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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.