c
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9 To be able to identify factors that have been cause the patient to have a vaginal
hysterectomy

9 To be able to know the cause, signs and symptoms, treatment and prevention of the
disease

9 To be able to know how vaginal hysterectomy affects the person physically,

psychologically and emotionally

9 To be able to formulate the right nursing care plan for the benefits of the patient

9 To be able to interpret the laboratory result finding

9 To be able to give accurate health teaching related to the condition of the patien

9 To assess the effect of hysterectomy for nonmalignant conditions on symptoms and

quality of life and to identify adverse effects 1 year after surgery

9 To be able to describe the development, physiology and nursing care of a client who has
undergone vaginal hysterectomy.

9 To be able to have a good working relationship with the patient.

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Name: Mrs. X

Age: 68 years old

Sex: Female

Address: 597 West Dagupan City

Educational Attainment: (not mentioned)

Civil Status: Married

Nationality: Filipino

Religion: Roman Catholic

Occupation: housewife

cc c 
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Mrs. X, a 68 yr. old female house wife from 597 West Dagupan City, was admitted on
July 16 at 12:45 pm with a chief complain of abdominal pain.

As the interview was conducted, Mrs. X told us that since July 12, 2010, she was
experiencing pain in her lower abdomen and she can¶t tolerate the pain at that time. She thought
that the pain would go away, since it didn¶t after 3days. At July 15, 2010 she had her check-up
under Dr. Macrina. The doctor gave her advice about her concern. And without hesitation on
July 16,2010 at 12:45 in the afternoon, Patient was admitted at the ER with the chief complaint
of hypogastric pain.

At that time the patient was brought to the ward. Instructions were given with Medication
& IVF. And to have the procedure on the following day. At July 17, 2010 around 2:25PM patient
was moved to O.R. for vaginal hysterectomy. Post-hysterectomy Doctor¶s orders were as fallows
which were carried out.

  
c 

Upon interview patient was asked about her menstrual history, she told us that at the age
of 13, she had her 1st menstrual period or menarche. Her menstrual cycle was regular, in her 28
day menstrual cycle; she had her period for 6 days.

Mrs. X had 8 pregnancies and had 8 deliveries. They were all normal spontaneous
delivery(4MALES & 4 FEMALES). She had a history of DM (NIDDM) & (+) HPT. She was
prescribed with medicine & she's taking it until this time.

She had her menopause at 45 yrs. old, after 6 months, she experienced an abdominal pain
that she couldn't tolerate & she think that there is something wrong with her vagina.

  c 
c 

Patient lives in a barangay. She claims that their yard is clean although patient speaks
about the open drainage and the way they eliminate their garbage is thru burning and if the
garbage is not thrown in a dump site. Their home is concrete and their toilet is owned and flush
while they use water coming from an artesian well for bathing, cleaning, washing etc. except for
drinking and for cooking they use mineral water as an alternative. The domesticated animal they
have is a dog.

 
c c
c 

The patient says that they have a wide rice field as a source of income and a monthly
allowance coming from their children.

They claim that they regularly eat 3x a day, usually consist of rice and easy to cook
foods(such as: hotdogs, tocino,etc). The husband claims that her wife is fun of eating sweet and
fatty foods which they believe was the cause of her diabetes aside from lack of exercise.
c c c

Vaginal hysterectomy is a procedure in which the uterus is surgically removed through

the vagina. One or both ovaries and fallopian tubes may be removed during the procedure as
well; removal of both ovaries and fallopian tubes is called bilateral salpingo-oophorectomy
(BSO).A vaginal approach may be used if the uterus is not greatly enlarged, and if the reason for
the surgery is not related to cancer.

Studies have shown that vaginal hysterectomy has fewer complications, requires a shorter
hospital stay, and allows a faster recovery compared to removal of the uterus through an
abdominal incision (abdominal hysterectomy).

