This is chapter 73

1. This is chapter 73 Care of Patients with Breast Disorders

2. Benign Breast Disorders Fibroadenoma, most common cause of breast masses during adolescence; may occur in patients in their 30s Solid, slowly enlarging, benign mass; round, firm, easily movable, nontender, and clearly delineated from the surrounding tissue Usually located in the upper outer quadrant of the breast

3. Fibrocystic Breast Condition Fibrocystic changes of the breast that include a range of changes involving the lobules, ducts, and stromal tissues of the breast Most often occurs in premenopausal women between 20 and 50 years of age Thought to be caused by an imbalance in normal estrogen-to-progesterone ratio

4. Collaborative Management Symptomatic management Hormonal manipulation Drug therapy�vitamins C, E, and B complex Diuretics Avoidance of caffeine Reduction of dietary fat Mild analgesics

5. Collaborative Management (Cont�d) Limited salt intake before menses Well-padded supportive bra Local application of heat or ice for pain relief

6. Ductal Ectasia Benign breast problem of women approaching menopause; caused by dilation and thickening of the collecting ducts in the subareolar area Mass that is hard with irregular borders, tender Greenish brown nipple discharge, enlarged axillary nodes, and edema over the site of the mass

7. Intraductal Papilloma Occurs most often in women 40 to 55 years of age Benign process in the epithelial lining of the duct, forming an outgrowth of tissue

8. Intraductal Papilloma (Cont�d) Trauma and erosion within the duct, resulting in bloody or serous nipple discharge Diagnosis aimed first at ruling out breast cancer

9. Gynecomastia Benign condition of breast enlargement in men Can be a result of primary cancer such as lung cancer Causes include: Drugs Aging Obesity

10. Gynecomastia (Cont�d) Underlying disease causing estrogen excess Androgen deficiency Breast cancer

11. Breast Cancer Types of breast cancer Complications include: Invasion of lymph channels causing skin edema Metastasis to lymph nodes Bone, lungs, brain, and liver�sites of metastatic disease from breast cancer Ulceration of overlying skin

12. Nipple Retraction

13. Peau d�orange

14. Breast Cancer in Men Of all breast cancers, only 1% occur in men. Breast cancer in men usually presents as a hard, painless, subareolar mass. Breast cancer in men is often a widely spread disease because it is usually detected at a later stage than in women.

15. Mammography Baseline screening mammography yearly beginning at age 40 years is recommended. Barriers to mammography.

16. Breast Self-Examination The goal of screening for breast cancer is early detection because breast self-examination cannot prevent breast cancer. Early detection reduces mortality rate. Teach breast self-examination.

17. BSE

18. Breast Care Clinical breast examination Cancer surveillance Prophylactic mastectomy Chemoprevention

19. Anxiety Interventions: Anxiety for the woman with breast cancer begins the moment the lump is discovered. Level of anxiety may be related to past experiences and personal associations with the disease. Allow the patient to ventilate feelings. Flexibility is the key to nursing care.

20. Potential for Metastasis For patients with late-stage breast cancer, nonsurgical treatment may be the only alternative; tumor may be removed with local anesthetic, follow-up treatment with hormonal therapy, chemotherapy, and sometimes radiation.

21. Potential for Metastasis (Cont�d) For breast cancer at a stage for which surgery is the main treatment, follow-up with adjuvant radiation, chemotherapy, hormone therapy, or targeted therapy is commonly prescribed.

22. Surgical Management

23. Surgical Management (Cont�d) Removal of the mass Neoadjuvant therapy Axillary node dissection Sentinel lymph node biopsy Breast-conserving surgery Modified radical mastectomy

24. Postoperative Care Avoidance of using the affected arm for blood pressure measurement, giving injections, or drawing blood Monitoring of vital signs Care of drainage tubes Comfort measures Mobility and diet Breast reconstruction

25. Adjuvant Therapy To decrease the risk of recurrence, adjuvant therapy consists of: Radiation therapy Chemotherapy Hormonal therapy Stem cell transplantation Targeted therapy

26. This is chapter 74 Care of Patients with Gynecologic Problems

27. Primary Dysmenorrhea One of the most common gynecologic problems, occurring most often in women in their teens and early 20s. Treatment: NSAIDs, acetaminophen, anti-prostaglandins, oral contraceptives Complementary and alternative therapies

