduce inflammation.
Loosen eye secretions: Warmth can help loosen mucus and other secretions in the eye, making them easier to remove.

Indications for Warm Eye Compresses

Pain Relief: Warm compresses can help reduce discomfort and pain in the eye area.
Reduce Inflammation: The warmth helps to decrease inflammation and swelling in the eye.
Improve Medication Absorption: Warm compresses can enhance the absorption of eye drops or ointments.
Promote Drainage: Warmth helps to loosen and drain secretions, which can be beneficial for superficial infections.
Dry eye: Warmth can help to stimulate tear production and lubricate the eye surface.
Stye (hordeolum): A stye is a painful red bump on the eyelid caused by a bacterial infection. Warm compresses can help to bring the stye to a head and promote drainage.
Blepharitis: This is a common eye condition that causes inflammation of the eyelids. Warm compresses can help to loosen debris and reduce inflammation.
Conjunctivitis (Pink eye): This is an infection of the conjunctiva, the thin transparent membrane that lines the inside of the eyelid and covers the white part of the eye. Warm compresses can help to soothe inflammation and promote drainage.
Eye strain: Warm compresses can help to relax eye muscles and relieve eye strain caused by prolonged computer use or reading.
Meibomian Gland Dysfunction (MGD): This condition involves a blockage of the oil glands in the eyelids, causing dry eye and other symptoms. Warm compresses can help to loosen and drain the oil glands.

Requirements

Tray	Bedside
Bowl with warm water	Screen
Sterile water or normal saline	Hand washing apparatus
Mackintosh cape and towel/dressing mackintosh
Sterile bowl
Cotton swabs
Receiver

Procedure

Steps	Action	Rationale
1	Identify the eye to be treated.	Ensure the correct eye to prevent error.
2	Follow the general rules.	Promote adherence to standards.
3	The patient may be seated or lying down for this procedure.	To ensure comfort for the patient.
4	Place the bowl with solution in a bowl of warm water.	Cold application is very uncomfortable for the patient.
5	Wash dry hands and put on gloves.	To prevent the chance of cross infection.
6	Place the swab in the warm solution (37°-41°C).	To improve circulation and relieve pain.
7	Squeeze out the excess solution.	To reduce the chance of scalding the patient and wetting patient’s clothes.
8	Instruct the patient to close the eye. Gently apply the swab on top of the affected eye.	To promote patient’s safety and prevent skin damage.
9	Change the compress every 2 minutes for the prescribed length of time.	To maintain a constant temperature for the duration of therapy.
10	Use a dry swab to clean and dry the eyes.	Promote patient’s comfort.
11	If required apply eye drops/ointment.	To prevent infection.
12	Thank and leave the patient comfortable.	Promotes patient’s well-being.

COLD EYE COMPRESS

Cold compress is placing of a cold compress/pack over the affected area or eye
to relieve discomfort.

Indications of Cold compress

Reduce inflammation: Cold compresses constrict blood vessels, reducing inflammation and swelling.
Relieve pain: The coldness helps numb the affected area, reducing pain and discomfort.
Reduce bleeding: Cold compresses can help stop minor bleeding by constricting blood vessels.
Control bruising: Applying cold compresses immediately after an injury can help reduce bruising by minimizing blood pooling.
To reduce swelling or bleeding: Cold compresses can help reduce swelling and bleeding in the eye area by constricting blood vessels.
To ease periorbital discomfort: Cold compresses can help ease pain and discomfort around the eye area.
To relieve itching: The coolness of the compress can help reduce itching in the eye area.

Requirements

Tray

Ice cubes/chips
Solution: sterile water or normal saline solution
Mackintosh and towel/Dressing mackintosh
Strapping
Cotton swabs
Clean gloves

At the bedside

Screen
Hand washing apparatus

Procedure of cold compress

Steps	Action	Rationale
1	Follow the general rules of nursing procedure.	Prevent solution from over the nose and into the eye.
2	Identify the eye to be treated.	To prevent errors.
3	The patient should lie down for this procedure.	To prevent the solution from wetting the patient’s clothes.
4	Position the mackintosh and towel to protect the patient’s clothes.	To prevent wetting the patient’s clothes.
5	Place the swab in the bowl of ice chips (18-27°C).	To make it easy to apply and provide comfort.
6	Wash dry hands and put on gloves.	To prevent infection.
7	Place the moist swab over the affected closed eye.	The swab helps to conduct the cold from the ice pack.
8	After 15-20 minutes, remove the cold compress.	To prevent skin change this can occur from vasoconstriction.
9	Use a dry swab to clean and dry the patient’s face.	To ensure comfort.
10	If required apply eye drops/ointment.	To prevent/treat infection.
11	Thank and leave the patient comfortable.	To ensure comfort.
12	Clear away and document procedure.	To ensure proper records are kept.

Eye Irrigation

Eye irrigation involves flushing the eye with a sterile solution to remove foreign bodies, irritants, or discharge. This process helps cleanse the eye, reduce inflammation, and improve visual clarity.

Eye irrigation is the washing of the conjunctiva sack with a stream of fluid(water). The gentle flow of the irrigation solution washes away the offending substance from the eye. The solution is typically sterile and isotonic to minimize irritation.

Purpose/Aims of Eye Irrigation:

To remove foreign bodies from the eye: This includes dust, dirt, small particles, or insects that may have entered the eye.
To remove chemicals which have been accidentally splashed into the eye(s): This includes chemicals, smoke, fumes, or allergens that may cause irritation.
To washout discharge: This includes mucus, pus, or other secretions that may accumulate in the eye.
Reduce inflammation: The flushing action can help reduce inflammation and swelling.
Improve visual clarity: Removal of foreign objects or discharge can improve vision.
Before administration of medication: Irrigation can help prepare the eye for medication application.
In preparation for eye operations: Irrigation can help cleanse the eye before surgery.

Indications for Eye Irrigation:

Foreign body sensation: If a patient feels something in their eye, such as a speck of dust or a small insect.
Chemical or irritant exposure: If the eye has come into contact with a chemical or irritant.
Discharge or secretions: If there is excessive discharge or secretions from the eye.
Eye infections: In some cases, eye irrigation can help remove infectious material and reduce inflammation in certain eye infections.