  
 
 c

Y
Y

An overview of the female reproductive system begins at the external genital area or
vulva which runs from the pubic area downward to the rectum. Two folds of fatty, fleshy tissue
surrounds the entrance to the vagina and the urinary opening: the labia majora or the outer folds,
and the labia minora or the inner folds, located under the labia majora. The clitoris, a relatively
short organ (less than an inch long), shielded by a hood of flesh. When stimulated sexually, the
clitoris will erect like a man¶s penis. The Hymen a thin membrane protecting the vagina,
stretches when you insert a tampon or have intercourse.



The external female genitals are collectively referred to as The Vulva. This consists of the labia
majora and labia minora (while these names translate as "large" and "small" lips, often the
"minora" can be larger, and protrude outside the "majora"), mons pubis, clitoris, opening of the
urethra (meatus), vaginal vestibule, vestibular bulbs, vestibular glands.

The term "vagina" is often improperly used as a generic term to refer to the vulva or female
genitals, even though - strictly speaking - the vagina is a specific internal structure and the vulva
is the exterior genitalia only. Calling the vulva the vagina is akin to calling the mouth the throat.


!!"#

The mons veneris, Latin for "mound of Venus" (Roman Goddess of love) is the soft mound at
the front of the vulva (fatty tissue covering the pubic bone). It is also referred to as the mons
pubis. The mons veneris is sexually sensitive in some women and protects the pubic bone and
vulva from the impact of sexual intercourse. After puberty it is covered with pubic hair, usually
in a triangular shape. Heredity can play a role in the amount of pubic hair an individual grows.
$#
%"

The labia majora are the outer "lips" of the vulva. They are pads of loose connective and adipose
tissue, as well as some smooth muscle. The labia majora wrap around the vulva from the mons
pubis to the perineum. The labia majora generally hides, partially or entirely, the other parts of
the vulva. There is also a longitudinal separation called the pudendal cleft. These labia are
usually covered with pubic hair. The color of the outside skin of the labia majora is usually close
to the overall color of the individual, although there may be some variation. The inside skin is
usually pink to light brown. They contain numerous sweat and oil glands. It has been suggested
that the scent from these oils are sexually arousing.

$#
#"

Medial to the labia majora are the labia minora. The labia minora are the inner lips of the vulva.
They are thin stretches of tissue within the labia majora that fold and protect the vagina, urethra,
and clitoris. The appearance of labia minora can vary widely, from tiny lips that hide between the
labia majora to large lips that protrude. There is no pubic hair on the labia minora, but there are
sebaceous glands. The two smaller lips of the labia minora come together longitudinally to form
the prepuce, a fold that covers part of the clitoris. The labia minora protect the vaginal and
urethral openings. Both the inner and outer labia are quite sensitive to touch and pressure.


#&"#

The clitoris, visible as the small white oval between the top of the labia minora and the clitoral
hood, is a small body of spongy tissue that functions solely for sexual pleasure. Only the tip or
glans of the clitoris shows externally, but the organ itself is elongated and branched into two
forks, the crura, which extend downward along the rim of the vaginal opening toward the
perineum. Thus the clitoris is much larger than most people think it is, about 4" long on average.
The clitoral glans or external tip of the clitoris is protected by the prepuce, or clitoral hood, a
covering of tissue similar to the foreskin of the male penis. However, unlike the penis, the
clitoris does not contain any part of the urethra.

"!&'"

The opening to the urethra is just below the clitoris. Although it is not related to sex or
reproduction, it is included in the vulva. The urethra is actually used for the passage of urine. The
urethra is connected to the bladder. In females the urethra is 1.5 inches long, compared to males
whose urethra is 8 inches long. Because the urethra is so close to the anus, women should always
wipe themselves from front to back to avoid infecting the vagina and urethra with bacteria. This
location issue is the reason for bladder infections being more common among females.

()!