28. Premenstrual Syndrome A collection of symptoms that are cyclic in nature Nutrition therapy Drug therapy�hormonal therapy. Oral contraceptives, gonadotropin-releasing hormone, serotonin-reuptake inhibitors Complementary and alternative therapies

29. Endometriosis Endometriosis is endometrial tissue implantation outside the uterine cavity.

30. Interventions Drug therapy Complementary and alternative therapy Surgical management

31. Dysfunctional Uterine Bleeding Bleeding that is excessive or abnormal in amount or frequency

32. Dysfunctional Uterine Bleeding (Cont�d) Associated with: Endocrine disturbances Polycystic ovary disease Stress Obesity or underweight Long-term drug use Anatomic abnormalities

33. Collaborative Management Nonsurgical management includes hormone manipulation. Surgical management includes: Dilation and curettage procedure Laser or balloon endometrial ablation Myomectomy Hysterectomy

34. Menopause Normal biologic event marked for most women by the end of menstrual periods (12 months of amenorrhea) Role of hormone replacement therapy in the management of symptoms Perimenopause indicated by changes in ovarian function Management

35. Vulvovaginitis Vaginal discharge and itching Inflammation of the lower genital tract resulting from a disturbance of the balance of hormones and flora in the vagina and vulva Characterized by itching, change in vaginal discharge, odor, or lesions

36. Toxic Shock Syndrome (TSS) First recognized in 1980 when it was found to be related to menstruation and tampon use Staphylococcus aureus Abrupt onset of high temperature, headache, sore throat, vomiting, diarrhea, generalized rash, hypotension Management

37. Uterine Prolapse Stages of uterine prolapse are described by the degree of descent of the uterus Dyspareunia, backache, pressure in the pelvis, bowel or bladder problems Pessaries Surgery

38. Uterine Prolapse (Cont�d)

39. Cystocele and Rectocele

40. Fistulas Abnormal opening between two adjacent organs or structures Urethrovaginal fistula Vesicovaginal fistula Rectovaginal fistula Management

41. Benign Neoplasms Ovarian cyst Uterine leiomyoma: Nonsurgical management Surgical management

42. Uterine Leiomyomas

43. Cervical Polyps Pedunculated tumors (on stalks) arising from the mucosa and extending to the opening of the cervical os Polyp removal�a simple office procedure

44. Endometrial (Uterine) Cancer Endometrial cancer is a reproductive cancer, of which adenocarcinoma is the most common type. The main symptom is postmenopausal bleeding. Diagnostic assessment includes these tests: CA-125 tumor marker Chest x-ray

45. Endometrial (Uterine) Cancer (Cont�d) Possible testing for gene causing HNPCC IV pyelography Barium enema CT of the pelvis Liver and bone scans Hysteroscopic examination of the uterus Proctosigmoidoscopy

46. Surgical Management Total hysterectomy and bilateral salpingectomy/oophorectomy

47. Surgical Management (Cont�d) Total abdominal hysterectomy and bilateral salpingo-oophorectomy Radical hysterectomy with bilateral pelvic lymph node dissection for stage II cancer

48. Nonsurgical Management Radiation therapy: Intracavitary radiation (brachytherapy) External radiation Drug therapy Chemotherapy Hormone therapy Complementary and alternative therapies

49. Cervical Cancer Disorder is a progression�from totally normal cervical cells, to premalignant changes in appearance of cervical cells (dysplasia), to changes in function, and ultimately to transformation to cancer Carcinoma in situ Preinvasive or invasive

50. Health Promotion and Maintenance HPV vaccine (Gardasil)

51. Clinical Manifestations Patient often asymptomatic Classic symptom�painless vaginal bleeding Watery, blood-tinged vaginal discharge that may become dark and foul-smelling as the disease progresses

52. Clinical Manifestations (Cont�d) Leg pain Flank pain Unexplained weight loss, pelvic pain, dysuria, hematuria, rectal bleeding, chest pain, and cough

53. Diagnostic Assessment Pap smear Squamous atypia, inflammatory atypia, or minor atypia abnormalities Bethesda system Colposcopic examination Endocervical curettage

54. Early Surgical Procedures Loop electrosurgical excision procedure Laser therapy Cryotherapy

55. Surgical Procedures Hysterectomy Pelvic exenteration

56. Ovarian Cancer Most common type�serous adenocarcinoma Vague abdominal discomfort, dyspepsia, indigestion, gas, and distention Ovarian antibody CA-125, ultrasound, IV pyelography, barium enema, upper GI radiographic series to rule out tumors

57. Nonsurgical Management Chemotherapy with agents such as cisplatin, carboplatin, and paclitaxel Radiation therapy

58. Surgical Management Total abdominal hysterectomy and bilateral salpingo-oophorectomy Staging

59. Vulvar Cancer Most are squamous cell carcinomas. Women often report irritation or itching in their perineal area or a sore that will not heal. Toluidine blue test identifies abnormal cells. Keyes dermal punch is used for tissue biopsy.