Requirements

Tray-sterile

Irrigating solution-Normal saline at 37°C or plain boiled cooled water(sterile).
Sterile gloves, patient’s towel
Lid retractor
Litmus paper
Undine or any small container with a pouring spout e.g. feeding cup, bulb syringe or Sterile irrigation set
Eye pad/waterproof pad
Gallipot of cotton balls or facial tissues
2 receivers, mackintosh cape and towel/dressing mackintosh
Boric acid 2 to 4 %
Gallipot of cotton

At the bedside

Wash hand equipment
Screen

Procedure

Steps	Action	Rationale
1	Follow the general rules for all nursing procedures.	Promotes adherence to standards.
2	Have the patient sit or lie down with the head tilted toward the side of the affected eye. Protect the patient and the bed with a dressing mackintosh or waterproof pad and a towel.	Gravity helps the flow of solution away from the unaffected eye and from the inner canthus of the affected eye toward the outer canthus.
3	Put on gloves. Clean the eye as before.	–
4	Place the curved part of the receiver at the cheek on the side of the affected eye to receive the irrigating solution. If the patient is sitting up, request the patient to hold the receiver.	Cavity aids the flow of solution.
5	Expose the lower conjunctival sac and hold the upper lid open with the non-dominant hand.	To avoid injury to the conjunctival sac and prevent reflex blinking.
6	Hold the irrigator about 2.5 cm from the eye. Direct the flow of the solution from the inner to the outer canthus along the conjunctival sac.	This minimizes the risk of injury to the cornea and prevents the spread of infection from the eye to the lacrimal sac, lacrimal duct, and the nose.
7	Irrigate until the solution is clear or all the solution has been used. Use only sufficient force gently to remove secretion from the conjunctiva without touching any part of the irrigating equipment.	To prevent injury to the tissues of the eye, as well as the conjunctiva, and promote comfort for the patient.
8	Tell the patient to close the eye and move the eye periodically.	Helps to move the secretion from the upper to the lower conjunctival sac.
9	Dry the area after irrigation with cotton balls. Offer the towel to the patient if the face and neck are wet.	To provide comfort.
10	Remove gloves and wash your hands.	–
11	Make the patient comfortable.	–
12	Document the procedure or findings.	–
13	Clear away.	–

Points to remember

For chemical burns, irrigate each eye for at least 15 minutes with normal saline solution to dilute and wash out the harsh chemicals.
If the patient cannot identify the specific chemical, use litmus paper to determine if the chemical is acidic or alkaline or to be sure the eye has been irrigated adequately.
When irrigating both eyes, ask the patient to tilt his head towards the side being irrigated to avoid contamination.
An irrigation fluid may be pre-packed in a disposable set for use or a sterile 50ml syringe may be used.

CARE OF THE PATIENT’S EYES Read More »

BLOOD TRANSFUSION

Blood transfusion refers to the intravenous replacement of lost or destroyed blood with compatible human blood.

TYPES OF BLOOD PRODUCTS

1. Whole Blood: Whole blood is indicated to the patient experiencing acute massive loss or hypovolemic shock. Whole blood restores volume and raises hemoglobin count and therefore oxygen capacity.

Indication: Acute massive blood loss (e.g., trauma) or hypovolemic shock.
Purpose: Replenishes blood volume, increases hemoglobin count (carrying oxygen), and improves oxygen-carrying capacity.

2. Packed Red Blood Cells (PRBCs): Red blood cells are separated from a unit of whole blood. 80% of plasma is removed leaving packed red blood cells which may be transfused to a patient to increase the number of red blood cells without overloading the circulatory system with fluids. Certain types of anaemia such as aplastic anaemia may be treated by this blood product.

Indication:
- Anemia (including aplastic anemia)
- Conditions requiring increased oxygen-carrying capacity without excessive fluid volume.
Purpose: Increases the number of red blood cells to improve oxygen delivery without overloading the circulatory system.

3. Platelet Concentration: Platelets may be administered to aid homeostasis in patients suffering from thrombocytopenia. Platelets assist in initiating the clotting process and other clotting factors such as prothrombin, fibrinogen and thromboplastin.

Indication: Thrombocytopenia (low platelet count), leading to bleeding disorders.
Purpose: Provides platelets to aid in hemostasis (stopping bleeding). Platelets initiate the clotting process, working alongside other clotting factors like prothrombin, fibrinogen, and thromboplastin.

4. Plasma: Plasma is the fluid part of blood after centrifuging in order to remove the red blood cells. Plasma is used to expand blood volume in cases of shock, burns, haemorrhage and while waiting for blood to be cross matched.

Indication:
- Shock (e.g., due to trauma, burns, or hemorrhage).
- While awaiting crossmatched blood for transfusion.
Purpose: Expands blood volume, providing essential proteins and clotting factors.

Indications for Blood Transfusion:

1. Severe Anemia:

Pregnancy
Sickle Cell Disease
Complicated Malaria

2. Preoperative: To address low blood volume levels.

3. Severe Burns: To replace lost fluids and proteins.

4. Postoperative: After major surgeries like:

Laparotomy (abdominal surgery)
Open reduction of internal fractures
Total abdominal hysterectomy

5. Trauma: Following road traffic accidents (RTAs) or other injuries.

6. Blood Clotting Factor Deficiencies: To provide missing clotting factors.

7. Specific Types of Anemia: When other treatment options are inadequate.

Note:

Blood type matching: It’s important to ensure the blood type of the donor matches the recipient to prevent transfusion reactions.
Rh factor compatibility: Rh factor is another important blood group factor that needs to be considered.
Crossmatching: A process to further ensure compatibility between donor and recipient blood.
Potential risks: Blood transfusions can carry risks, including allergic reactions, infections, and transfusion-related acute lung injury (TRALI).
Alternatives to blood transfusion: Options like erythropoietin (for anemia) and medications to increase platelet production are sometimes available.

REQUIREMENTS

As for intravenous infusion with addition of: –

Top shelf

Blood giving set with a filter
Larger needle or cannula

Bottom shelf

Unit of blood.
Normal saline.
Observation chart, fluid balance chart.
Patients chart with details of transfusion.
Medicines as prescribed.

Procedure

The technique of transfusion is similar to intravenous infusion.

On completion of the transfusion the empty bottle must not be washed and should be kept on the ward for 24 hours, in case it is needed for testing in the case of reaction.
Record the following on the patient’s chart: –

Date and time of starting and completing the transfusion.
Number of the blood bottle.
Amount of blood transfused.
Names of nurses or doctor who checked the blood and set up the transfusion.
Patient’s initial response to the transfusion.
Urinary output

Administer normal saline before and after blood transfusion.