The hymen is a thin fold of mucous membrane that separates the lumen of the vagina from the
urethral sinus. Sometimes it may partially cover the vaginal orifice. The hymen is usually
perforated during later fetal development. Because of the belief that first vaginal penetration
would usually tear this membrane and cause bleeding, its "intactness" has been considered a
guarantor of virginity. However, the hymen is a poor indicator of whether a woman has actually
engaged in sexual intercourse because a normal hymen does not completely block the vaginal
opening. The normal hymen is never actually "intact" since there is always an opening in it.
Furthermore, there is not always bleeding at first vaginal penetration. The blood that is
sometimes, but not always, observed after first penetration can be due to tearing of the hymen,
but it can also be from injury to nearby tissues.A tear to the hymen, medically referred to as a
"transection," can be seen in a small percentage of women or girls after first penetration. A
transection is caused by penetrating trauma. Masturbation and tampon insertion can, but
generally are not forceful enough to cause penetrating trauma to the hymen. Therefore, the
appearance of the hymen is not a reliable indicator of virginity or chastity.
!"#!)

The perineum is the short stretch of skin starting at the bottom of the vulva and extending to the
anus. It is a diamond shaped area between the symphysis pubis and the coccyx. This area forms
the floor of the pelvis and contains the external sex organs and the anal opening. It can be further
divided into the urogenital triangle in front and the anal triangle in back.

The perineum in some women may tear during the birth of an infant and this is apparently
natural. Some physicians however, may cut the perineum preemptively on the grounds that the
"tearing" may be more harmful than a precise cut by a scalpel. If a physician decides the cut is
necessary, they will perform it. The cut is called an episiotomy.

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*#

The vagina is a muscular, hollow tube that extends from the vaginal opening to the cervix of the
uterus. It is situated between the urinary bladder and the rectum. It is about three to five inches
long in a grown woman. The muscular wall allows the vagina to expand and contract. The
muscular walls are lined with mucous membranes, which keep it protected and moist. A thin
sheet of tissue with one or more holes in it, called the hymen, partially covers the opening of the
vagina. The vagina receives sperm during sexual intercourse from the penis. The sperm that
survive the acidic condition of the vagina continue on through to the fallopian tubes where
fertilization may occur. The vagina is a muscular tube that extends from above the inferior extent
of the cervix of the uterus (that project into the upper position of the vagina) to its external
opening in the vestibule. Its long axis is approximately parallel to the lower portion of sacrum.

Purposes of the Vagina

‡ Receives a males erect penis and semen during sexual intercourse.
‡ Pathway through a womans body for the baby to take during childbirth.
‡ Provides the route for the menstrual blood (menses) from the uterus, to leave the body.
‡ May hold forms of birth control, such as a diaphragm, FemCap, Nuva Ring, or female condom.


!"#+

The cervix (from Latin "neck") is the lower, narrow portion of the uterus where it joins with the
top end of the vagina. Where they join together forms an almost 90 degree curve. It is cylindrical
or conical in shape and protrudes through the upper anterior vaginal wall. Approximately half its
length is visible with appropriate medical equipment; the remainder lies above the vagina beyond
view. It is occasionally called "cervix uteri", or "neck of the uterus".

During menstruation, the cervix stretches open slightly to allow the endometrium to be shed.
This stretching is believed to be part of the cramping pain that many women experience.
Evidence for this is given by the fact that some women's cramps subside or disappear after their
first vaginal birth because the cervical opening has widened.

&!"

The uterus is shaped like an upside-down pear, with a thick lining and muscular walls. Located
near the floor of the pelvic cavity, it is hollow to allow a blastocyte, or fertilized egg, to implant
and grow. It also allows for the inner lining of the uterus to build up until a fertilized egg is
implanted, or it is sloughed off during menses.

The uterus is only about three inches long and two inches wide, but during pregnancy it changes
rapidly and dramatically. The top rim of the uterus is called the fundus and is a landmark for
many doctors to track the progress of a pregnancy. The uterine cavity refers to the fundus of the
uterus and the body of the uterus.

Some problems of the uterus include uterine fibroids, pelvic pain (including endometriosis,
adenomyosis), pelvic relaxation (or prolapse), heavy or abnormal menstrual bleeding, and
cancer. It is only after all alternative options have been considered that surgery is recommended
in these cases. This surgery is called hysterectomy. Hysterectomy is the removal of the uterus,
and may include the removal of one or both of the ovaries. Once performed it is irreversible.
After a hysterectomy, many women begin a form of alternate hormone therapy due to the lack of
ovaries and hormone production.

,#
$!