60. Management Laser therapy Radiation therapy Surgical management�vulvectomy or skinning vulvectomy or radical vulvectomy

61. Vulvectomy

62. Postoperative Care Providing wound care Promoting urinary and bowel elimination Managing pain Addressing sexuality

63. Vaginal Cancer Rare Treatment with any of these: Laser therapy Wide excision Partial or total vaginectomy Topical chemotherapy Radiation therapy

64. Fallopian Tube Cancer Rarest of all gynecologic cancers Most common symptoms�postmenopausal bleeding, increased abdominal pain, watery vaginal discharge, leukorrhea Treatment�total abdominal hysterectomy and bilateral salpingo-oophorectomy with omentectomy

65. This is chapter 75 Care of Male Patients with Reproductive Problems

66. Benign Prostatic Hyperplasia Glandular units in the prostate that undergo an increase in the number of cells, resulting in enlargement of the prostate gland Hyperirritable bladder, urgency and frequency, hypertrophied bladder wall muscles, cellules and diverticula, hydroureter, hydronephrosis, and overflow urinary incontinence

67. BPH

68. Potential Complications of BPH

69. Assessment Urinary pattern, frequency, nocturia, and other symptoms of bladder neck obstruction Lower urinary tract symptoms Hesitancy, intermittency, reduced force and size of urinary stream, a sensation of incomplete bladder emptying, and post-void dribbling Hematuria

70. Laboratory Assessment Complete blood count Blood urea nitrogen and creatinine levels Prostate-specific antigen Other diagnostic studies

71. Drug Therapy 5-alpha reductase inhibitor (5-ARI) Alpha-blocking agents Alpha blockers Estrogens and androgens Antimuscarinic agent

72. Other Nonsurgical Measures Thermotherapy

73. Surgical Procedures Transurethral resection of the prostate (TURP) Suprapubic prostatectomy Retropubic prostatectomy Perineal prostatectomy

74. Prostatectomy Procedures

75. Continuous Bladder Irrigation Three-way urinary catheter with a 30- to 45-mL retention balloon through the urethra into the bladder Traction via taping to patient�s abdomen or thigh Uncomfortable urge to void continuously Antispasmodic medications

76. CBI

77. Postcatheterization Care Patient feels burning on urination as well as some urinary frequency, dribbling, and leakage. Symptoms are normal and will subside. Monitor fluid intake.

78. Prostate Cancer Most common invasive cancer among men in the United States One of the slowest growing malignancies; metastasizes in a predictable pattern First symptoms related to bladder neck obstruction

79. Prostate Cancer (Cont�d) Digital rectal examination Prostate-specific antigen Biopsy necessary to confirm suspected prostatic cancer

80. Prostate Cancer (Cont�d)

81. Surgical Management Minimally invasive surgery Open surgical technique Prostatectomy TURP Bilateral orchiectomy Preoperative care

82. Postoperative Care of Radical Prostatectomy Hydration with IV therapy Caring for wound drains Preventing emboli Preventing pulmonary complications Antibiotics Analgesics

83. Postoperative Care of Radical Prostatectomy (Cont�d) Laxative and stool softener Indwelling urinary catheter Antispasmodic

84. Complications Urinary incontinence Erectile dysfunction

85. Nonsurgical Management Radiation therapy Hormonal therapy Chemotherapy Cryotherapy Complementary and alternative therapies Targeted therapy

86. Erectile Dysfunction Inability to achieve or maintain an erection for sexual intercourse Organic erectile dysfunction Functional erectile dysfunction Assessment: Medical, social, sexual history Complete physical examination Duplex Doppler ultrasonography test

87. Interventions Drug therapy includes sildenafil (Viagra), vardenafil (Levitra), and tadalafil (Cialis). Avoid alcohol before sexual intercourse. Common side effects include headaches, facial flushing, and stuffy nose. Men who take nitrates should not take these drugs; profound hypotension and reduced blood flow to vital organs can result.