Complications of Blood Transfusion

The following are some of the adverse reactions which may occur during blood transfusion:

1. Allergic Reactions:

Cause: Hypersensitivity to components within the blood product.
Signs & Symptoms: Itching, flushing, hives (urticaria), respiratory distress, and anaphylactic shock.
Management:
- Stop the transfusion immediately.
- Notify the doctor urgently.
- Administer antihistamines if prescribed.

2. Febrile Reaction:

Cause: Antibodies in the recipient’s blood reacting to donor white blood cells.
Signs & Symptoms: Fever, chills, and headache during transfusion.
Management:
- Stop the transfusion immediately.
- Inform the doctor.
- Provide symptomatic relief (extra blankets, prescribed antipyretics).
- Reassure the patient.

3. Incompatibility Reaction:

Cause: Mismatched blood types (e.g., giving type A blood to a type B recipient). This is a serious, potentially life-threatening reaction.
Signs & Symptoms: Immediate onset of shivering, chills, headache, low back pain, nausea, vomiting, hemoglobinuria (hemoglobin in the urine), and acute renal failure.
Management:
- Stop the transfusion immediately.
- Notify the doctor.
- Keep the vein open with normal saline.
- Treat shock if present.
- Return the blood unit to the blood bank for rechecking.
- Collect blood samples from the recipient and urine specimen to check for hemoglobinuria.
- Administer diuretics as prescribed.

4. Circulatory Overload:

Cause: Infusion of blood volume faster than the circulatory system can handle.
Signs & Symptoms: Distended neck veins, shortness of breath (dyspnea), dry cough, and pulmonary edema.
Management:
- Stop the transfusion immediately.
- Inform the doctor, who may decide to stop the transfusion completely or slow the infusion rate.
- Administer prescribed medications.
- Monitor and record vital signs frequently.

5. Pyogenic Reaction:

Cause: Bacterial contamination of the blood product or transfusion equipment.
Signs & Symptoms: High fever, chills, nausea, and vomiting.
Management:
- Stop the transfusion immediately.
- Provide tepid sponge baths for fever reduction.
- Inform the doctor and the blood bank.
- Monitor vital signs closely.
- Return the blood unit to the blood bank.
- Administer antibiotics and antipyretics as prescribed.

6. Transmission of Infectious Diseases:

Cause: Blood products can potentially transmit diseases like malaria, syphilis, viral hepatitis, and HIV/AIDS.
Prevention: Careful screening of donor blood is essential to minimize this risk.

THE ROLES OF A NURSE BEFORE, DURING AND AFTER BLOOD TRANSFUSION

Before Blood Transfusion (Nurse’s Interventions)

Verify Prescription: Ensure that a blood transfusion has been prescribed by the doctor as indicated in the patient’s file.
Patient Identification: Properly identify the patient to be transfused.
Explain Procedure: Explain the procedure to the patient to alleviate anxiety.
Counsel and Educate: Counsel, reassure, and provide health education to the patient and their relatives about the benefits of the blood transfusion.
Establish IV Line: Insert a cannula into the identified vein to establish an IV line, maintain it in situ, and obtain a blood sample for laboratory grouping and cross-matching to obtain a compatible donor.
Collect Blood Pack: Collect the compatible blood pack from the laboratory for the patient to be transfused.
Inspect Blood Pack:
- Verify the blood group.
- Confirm the patient’s name on the blood pack.
- Check the expiry date.
- Verify the Rh factor.
- Confirm the reference number.
Check for Leaks and Clots: Inspect the blood pack for leakages and change it if necessary. Check for the color and presence of clots, replacing the pack if clots are present.
Confirm Infusion Set Integrity: Ensure the infusion set is intact.
Take Vital Observations: Record vital signs, including BP, TPR, and maintain a temperature chart.
Patient Positioning: Position the patient’s arm comfortably.
Warm Blood: Warm the blood to room temperature to prevent chills.
Connect Blood Pack: Firmly connect the blood pack to the infusion system on the drip stand.
Fill Air Chamber: Fill the air chamber with a little blood and expel air from the infusion set by running blood through it.
Administer Prescribed Treatment: Administer any prescribed medications.

During Transfusion

Note Start Time: Record the time the transfusion begins.
Monitor Blood Flow Rate: Ensure the blood flow rate is normal.
Watch for Reactions: Observe the patient for any adverse reactions, stopping the transfusion immediately if they occur.
Take Vital Observations: Continuously monitor vital signs to ensure the patient remains stable.
Check Infusion Site: Inspect the infusion site for swelling, leakages, pain, and check the infusion system for blood clotting.
Disconnect After Transfusion: After successful transfusion, disconnect the transfusion system from the infusion line.
Record End Time: Document the time the transfusion ends.
Thank the Patient: Thank the patient for their cooperation.

After Transfusion

Monitor for Reactions: Continuously monitor the patient for post-transfusion reactions.
Monitor Vital Signs: Keep a close watch on vital signs and maintain a temperature chart.
Keep Blood Pack: Retain the empty blood pack at the bedside for 8-12 hours.

Note:

Administer normal saline before and after the blood transfusion.
Administer whole blood and packed red blood cells over 4 hours.
Administer plasma, platelets, and cryoprecipitate over 20 minutes.

BLOOD TRANSFUSION Read More »

INSTIlLING MEDICATION

INSTILLING MEDICATION INTO EAR

Requirements

Tray

Cotton tipped applicators.
Cotton balls.
Bowl with warm normal saline.
Medication bottle with dropper.
Receiver.
Clean gloves.

At the side

Screen
Vomit bowl

Procedure.

Step	Action	Rationale
1	Refer to general rules on nursing procedure and medicine administration.
2	Obtain assistance in case of children or infants.	Prevents accidental injury due to sudden movement during the procedure.
3	Using a cotton-tipped applicator, clean the meatus of the ear canal.	Removes any discharge before instillation.
4	Warm medication container in hands or place in warm normal saline.	Promotes patient’s comfort and prevents vertigo and vomiting.
5	Fill ear dropper, particularly with medication.
6	Straighten auditory canal: – For infants or children under 3 years, pull pinna down and back. – For an adult or child older than 3 years, pull pinna upward and backward.	Straining the canal ensures the solution flows the entire length of the auditory canal.
7	Instill the correct number of drops along the side of the ear canal by holding the dropper ½ to 1 cm above the ear canal.	Reduces trauma to the tympanic membrane.
8	Press gently and firmly a few times on the tragus of the ear.	Pressing assists the flow of medication into the ear canal.
9	Request the patient to remain in a side-lying position for about 5 minutes.	Prevents drops from escaping and enables medication to reach all sides of the canal.
10	Insert a small piece of cotton swab at the meatus of the auditory canal for 15-20 minutes.	Cotton helps to retain medication when the patient is upright.
11	Assess for patient comfort, response, and check for discharge/drainage from the ear.
12	Replace requirements and wash hands.	Reduces the spread of microorganisms.
13	Document medication administration, name of medication administered, and patient’s response.	Ensures accurate record keeping and continuity of care.