At the upper corners of the uterus are the fallopian tubes. There are two fallopian tubes, also
called the uterine tubes or the oviducts. Each fallopian tube attaches to a side of the uterus and
connects to an ovary. They are positioned between the ligaments that support the uterus. The
fallopian tubes are about four inches long and about as wide as a piece of spaghetti. Within each
tube is a tiny passageway no wider than a sewing needle. At the other end of each fallopian tube
is a fringed area that looks like a funnel. This fringed area, called the infundibulum, lies close to
the ovary, but is not attached. The ovaries alternately release an egg. When an ovary does
ovulate, or release an egg, it is swept into the lumen of the fallopian tube by the frimbriae.
Once the egg is in the fallopian tube, Cilia tiny hairs in the tube's lining assist the oocyte
transport to fertilization site and help push it down the narrow passageway toward the uterus.
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Vaginal hysterectomy is a procedure in which the uterus is surgically removed through
the vagina. One or both ovaries and fallopian tubes may be removed during the procedure as
well; removal of both ovaries and fallopian tubes is called bilateral salpingo-oophorectomy. A
vaginal approach may be used if the uterus is not greatly enlarged, and if the reason for the
surgery is not related to cancer.

'!"!
"!
&'"!!
&(,!
2
'( &!"!3&)(

a) Subtotal hysterectomy - the womb is removed but the cervix is left in place.
b) Total hysterectomy - the womb and the cervix are removed.
c) Radical hysterectomy - the womb, part of the vagina and the fallopian tubes are removed.

 !

$")
&!"#!
$!!4#* ² Excessive uterine bleeding, called menorrhagia, can lead to

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

Irregular uterine bleeding, called metrorrhagia, can also occur in women with menorrhagia.
Metrorrhagia is defined as bleeding or spotting that occurs at times other than during the
expected menstrual period.

Menorrhagia and metrorrhagia are generally treated first with medication or other surgical
alternatives to hysterectomy. owever, abnormal uterine bleeding that does not improve with
conservative treatments may require hysterectomy.

#$"#4 ² Fibroids (also known as leiomyoma) are noncancerous growths of uterine muscle.
Fibroids may become larger during pregnancy, and typically shrink after menopause. They may
cause excessive and irregular uterine bleeding.

!#3
"*
,", ! ² Pelvic organ prolapse occurs due to stretching and weakening of the
pelvic muscles and ligaments. This allows the uterus to fall (or prolapse) into the vagina. It is
usually related to pregnancy, vaginal childbirth, genetic factors, chronic constipation, or lifestyle
factors (repeated heavy lifting over the lifetime).

!"#3
$")#&#! ² Precancer or carcinoma of the cervix that does not resolve after other
procedures (such as cone biopsy, laser or cryosurgery) may require hysterectomy.)

4)!&"#
'(,!", # ² Endometrial hyperplasia is the term used to describe excessive

growth of the endometrium (the tissue that lines the uterus). It can sometimes lead to endometrial
cancer. Although endometrial hyperplasia can often be treated with medication, a hysterectomy
is sometimes needed or preferred to medical therapy.
'"#3
,!#3
,# ² Chronic pelvic pain can be due to the effects of endometriosis or
scarring (adhesions) in the pelvis and between pelvic organs. However, pelvic pain can also be
caused by other sources, including the gastrointestinal and urinary systems. t is important for a
woman with pelvic pain to ask about the probability that her pain will improve after
hysterectomy.

"!&)!&

"!,!"&#!
"!

1. Determine if the patient knows the reason for hysterectomy, what the procedure involves,
and what to expect post operatively.

2. Keep the patient NPO from midnight and night before surgery and have the patient void
before surgery.

3. Administer an enema before surgery to evacuate the bowel and prevent contamination
and trauma during surgery.

4. Perform vaginal irrigation before surgery to cleanse the area and ensure that a skin
preparation is done if ordered.

5. Administer preoperative medication to help the patient relax.

 &,!"&#!
3"!