88. Vacuum Devices Cylinder fits over the penis and sits firmly against the body. Vacuum is created to draw blood into the penis to maintain an erection. Rubber ring (tension band) is placed around the base of the penis to maintain the erection; cylinder is removed.

89. Injecting the Penis Vasodilating drugs can make the penis erect by engorging it with blood Caverject Paverine Regitine Combination of any or all of these drugs

90. Intraurethral Applications Alprostadil is a self-administered suppository that is placed in the urethra with an applicator. Erection occurs in about 10 minutes and lasts 30 to 60 minutes. Burning of the urethra can occur after application, as well as syncope.

91. Prosthesis Penile implants are used when other modalities fail. Implants are semirigid, malleable, or hydraulic inflatable and multicomponent or one-piece instruments. Reservoir is placed in the scrotum. Major disadvantages are device failure and infection.

92. Testicular Cancer Although uncommon, this cancer is the most common malignancy in men 15 to 34 years of age. With early detection by testicular self-examination and treatment with combination chemotherapy, testicular cancer can be cured. Germ cell tumors arise from sperm-producing cells. Non�germ cell tumors

93. Laboratory Assessment Alpha-fetoprotein (AFP) Beta human chorionic gonadotropin (hCG) Lactate dehydrogenase (LDH) Ultrasound Computed tomography Magnetic resonance imaging

94. Interventions Surgery is the main treatment for testicular cancer Preoperative care Operative procedure Postoperative care

95. Nonsurgical Management Chemotherapy Radiation therapy

96. Risk for Sexual Dysfunction Interventions include: Oligospermia, azoospermia Health teaching about reproduction, fertility, and sexuality Sperm storage Other reproductive options

97. Potential for Metastasis Interventions include: Surgical management Preoperative care Operative procedures�radical retroperitoneal lymph node dissection, orchiectomy

98. Potential for Metastasis (Cont�d) Postoperative care; expected problems include: Pain from surgical incisions Immobility Injuries related to invasive catheters or tubes

99. Hydrocele Cystic mass is usually filled with straw-colored fluid that forms around the testis resulting from impaired lymphatic drainage of the scrotum, causing a swelling of the tissue surrounding the testes. Hydrocele may be drained via needle and syringe, or it may be removed surgically.

100. Spermatocele A sperm-containing cyst develops on the epididymis alongside the testicle. Normally, spermatoceles are small and asymptomatic and require no interventions. If they become large enough to cause discomfort, a spermatocelectomy is performed.

101. Varicocele A cluster of dilated veins occur behind and above the testis. Varicoceles can also cause infertility. Varicocelectomy is performed through an inguinal incision in which the spermatic veins are ligated in the cord.

102. Common Problems

103. Cancer of the Penis Epidermoid (squamous) carcinomas developing from squamous cells Circumcision in infancy�almost always eliminates the possibility of penile cancer Painless, wartlike growth or ulcer Excisional biopsy Radiation therapy Penectomy

104. Phimosis and Paraphimosis Constricted prepuce that cannot be retracted over the glans; prepuce remains down around the tip of the penis Emergency requiring immediate treatment Circumcision Warm bath to allow dressing to loosen Barbiturate sleeping medications

105. Priapism Uncontrolled and long-maintained erection without sexual desire; causes the penis to become large and painful Can occur from: Thrombosis of veins of corpora cavernosa Leukemia Sickle cell disease

106. Priapism (Cont�d) Diabetes mellitus Malignancies Abnormal reflex Some drug effects Recreational drugs Prolonged sexual activity

107. Collaborative Management Urologic emergency Goal of intervention�to improve the venous drainage of the corpora cavernosa Meperidine Warm enemas Urethral or suprapubic catheterization Large-bore needle or surgical intervention

108. Prostatitis Inflammation of the prostate gland Acute bacterial prostatitis Chronic bacterial prostatitis Nonbacterial/chronic pelvic pain syndrome Asymptomatic inflammatory prostatitis

109. Epididymitis Inflammation of the epididymis resulting from an infection or noninfectious source such as trauma Treatment�bedrest with scrotum elevated on a towel, scrotal support when ambulating Comfort measures Epididymectomy S&PS&P

110. Orchitis Acute testicular inflammation resulting from trauma or infection Treatment�bedrest with scrotal elevation, application of ice, and administration of analgesics and antibiotics Mumps orchitis S&PS&P