Points to remember;

Use sterile technique in administration when administering medication in perforated tympanic membrane.
Consider side effects and toxic effects and contraindications of various medicines.

INSTILLING MEDICATION INTO THE EYES

Requirements

Tray

Sterile gloves sterile cotton balls soaked in sterile normal saline.
Dry cotton balls.
Adhesive strapping.
Receiver.
Dry sterile dressing pad.
Medication.

At the side

Screen.

Procedure

Step	Action	Rationale
1	Refer to general rules on nursing procedure and medicine administration.
2	Check ophthalmic preparation for name, name expiry date.	Prevention medication error
3	Request the patient to look up the ceiling and give the patient a sterile absorbent cotton swab.	If looking up prevents blinking and in this position the cornea is protected by an upper lid.
4	Expose the lower conjunctival sac by pacing thumb or fingers of non-dominant hand just below the eye on the zygomatic arch and gently draw down the skin on the cheek.	Placing fingers on the bony prominence avoids pressure to the eyeball and prevents a person from blinking or squinting.
5	For liquid medication; discard the first drop. For ointment; discard the first ointment bead, hold the tube above the conjunctival sac from the canthus outwords.	It is considered to be contaminated.
6	Approach the eye from the side and instill the correct number of drops into the outer third of the conjunctiva holding the dropper 1-2 cm above the eye.	Patient is less likely to blink if a side approach is used.
7	Request the patient to squeeze on nasolacrimal duct for at least 30 seconds after instilling liquid medication.	Pressure prevents medication running down the duct.
8	Request the patient to close eyes but not to squeeze them.	Squeezing can injure eye and push out medication .
9	Clean the eyelid as needed by wiping from inner canthus to outer canthus.	Prevents spread of infection into the lacrimal duct.
10	Apply eye pad if required and secure it, request patient not to rub the eye.	Reduces risk of injury.

Key points;

If more than one eye drop is ordered, wait 5 minutes between each medication.
If medication for both eyes, place, in the unaffected eye first.

ADMINISTERING NASAL DROPS

Requirements

Tray

Prepared medication.
Pen light.
Receiver toilet paper.
Clean dropper.
Facial flannels.

At the side

Screen
Small pillow.

Procedure

Step	Action	Rationale
1	Refer to general rules on nursing procedure and medicine administration.
2	Inspect the condition of the nose and sinuses using a penlight and palpate sinuses for tenderness.	Provides baseline data to monitor effects.
3	Wash hands and put on gloves.	Promotes infection prevention.
4	Request patient to clear or blow nose gently unless contraindicated (increased intracranial pressure or nose bleeds).	Removes mucous and secretions that can block the nasal passages.
5	Position patient supine, and position head properly for access to the posterior pharynx, tilt patient’s head backward.	Allows medication to flow into affected sinuses.
6	Support the patient’s head with the non-dominant hand and instruct the patient to breathe through the mouth.	Prevents straining of the muscles and mouth breathing reduces the chances of aspirating nasal drops.
7	Hold dropper ½ – 1 cm above nares and instill prescribed number of drops towards the midline of the ethmoid bone.	Avoids contamination of the dropper.
8	Have the patient remain in the supine position for 5 minutes and offer a facial towel to blot the nose but do not blow.	Prevents premature loss of medication through nares and allows maximum dose to be absorbed.
9	Assist patient to a comfortable position after the medication is absorbed.	Restores comfort.
10	Assess patient response, replace requirements, and wash hands.	To detect reactions and maintain a hygienic environment.
11	Document and record administration of medication.	Ensures accurate record keeping and continuity of care.

ADMINISTERING MEDICATION THROUGH NASO-GASTRIC TUBE

Requirements

Tray

All requirements for passing a tube.
Medication.
Mortar or pestle if tablets are used.

At the side

Screen

Procedure

Step	Action	Rationale
1	Refer to general rules on nursing procedure and medicine administration.
2	Position patient and place mackintosh and towel under the chest.	Protects patient from spillage.
3	Elevate the head of the bead 35° -45°	Protects patient from aspiration.
4	Assess placement of the tube, if correct flush 15-30ml of water (adults) or 5-10ml in children.	Helps to maintain tube patency.
5	Administer the prepared medication in the same manner as feeds are administered. Administer each medication and flush with 5ml after each, do not mix medications.	To avoid medicine reactions.
6	After administering the prescribed medications flush the tubing with at least 30 ml of water.	Prevents clogging of feeding tube
7	Assess patient response, replace requirements and wash hands.
8	Document and record administration of medication.

APPLYING TOPICAL MEDICATIONS

Requirements

Tray

Gloves
Water in a bowl
Soap in a dish
Cotton balls or gauze pieces
Medicine (ointment, lotion or liniment) in appropriate container
Adhesive tape and dressing pad

Procedure

Step	Action	Rationale
1	Refer to general rules on nursing procedure and medicine administration.	To maitain Standards
2	Expose only the area where lotion/liniment is to be applied
3	Powders; make sure the skin surface is dry and sprinkle evenly over the area till a fine layer covers the skin. Cover Area if required.
4	Lotions; shake the container and put a small amount of lotion on a gauze dressing pad and apply it evenly in the direction of hair growth.
5	Creams, ointments, and pastes; take a small quantity of medication in gloved hand, smear it evenly over skin using long strokes in the direction of hair growth.
6	Spray; shake the container well to mix the contents, hold the container at 15 – 30 cm away from the area and spray, ensuring that it does not enter the eyes.
7	Transdermal patches; select clean dry area which is free of air, take the patch holding it without holding the adhesive edges and apply it firmly using palm of hand and press it for 10 seconds, remove the patch at the appropriate time.
8	Observe the area carefully for changes in color, swelling appearance of a rash.
9	Document and record administration of medication.

ADMINISTERING RECTAL AND VAGINAL MEDICATION.

Requirements

Tray

Rectal suppository.
Clean gloves.
Application plunger in case of vaginal cream.
Receiver.
Lubricating jelly.
Toilet paper receiver.
Swabs in a gallipot.
Mackintosh and towel.

