Nurse Care Plan

Cancer of the cervix is one type of primary uterine cancer (the other being uterine-endometrial cancer) and is predominately epidermoid. Invasive cervical cancer is the third most common female pelvic cancer. It is estimated that 3710 women will die fromcervical cancer in 2005. The death rate from cervical cancer has steadily declined over the past 50 years owing to the increased use of the Papanicolaou exam, which detects cervical changes before cancer develops. Cervical cancer is of three types: dysplasia, carcinoma in situ (CIS), and invasive carcinoma. In dysplasia, the lower third of the epithelium contains abnormal cells with the earliest form of premalignant changes. These changes are considered preinvasive, and the atypical cells have some degree of surface maturation. CIS is carcinoma confined to the epithelium. The full thickness of the epithelium contains abnormally proliferating cells. Both dysplasia and CIS are considered preinvasive cancers and, with early detection, have a 5-year survival rate of 73% to 92%. Invasive carcinoma occurs when cancer cells penetrate the basement membrane. Metastasis occurs through local invasion and by way of the lymphatic ducts. As many as 10 years can elapse between the preinvasive and the invasive stages. A further 5 years can be added if one considers the precancerous changes that occur in atypical cells and dysplasia as the first step of malignancy.

Worldwide studies suggest that sexually transmitted human papillomaviruses (HPVs), type 16 or 18, are the primary cause of cervical cancer. Major risk factors associated with cancer of the cervix include early sexual activity, multiple sexual partners, or early first pregnancy; postnatal lacerations; grand multiparity; sexual partners with a history of penile or prostatic cancer or those uncircumcised; exposure to diethylstilbestrol (DES) in utero; smoking, use of oral contraceptives for more than 10 years, and a history of cervicitis or sexually transmitted diseases.
Nursing care plan physical examination and assessment
Because early cervical cancer is usually asymptomatic, establish a thorough history with particular attention to the presence of the risk factors and the woman’s menstrual history. Establish a history of later symptoms of cervical cancer, including abnormal bleeding or spotting (between periods or after menopause); metrorrhagia (bleeding between normal menstrual periods) or menorrhagia (increased amount and duration of menstrual bleeding); dysparuenia and postcoital bleeding; leukorrhea in increasing amounts and changing over time from watery to dark and foul; and a history of chronic cervical infections. Determine if the patient has experienced weight gain or loss; abdominal or pelvic pain, often unilateral, radiating to the buttocks and legs; or other symptoms associated with neoplasms, such as fatigue.

Conduct a pelvic examination. Observe the patient’s external genitalia for signs of inflammation, bleeding, discharge, or local skin or epithelial changes. Observe the internal genitalia. The normal cervix is pink and nontender, has no lesions, and has a closed os. Cervical tissue with cervical cancer appears as a large reddish growth or deep ulcerating crater before any symptoms are experienced; lesions are firm and friable. The Pap smear is done before the bimanual examination. Palpate for motion tenderness of the cervix (Chandelier’s sign); a positive Chandelier’s sign (pain on movement) usually indicates an infection. Also examine the size, consistency (hardness may reflect invasion by neoplasm), shape, mobility (cervix should be freely movable), tenderness, and presence of masses of the uterus and adnexa. Conduct a rectal exam; palpate for abnormalities of contour, motility, and the placement of adjacent structures. Nodular thickenings of the uterosacral and cardinal ligaments may be felt.

Uneasiness, embarrassment about a pelvic examination, or fear of the unknown may be issues for the patient. Determine the patient’s level of knowledge about a pelvic exam and what she expects. Determine her recommended Pap test screening schedule, as well as how she obtains the results and their meaning. If the patient requires follow-up to a positive Pap smear, assess her anxiety and coping mechanisms. Stressors may be fear of the unknown, of sexual dysfunction, of cancer, or of death, or she may have self-concept disturbances.

Nursing care plan primary nursing diagnosis: Pain (acute) related to postprocedure swelling and nerve damage.

Nursing care plan intervention and treatment
Teaching about and providing access to regular Pap screening tests for high-risk and other women are the most important preventive interventions. The importance of regular Pap smears cannot be understated because cervical CIS is 100% curable. Embarrassment, modesty, and cultural values may make seeking a gynecological examination most difficult for some women. Provide clear explanations and respect the patient’s modesty.

When a patient requires surgery, prepare her mentally and physically for the surgery and the postoperative period. Be certain to teach the patient about vaginal discharges that may follow a surgical procedure. Teach the patient that she will probably have to refrain from douching, using tampons, and coitus until healing occurs. Discuss any changes that may affect the patient’s sexual function or elimination mechanisms. Explain to the patient that she will feel fatigued and that she should gradually increase activity, but should not do heavy lifting or strenuous or rough activity or sit for long periods. Encourage the patient to explore her feelings and concerns about the experience and its implications for her life and lifestyle. Provide the patient who has undergone a hysterectomy with information about what to expect.

If internal radiation is the treatment, the primary focus of the nursing interventions is to prepare the patient for the treatment, to promote her comfort, and to lessen her sense of isolation during the treatment. Explain to the patient and significant others the reason for the time-restricted visits while the insert is in place. Nursing care is of shorter duration and of essential nature only during this time; therefore, ensure that before the insertion of the implant, the patient has a bath and clean bed linen. Decrease the patient’s feelings of isolation by providing diversionary activities and frequent interaction from a safe distance. If the patient has external radiation, teach her about how the treatment is given, how the skin is prepared, and how blood tests to monitor white blood cell count are done. Explain that her immunity to common colds and other illnesses is lessened, and teach the patient the proper use of antiemetics and antidiarrhetics.

Treatment depends on the stage of the cancer, the woman’s age, and concern for future childbearing. Preinvasive lesions (CIS) can be treated by conization, cryosurgery, laser surgery, or simple hysterectomy (if the patient’s reproductive capacity is not an issue). All conservative treatments require frequent follow-up by Pap tests and colposcopy because a greater level of risk is always present for the woman who has had CIS. A cone-shaped piece of tissue is removed from the cervix after epithelial involvement is clearly outlined as described with the cone biopsy. The cone includes all the abnormal and some normal tissue. Following this procedure, the woman can still have children. The major complication is postoperative bleeding.

Nursing care plan discharge and home health care guidelines
Make sure the patient knows all the postprocedure complications. Provide a phone number to call if any complications occur. Ensure that the patient understands the need for ongoing Pap smears if appropriate. Vaginal cytological studies are recommended at 4-month intervals for 2 years, every 6 months for 3 years, and then annually.