1. Provide adequate pain control.

2. Encourage patient to splint incision when moving.

3. Encourage the patient to ambulate as soon as possible to decrease flatus and abdominal
distention.

4. Institute sitz baths or ice packs as prescribed to alleviate perineal discomfort.

5. Monitor intake and output, bladder distention, and for signs and symptoms of bladder
infection.

6. Make sure the patient voids after surgery. Catheterize the patient intermittently if
uncomfortable or has not voided for 8 hours. Maintain patency of indwelling catheter if
one is in place.
 7. Catheterize for residual urine after the patient voids if ordered; should be less that 3oz
(100ml). Continue to check if more than 3oz voided to prevent bladder infection.

8. Encourage the patient to empty the bladder round the clock, not only when feeling the
urge because of loss of sensation of bladder fullness.

9. Ensure adequate hydration to decrease risk of urinary infection.

10. Assess vaginal drainage for amount, color, and odor. Assess incision site and vital signs
for signs of infection.

11. Administer antibiotics as prescribed.

12. Assist with use of incentive spirometer, coughing and deep breathing, and ambulation to
decrease risk of pulmonary infection.

13. Discuss changes about sexual functioning such as shortened vagina and possible
dyspareunia due to dryness.

14. Offer suggestions to improve sexual functioning.

a. Use of water-soluble lubricant.

b. Change postion²female dominant offers more control of depth of

penetration.

Doctor¶s Order:

š General liquids for dinner, liquids on breakfast, then NPO

š TPR & shift &record
š Attach CP clearance c/o Dr. Tang
š Start IVF of D5LRŒL to mn @ 30gtts/min @ 6am tom
š Nutronidazale 500mg 2tabs @bedtime
š Cutixitin (numowel) 1gm I.V. q 8¶ ANST ( 1st dose 1hrs prior to OR)
š Feet enema in am prior to OR
š Prepare 1unit whole blood type ³A´ + on possible OR use
š For vaginal hysterectomy tom pm (on call)
š Inform OR
š Inform anesthesiologist (Dr. Vinluan)
š Shave perineum
š Refer accordingly

Addendum:

š Amlodipine 5mg tab tonight

July 17, 2010

š May trans out to regular room
š For vaginal hysterectomy @ 2pm
š Inform Dr. Tang
July17, 2010(6:15)

š To OR s/p vaginal hysterectomy

š V/s q 15mins until stable then 1°
š NPO till further orders
š I&O q 7¶ & record please
š FOB till 8pm
š Morphine precaution please
š IVF: 1.D5LRs 1L x 8°
2.D5LRs 1L x 8°

3.D5LRs 1L x 8°

Meds:

š Cutixitin (Numowel) 1gm I.V. q 8¶

š Morphine SO4 0.03% 6cc per q 12 x 1 more dose c/o ROD w/ BP precaution next dose
@ 6am
š Ketorolac (Remopain) 30mg I.V q 6¶ x 4 dose (-ANST)
š Repeat hgb, hct at 12am
š WOF, apnea ,cyanosis

July 17, 2010 (6:50)

Verbal Order:

š Cefoxitin to Cefrulin (cizco) 1gm IV q 8° (ANST)

š May trans out to regular room

July 18, 2010(10:35am)

š may give IVF & I.V.meds

July 18, 2010(11:20am, (+)flatus)

Text order:

š May have SBE, crackers, juice

š Count IVF & I.V.meds
š May nit up
š Vaginal packing removal
š May have soft diet once at am

July 18, 2010(9:15pm)

š Resume Ambuliance 5mg 1 tab now then 1 tab OD before supper

July 18, 2010(9:55pm)

š Refer now Amlodipine

July 19,2010(12;10pm, (+) BM)

Text order:

š May have soft diet now then than DAT this pm

š Consume IVF & I.V meds

July 19, 2010,((+)BM/ Afebrile)

š DAT

š Consume IVF * I.V.meds

š Remove IFC

š Ambulate

š Cefalexin 500mg, cap TID

July 20, 2010(2am)

š May go home

š Instruct home meds/ post-op care:

1). Cefalexin 500mg, cap TID x a week

2). FeSO4, cap OP x 1months

3). Avoid exertion/ constipation/ valsneva

4). Daily perineal washing

*follow up @my clinic after 1week (July 26, 2010)