At the side

Screen

Procedure

Rectal

Steps	Action	Rationale
1.	Refer to general nursing procedures.	Keeps standard.
2.	Review patient’s information about the medicine.	Ensures safe and correct medical administration.
3.	Receive patient knowledge about the intended administration.	Ensures patient privacy and positions ensures easy access to anus.
4.	Screen bed and position patient in left lateral with upper leg flexed.	Provides privacy.
5.	Wash hands and put on gloves.	Reduces transfer of infection.
6.	Keep the patient draped with only the anal area exposed.	Maintains privacy and facilitates relaxation.
7.	Remove suppository from foil wrap and lubricate rounded end with jelly, lubricate gloved finger of dominant hand.	Lubrication reduces friction.
8.	Request the patient to take slow deep breaths.	Facilitating suppository through constricted sphincter causes less pain.
9.	Retract patient’s buttocks with non-dominant hand, with index finger of dominant hand insert suppository along rectal wall to 10 cm in adult and 5 cm in children.	Promotes eventual absorption.
10.	Withdraw your finger and wipe the patient’s anal area with toilet paper.	Promotes comfort.
11.	Request the patient to remain flat or on one side for 5 minutes.	Prevents expulsion of the medication.
12.	Check within 5 minutes to determine the suppository is in place, request the patient to retain the suppository for 30-45 minutes.	Ensures effectiveness of medication.
13.	Clean, remove gloves and wash hands.	Infection prevention.
14.	Record and report all patients’ responses to medication including any reactions.	Ensures the effect of medicine.

Vaginal

Steps	Action	Rationale
1.	Explain to the patient that insertion is painless and will bring relief from itching, pain and discomfort.	Reduces anxiety and ensures cooperation.
2.	Request patient to empty bowel and bladder.	Promotes effectiveness.
3.	Position patient in semi recumbent, cover patient leaving the perineal area only.	Ensures patient privacy.
4.	Prepare requirements, unwrap suppository, for cream, fill applicator as instructed.	Promotes infection control.
5.	Put on gloves, inspect perineal/vaginal discharge.	Prevents infection.
6.	Apply medicine gently into the vaginal wall.	Ensures correct administration.
7.	Request the patient to remain flat or on one side for 5-10 minutes following insertion.	Ensures absorption.
8.	Apply a clean perineal pad if excessive discharge or cream leakage.	Promotes patient’s comfort.
9.	Clean, remove gloves and wash hands.	Infection prevention.
10.	Record and report all patients’ responses to medication including any reactions.	Promotes communication between team members.

INSTIlLING MEDICATION Read More »

Cancers of Reproductive Health Organs

Breast Cancer

Breast cancer occurs when cells in the breast grow and divide uncontrollably, forming a mass of tissue known as a tumour.

Breast cancer can invade nearby tissues and travel to other body parts, forming new tumours, a process called metastasis.

Clinical Manifestations

Early Signs of Breast Cancer

Asymptomatic: Sometimes, breast cancer shows no symptoms at all, especially in the early stages. This means you might not notice anything unusual.
Size and Shape Changes: A noticeable change in the size or shape of the breast.
Lump: A mass or lump that may be as small as a pea.
Persistent Lump or Thickening: A lump or thickening in or near the breast or underarm that persists through the menstrual cycle.
Skin Changes: Dimpling, wrinkling, scaliness, or inflammation of the skin on the breast or nipple.
Redness: Redness of the skin on the breast or nipple.
Distinct Area: An area distinctly different from other areas on either breast.
Nipple Discharge: Blood-stained or clear fluid discharge from the nipple.

Others;

Unilateral nipple discharge: When fluid, which could be clear, bloody, or another color, leaks from only one nipple.
Change in breast size: One breast might become noticeably larger or smaller than the other, or there could be a change in the overall size of the breast.
Nipple or skin retraction: The nipple may become inverted or pulled inward, or there may be dimpling or puckering of the skin on the breast.
Local lymphadenopathy: Swollen or enlarged lymph nodes in the armpit or collarbone area, indicating possible spread of cancer.
Skin changes-orange-like appearance (Peau d’orange): The skin on the breast might take on an orange peel-like appearance, due to changes caused by cancer cells blocking lymph vessels.
Nipple or skin ulceration: Sores or ulcers on the breast or nipple that do not heal or go away.
Breast pain: Persistent or unusual pain in the breast, although breast cancer does not cause pain in its early stages.
Symptoms of metastasis: If the cancer has spread to other parts of the body, symptoms may include bone pain, shortness of breath, jaundice, or neurological symptoms like headaches or seizures.

Risk Factors

Age: Being 55 or older increases the risk of breast cancer.
Sex: Women are much more likely to develop breast cancer than men.
Family History and Genetics: A family history of breast cancer increases the risk especially if close relatives like mother, sister, or daughter have had it. About 5% to 10% of breast cancers are due to inherited abnormal genes like the BRCA1 and BRCA2 genes.
Smoking: Tobacco use is linked to many cancers, including breast cancer.
Alcohol Use: Drinking alcohol increases the risk of certain types of breast cancer.
Obesity: Obesity increases the risk of breast cancer and recurrence.
Radiation Exposure: Prior radiation therapy, especially to the head, neck, or chest, increases risk.
Early onset menarche: Starting menstruation at a young age, usually before age 12.
Late menopause: Continuing menstruation later in life, usually after age 55.
Delayed first pregnancy (after 30 years of age): Not becoming pregnant for the first time until after the age of 30.
Null parity: Never having given birth to a child.
Family history (maternal or paternal) BRCA1 and BRCA2 genes: A family history of breast cancer,
History of breast biopsy: Previous biopsies or other breast procedures may indicate increased risk.
Use of Hormonal therapy for more than 4 years: Long-term use of hormone replacement therapy (HRT), which involves taking oestrogen and progesterone to relieve symptoms of menopause.

Stages of Breast Cancer

Staging helps describe the extent of cancer by determining the size, location, and spread of the tumour.

Stage 0: Non-invasive; cancer has not broken out of the breast ducts.
Stage I: Cancer cells have spread to nearby breast tissue.
Stage II: Tumour is smaller than 2 cm and has spread to underarm lymph nodes or is larger than 5 cm without spreading to underarm lymph nodes.
Stage III: Cancer has spread beyond the breast to nearby tissues and lymph nodes but not to distant organs (locally advanced breast cancer).
Stage IV: Cancer has spread to distant organs such as bones, liver, lungs, or brain (metastatic breast cancer).

Diagnosis/Investigations:

History Taking: About family history of breast cancer,medical history, and any other symptoms.
Self Breast Examination and Breast Examination: For any lumps, changes in size or shape, or other abnormalities.
Mammogram: Special X-ray of the breasts that can detect changes or abnormal growths, even before they can be felt. It’s a common screening tool for breast cancer.
Ultrasonography: Also known as ultrasound, Uses sound waves to create images of breast tissues. It helps in diagnosing lumps or other abnormalities found during a physical examination or mammogram.
Positron Emission Tomography (PET) Scan: This test uses special dyes to highlight areas of the body with abnormal metabolic activity, which can indicate the presence of cancer cells.
Magnetic Resonance Imaging (MRI): MRI uses magnets and radio waves to produce detailed images of breast structures. It’s especially useful for evaluating the extent of the disease in the breast.
TNM System: This is a staging system used to describe the extent of the cancer based on the size of the tumour (T), whether it has spread to nearby lymph nodes (N), and whether it has metastasized to other parts of the body (M).
Full Blood Count: This blood test helps assess the overall health and can indicate if there are any abnormalities or signs of infection or inflammation.
Renal and Hepatic Profile: Blood tests to assess the function of the kidneys and liver, as metastatic breast cancer can spread to these organs.
Chest X-Ray: This test may be done to check for any signs of metastasis to the lungs.
Biopsy (Preferably Fine Needle Aspiration): A biopsy is the definitive way to diagnose breast cancer by analyzing a sample of breast tissue under a microscope. Fine needle aspiration is a less invasive biopsy method often used for initial diagnosis.

Management of breast Cancer

Management depends on the tumour’s location and size, lab test results, and whether the cancer has spread.

Stage 0 (Cancer in situ):

Young Women: Conservative surgery only, such as lumpectomy.
Advanced Age: Mastectomy only.

Early Stage (Stage I and II):

Surgery: Modified radical mastectomy and lymphadenectomy for advanced age, and simple mastectomy or wide local lumpectomy for young age.
Hormonal Therapy: Tamoxifen 20 mg orally daily for 5 years, but may cause retinal damage. Blocks hormones that fuel certain cancers.
Chemotherapy:
- Cyclophosphamide: 30 mg/kg IV single dose.
- Fluorouracil: 300-1000 mg/m2 IV, given every 4 weeks based on patient response.
- Paclitaxel: 6mg/ml in combination with Cisplatin 1mg/ml.

Late Cancer (Stage III and IV):

Hormonal Therapy: Same as for early stage, Tamoxifen 20mg orally daily for 5 years, but may cause retinal damage.
Chemotherapy: same as for early stage.
Radiation Therapy: Uses high-energy rays to kill cancer cells.
Immunotherapy: Helps the immune system fight cancer.
Targeted Drug Therapy: Uses drugs to target specific cancer cells.

Types of Breast Cancer Surgery

Lumpectomy (Partial Mastectomy): Removal of the tumour and some surrounding tissue, often followed by radiation therapy.
Mastectomy: Removal of the entire breast.
Axillary Lymph Node Dissection: Removal of multiple lymph nodes.
Modified Radical Mastectomy: Removal of the entire breast, underarm lymph nodes, and chest wall muscles if the cancer has spread. Reconstruction may be an option.

Mastectomy

Mastectomy is a planned surgical procedure involving the removal of the breast tissue.

There are different types of mastectomy:

Partial Mastectomy: Removal of lumps with surrounding normal tissue.
Simple Mastectomy: Removal of breast tissue with node biopsy.
Extended Simple Mastectomy: Removal of breast tissue, axillary tail, and nodes.
Total Mastectomy: Complete removal of the breast leaving the pectoralis muscle intact.
Radical Mastectomy: Removal of breast, skin, muscle, and nodes.
Modified Radical Mastectomy: Removal of breast, skin, muscles, and nodes with subsequent skin grafting.

Pre-operative Care

Admission: Patient admitted to a surgical ward.
History Taking: Record medical, surgical, and gynaecological history.
Observations: Vital signs monitoring, general examination. And the doctor is informed.
Investigations: Various tests including urinalysis, blood tests, and imaging.
Patient Education: Inform the patient about the surgery, its purpose, complications, and anaesthesia side effects.
Informed Consent: Obtain consent from the patient.
Preparation: IV line, blood booking, catheterization, pre-medications administration, and changing into hospital gown
Feeding: No feeds or drinks on the day of the operation
Rest and sleep: Ensure enough rest and sleep i.e. minizing noise, reducing bright light.

Morning at the day of the operations

IV line is put up
Booking for blood in the laboratory
Catheterisation of the patient
Administration of pre-medications
Helping the patient to change into hospital gown
Removal of all ornaments from the patient and keep them properly.
Continuous counselling to relieve anxiety
Preparation of patients medical document
Taking the patient to the theatre and handing her over to the theatre.

Post-operative Management

When the operation is finished, the information from the theatre will be sent to the ward and 2 nurses will go and collect the patient, reports are received from the surgeon, recovery room nurses and anaesthetists and then the patient is wheeled to the ward.

Patient Reception: Patient is received in a warm bed, flat position and turned to one side. As soon as she gains consciousness sit her in the bed leaning on the affected side to aid drainage.
Arm Care: Elevation and positioning as per surgeon’s orders.
Observation: Regular monitoring of temperature, pulse, respiration, blood pressure, bleeding, and edema.
Medical Treatment: Pain relief, antibiotics, vitamins, and supportives.

Pethidine 100mg 8 hourly for 3 doses on change to panadol to complete 5 days
Antibiotics: ampicillin or gentamicin as ordered
Supportives: vitamins like vitamin c, Iron, folic acid, diazepam

Wound Care: Inspection, dressing, drainage management, and stitch removal. Stitches are removed on the 8th – 10th day.
Wound and Drainage Care

Aseptic Care: Avoid unnecessary touching; inspect for tension or edema.
First Dressing: Done 48-72 hours post-surgery.
Drain Management: Monitor and remove drainage when discharge ceases.

Nursing Care After Mastectomy

Initial Care: Patient received in a warm bed in a flat position with head turned to one side.
Positioning: Once conscious, position the patient upright to aid drainage.
Vital Observations: Check vitals every 15 minutes in the first hour, then every 30 minutes for the next hour until stable.
Site Observation: Monitor for bleeding and edema.
IV and Blood Transfusion: Ensure correct flow rates.
Welcome and Explanation: Explain the procedure and provide comfort.
Analgesics and Antibiotics: Administer as prescribed (e.g., Pethidine, Ampicillin).
Supportive Care: Provide vitamins and minerals.
Hygiene: Provide bed baths and oral care until self-sufficient.
Diet: Encourage fluids and nutritious food.
Elimination: Promote regular bowel and bladder emptying.
Exercise: Begin chest, arm, and leg exercises to prevent deformity and contractures.
Psychotherapy: Reassure and counsel on using artificial breasts.

Advise on discharge

Radiotherapy: Start when the wound heals (6-8 weeks), lasting 2 months.
Follow-Up: Every 2 months for up to 2 years.
Chemotherapy: Continue as prescribed.
Regular Checkups: Monitor for metastasis.
Cancer Institute Visits: Attend radiotherapy.
Artificial Breast Use: Educate on proper use.

Complication

Necrosis: Death of suture line tissue.
Nerve Damage: Potential paralysis of the arm.
Contractures: Tightening of muscles and joints.
Sloughing: Shedding of dead tissue.
Infections: Risk of infection at the wound site.
Gaping: Opening of the wound.
Chronic Sinus: Persistent drainage site.
Oedema: Swelling of the arm.
Thrombosis: Blood clots in the axillary vein.
Cosmetic Deformity: Changes in appearance post-surgery

The Cervix

The cervix is a vital part of the female reproductive system, connecting the uterus to the vagina. It has two main types of cells:

Squamous cells: Flat, thin cells found in the outer layer of the cervix (ectocervix).
Glandular cells: Column-shaped cells that produce cervical mucus and are found in the cervical canal (endocervix).

Glandular cells from the cervical canal frequently migrate outside the canal and undergo changes to become squamous cells. This transformation process is known as squamous metaplasia, occurring in a region called the transformation zone.

Cervical Cancer

Cervical cancer is a malignant tumor found in the tissues of the cervix, occurring when abnormal cells in the cervix turn into cancer cells. These cancer cells can invade the surface cells (epithelium) and the underlying tissue (stroma) of the cervix, most commonly beginning in the transformation zone.

Epidemiology

Around 3,100 women are diagnosed with cervical cancer each year in the UK.
In Australia, about 780 women are diagnosed annually.
In Uganda, 2,464 women die from cervical cancer annually, with over 3,577 new cases diagnosed each year, making it a leading cause of death among women in the country.

Types of Cervical Cancer

Squamous cell carcinoma: Begins in the flat, thin cells lining the bottom of the cervix; accounts for 80-90% of cervical cancers.
Adenocarcinoma: Develops in the glandular cells lining the upper portion of the cervix; accounts for 10-20% of cervical cancers.
Mixed carcinomas: Involve both types of cells.

Causes of Cervical Cancer

The exact cause is unknown, but several risk factors have been identified:

Human papillomavirus (HPV): A major cause, with types 16 and 18 being the most oncogenic.
Smoking: Chemicals in cigarette smoke can damage cervical cells.
Immunosuppression: Conditions like HIV/AIDS weaken the immune system.
Oral contraceptives: Long-term use increases risk, which decreases after stopping the pill.
Other STIs: Infections like herpes and chlamydia can increase risk.
Circumcision: Women with uncircumcised partners are at higher risk.
Early sexual intercourse: Exposure to sperm can promote cell division in the transformation zone.
High parity: Multiple pregnancies can cause cervical trauma.
Repeated induced abortions: Can cause cervical trauma.
Exposure to chemicals: Occupational exposure to substances like tetrachloroethylene.

Symptoms of Cervical Cancer

Early symptoms may not be noticeable but can include:

Vaginal bleeding (between periods, after intercourse, post-menopausal)
Unusual vaginal discharge (watery, pink, foul-smelling)
Pelvic pain (during intercourse or otherwise)

Advanced stages can present with:

Severe weight loss, anemia, dehydration
Fatigue
Back pain
Pain or swelling in the legs
Urinary or fecal incontinence
Bone fractures
Hematuria
Enlarged organs
Rectal bleeding
Tenesmus (desire to defecate)
Fistulas

Staging of Cervical Cancer

Staging describes the extent of cancer spread. Federation for International Gynecology and Obstetrics (Figo) staging.

Stage 0: Carcinoma in situ (pre-invasive)

Stage I: Confined to the cervix

1a: Microscopic invasion
1b: Clinically visible lesion confined to the cervix

Stage II: Beyond the uterus but not to pelvic wall or lower third of vagina.

IIa: Limited to 2/3 of the vagina
IIb: Parametrial invasion(Cancer cells found outside the smooth muscles of the cervix.

Stage III: To pelvic wall, involves lower third of vagina, or causes hydronephrosis

IIIa: Invasion of lower 1/3 of the vagina.
IIIb: Invasion of pelvic sidewall +/- hydronephrosis

Stage IV: Invades bladder/rectum mucosa or distant metastasis.

Can spread by:

Direct spread to parametria on both sides, upper part of cervix, uterus, vaginal wall, bladder.
Lymphatic spread to lymph nodes in parametria, obturator nodes, external and internal iliac nodes, inguinal nodes, sacral nodes, hypogastric glands and rarely aortic and lumbar glands.
Blood spread to the lungs, liver, bone and intestines implantation.

Diagnosis of Cervical Cancer

1. History and Examination: Includes speculum and colposcopic examination.

2. Colposcopy-directed biopsy: Examination and tissue sample collection. Cervix-lesion may be in the form of an ulcer, Cauliflower growth.

3. Pap smear(papanicolau): Detects early-stage cancer or precancerous changes. The doctor scrapes a sample of cells from the cervix. For a Pap test, the lab checks the sample for cervical cancer cells or abnormal cells that could become cancer later if not treated.

4. Acetic Acid Test: This is of two types;

Unaided Visual Inspection (UVI): 3% acetic acid is painted on to the cervix. The abnormal area stains white and is biopsied to find out what type of lesion it is.
Aided Visual Inspection(AVI): cervix is painted with 3% acetic acid using a magnifying instrument to find the lesions present.

5. HPV testing: Identifies high-risk HPV strains.

6. Other tests: Full blood count, urea and electrolyte levels, liver function tests.

7. Biopsy: This is a surgical removal of tissue to look for cancer cells and usually done under local anesthesia. This may be done if cervical smear reveals evidence of cervical intraepithelial neoplasia. The tissue sample obtained is sent to the pathologist for histology and for confirmation.

Treatment and Prevention of Cervical Cancer

Pre-invasive: Pre invasive- lesions are destroyed using methods like liquid carbon dioxide, laser beam(leep)loop, electric excision procedure where the doctor uses an electric wire loop to slice off a thin, round piece of cervical tissue. Lesions destroyed using cryotherapy, laser beam, or LEEP.
Invasive carcinoma: Treatment is by wertheim’s hysterectomy. This involves total hysterectomy with removal of the upper 1/3 of the vagina as well as dissection of the lymph nodes including Para-aortic nodes plus salpingo-oophorectomy and this can be followed by radiotherapy. Treated with surgery (e.g., hysterectomy), chemotherapy, and radiotherapy.
Radiation therapy: This is the use of high-energy rays to kill cancer cells.
It’s an option for women with any stage of cervical cancer and may prefer radiation therapy to surgery.
It may also be used after surgery to destroy any cancer cells that remain in the area.
For women with cancer that extends beyond the cervix may need to combine radiation therapy and chemotherapy.

Surgical Management

Surgery is an option for women with Stage I or II cervical cancer. If you have a small tumor, the type of surgery may depend on whether you want to get pregnant and have children later on. Some women with very early cervical cancer may decide with their surgeon to have only the cervix, part of the vagina, and the lymph nodes in the pelvis removed (radical trachelectomy).

Prevention

Primary Prevention: Includes vaccination, health education, promoting safe sexual practices, reducing drug abuse, and regular screening.
Secondary Prevention: Early detection through regular screening and prompt treatment of precancerous lesions.

Primary Prevention

Since cervical cancer is often caused by a sexually transmitted infection (STI), steps can be taken to prevent its incidence. Primary prevention involves reducing or eliminating risk factors.

Vaccination: Encourage HPV vaccination to prevent cervical cancer.

Community Health Education

Promote awareness about the importance of early marriages and safe sexual practices.
Conduct educational programs to reduce drug abuse and promote the use of condoms.
Advocate for reducing the number of sexual partners.
Encourage behavior change and improved hygiene.

Men Involvement: Involve men in educational programs to promote understanding and support for prevention measures.

Income Generating Activities: Support income-generating activities to improve community well-being and reduce risk factors associated with poverty.

Secondary Prevention

Secondary prevention involves methods to detect cancer in its earliest stages so that treatment can begin as soon as possible.

Screening

Promote regular Pap smear tests to detect early cervical changes.
Ensure early referral to higher levels of care for further evaluation and treatment if needed.

Awareness and Training

Create awareness among health workers about the importance of early detection.
Train healthcare providers to perform screenings effectively.

Cost and Accessibility

Reduce the cost of screening to make it more accessible to the population.
Provide additional radiotherapy units in the country to extend services closer to the people.

Endometrial Cancer/Uterine Cancer

Endometrial cancer is a malignant tumor within the endometrium, resulting in abnormal cell growth that can invade or spread to other parts of the body.

Incidence/Epidemiology

It is the sixth most common cancer in women globally.
More common in developed countries, with a lifetime risk of 1.6% compared to 0.6% in developing countries.
Occurs in 12.9 out of 100,000 women annually in developed countries.
Most frequently appears during peri-menopause (ages 50-65).
75% of cases occur after menopause.
Women younger than 40 make up 5% of cases; 10-15% occur in women under 50.

Causes/Risk Factors

The exact cause is idiopathic, but it is associated with:

High blood pressure
Diabetes
Excessive or long-term estrogen exposure
Polycystic ovary syndrome (PCOS)
Functioning ovarian tumors
Anovulation
Infertility
Family history or genetic factors
Obesity
Late menopause
Early menarche
Age above 55 years
Excessive use of tamoxifen
Nulliparity (never having had children)

Classifications of Endometrial Cancer

Type 1 Endometrial Carcinoma: Estrogen-related, occurs in younger, obese, premenopausal women, usually low-grade and endometrioid.
Type 2 Endometrial Carcinoma: High-grade, usually serous or clear cell, affects older women.
Type 3 Endometrial Carcinoma: Hereditary or genetic types, some related to Lynch II syndrome.

Clinical Presentation

Vaginal bleeding or spotting in postmenopausal women (90% of cases).
Abnormal menstrual cycles or heavy, frequent bleeding in premenopausal women.
Thin white or clear vaginal discharge in postmenopausal women.
Enlarged uterus on physical examination.
Lower abdominal pain, pelvic cramping, painful sexual intercourse, painful or difficult urination (with metastasis).

Diagnosis

History and physical examination.
Dilation and curettage.
Transvaginal ultrasound to examine endometrial thickness in postmenopausal bleeding.
Endometrial biopsy.
CT scan.

Differential Diagnosis

Senile endometritis/vaginitis.
Dysfunctional uterine bleeding.
Submucous myoma/endometrial polyps.
Cervical cancer.
Uterine sarcoma.
Primary carcinoma of the fallopian tube.

Management

Surgery

Stage I: Total Abdominal Hysterectomy and Bilateral Salpingo-Oophorectomy (TAH-BSO).
Stage II: Radical Hysterectomy.
Stage III: Radical surgery with maximal debulking followed by radiotherapy.
Stage IV: Radical radiotherapy, with or without hormonal therapy and/or chemotherapy.

Radiotherapy

Most patients with early-stage disease receive a combination of surgery and radiotherapy based on histopathological findings.
Surgery alone is limited to patients with endometrioid type carcinoma confined to less than 50% of the myometrial thickness.

Hormonal Therapy

Progestogens are the most commonly used form of hormonal therapy in endometrial cancer.

Chemotherapy

Chemotherapy is uncommon but should be considered in fit patients with systemic disease. Commonly used medications include:

Doxorubicin (Anthracycline) and Cisplatin
Carboplatin (Platinum Medicines): Use is limited by the patient’s advanced age and poor performance status.
Typical regimen: Cisplatin 50 mg/m² IV, Adriamycin 45 mg/m² IV on Day 1, followed by Paclitaxel 160 mg/m², repeated every 21 days.
Alternative regimen: Carboplatin and Paclitaxel as for ovarian cancer.

Ovarian Cancer

Ovarian cancer is a malignant growth within the ovarian tissue.

Etiology and Pathogenesis

There is a link between ovulation and epithelial ovarian cancer. Combined hormonal contraception reduces the risk by approximately 50%. Risk factors include having a first-degree relative with ovarian cancer.