ASSIGNMENT I

TOPIC- REPRODUCTIVE TRACT MALIGNANCY

INCLUDING PID, CA BREAST AND FIBROID UTERUS.

Ms. Saima Habeeb

Ph.D (N) Scholar

REPRODUCTIVE TRACT MALIGNANCIES:

Female genital tract malignancy is the most common carcinoma. Around 70,000 new cases of
uterine cancers and 75,000 new cases of breast cancers are reported in India every year. In the
developed countries ovarian cancer is the most common cancer and in developing countries,
carcinoma cervix is the most common malignancy. As per the national centre for health statistics,
cancer is the second leading cause of death amongst women aged between 25-44 years. One of
the common sites of tumours in females is the female genital tract. The few common sites are
cervix, ovary and endometrium. These malignancies are seen worldwide but their distribution
varies from one place to another. Around 75% of the ovarian cancer patients report with
advanced stage of disease leading to increased mortality. In the present era, due to the presence
of advanced screening and treatment modalities in developed countries, there has been a drastic
decline in the incidence and mortality associated with cervical cancer. On the contrary, in
developing countries due to low resources and lack of awareness there hasn't been much
improvement in the screening programmes. People of rural areas do not have much access to the
health care services due to which cervical cancer is the most common genital carcinoma in
developing countries.

MEANING: Reproductive tract malignancies means malignancy start in the organs related to
reproduction. These organs are located in the pelvis. Female genital tract is most common site
for tumours in females. The most common type of female genital tract cancers are – cervical,
ovarian and endometrial carcinoma. There are other less common tumours including tumours of
vagina, vulva and fallopian tubes. (Blaustein’s Pathology of the Female Genital Tract, 2002).

DEFINITION: Cancers can occur in any part of the female reproductive system—the vulva,
vagina, cervix, uterus, fallopian tubes, or ovaries. These cancers are called gynecologic cancers
or reproductive tract malignancies. Gynecologic cancers can directly invade nearby tissues and
 organs or spread (metastasize) through the lymphatic vessels and lymph nodes (lymphatic
system) or bloodstream to distant parts of the body.

Cancers of the female reproductive system - namely cancer of the cervix uteri (cervical cancer),
ovarian, vulvar, vaginal, fallopian tube cancers, and choriocarcinoma - are an important cause of
cancer morbidity and mortality worldwide. Cervical, endometrial, and ovarian cancers are
relatively common, whereas vulvar, vaginal, fallopian tube cancers, and choriocarcinomas are
very rare.

The most common reproductive malignancies in women are:

o Uterine Corpus Malignancy —begins in the uterus (womb), the organ where the baby grows
when a woman is pregnant.

o Ovarian Malignancy —begins in the ovaries, the two organs that make and house a woman's
eggs.

o Uterine Cervix Malignancy (Cervical Carcinoma) —begins in the cervix, the lower end of the
uterus that attaches to the vagina.

o Vulvar Malignancy —begins in the vulva, the area around the opening of the vagina.

o Vaginal Malignancy –begins in the vagina, the hollow channel that leads from the uterus to the
outside of the body.

 Breast cancer is sometimes considered a reproductive cancer too. Breast cancer begins in the
tissues that make up the breast.
 INCIDENCE:
Female genital tract malignancies have worldwide distribution, but vary from one region to
another. Dinshaw Nene et al. (1997) did population based rural cancer registry in Barshi,
Paranda and Bhum areas in Maharastra under the National Cancer Registry Programme of
ICMR. According to this registry the leading site of cancer in females was cancer cervix (50.7%)
the most common site followed by cancer breast (15.1%), esophagus (4.2%), ovary (2.2%) oral
cavity and stomach (1.4%).

 The Uterine corpus malignancy represents the second most common site for malignancy of the
female genital systems. Endometrial carcinoma occurs predominately in developed countries and
is frequently associated with obesity.

 Cervical carcinoma is the second most common cancer in women worldwide and the most
common female genital cancer in the developing countries. More than 85% of the global burden
of cervical cancer occurs in less developed regions, where it accounts for 13% of all cancers in
women.
 Tumours of the ovary represent about 30% of all cancers of female genital tract. Ovarian cancer
is a major cause of death from female genital tract malignancies. About 75% of the patients with
ovarian cancer present with advanced stages of the disease due to nonspecific symptoms of the
disease and failure to detect the tumor early.

 Cancer of the vagina is relatively rare, accounting for about 1%- 2% of gynaecological
malignancies.

 The vulva is formed by the labia majora , labia minora, clitoris , mons pubis and the associated
structures of the vestibule including the urethral meatus. Benign tumours of vulva including
condyloma acumintum and others. Squamous cell carcinoma is the most common malignant
tumours of the vulva occurs predominantly in older age group.

ETIOLOGY AND LIFE-STYLE RELATED FACTORS

So far, the etiology of cancers of the female reproductive system has been primarily
attributed to lifestyle factors.

Endometrial cancer/ Uterine sarcomas

 Endometrial cancer affects postmenopausal women almost exclusively.

 Endometrial cancer risk has been previously associated with several host factors,
including high body mass index, nulliparity or low parity, early age at first birth, history
of type 2 diabetes mellitus (non-insulin dependent), and family history of cancer,
particularly endometrial cancer.
 Uterine sarcomas are of largely unknown etiology.
 Possible etiological factors include a history of pelvic radiation, obesity, long use of
estrogen hormone replacement therapy or tamoxifen, and use of oral contraceptives. The
incidence of uterine sarcoma also varies between races; the age-adjusted incidence for
 Blacks has been reported at twice that of Whites and more than twice that of women of
other races.

Ovarian cancer

 The etiology of ovarian cancer is not well understood.

 According to the IARC, there is sufficient evidence that epithelial ovarian cancer is
caused by estrogen hormone replacement therapy and tobacco smoking, and limited
evidence regarding perineal use of talc-based body powder and exposure to X-radiation
and gamma (γ)-radiation (for medical purposes).
 Besides these risk factors, having a family history of the disease increases risk, as does
being a carrier of mutations in BRCA1/BRCA2 genes , or being affected by hereditary
non-polyposis colorectal cancer syndrome.
 Several studies indicate that height and body weight are associated with risk, in particular
among non-users of hormone replacement therapy.

Cervical carcinoma:

 Cervical cancer is caused by persistent infection with human papilloma virus (HPV)
types 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, or 59;
 persistent infections with HPV16 and 18 cause about 70% of all cervical cancers
worldwide.
 Persistent infection with HPV types 26, 53, 66, 67, 68, 70, 73, or 82 may also be causally
related to cervical cancer.
 Other exposures that are considered carcinogenic to the cervix uteri are in utero exposure
to diethylstilbestrol (associated with SCC of the cervix), use of combined estrogen-
progestogen oral contraceptives (associated with both in situ and invasive cervical
cancer), human immunodeficiency virus type 1 (HIV1) infection, and tobacco smoking.

Vulvular carcinoma:
 The etiology remains unclear. But the following factors are often related.

 Usually occurring in postmenopausal women.

 Increased association with obesity, hypertension, diabetes and nulliparity.
 Human papilloma virus has been detected in patients with invasive vulvular cancer.

Vaginal carcinoma:

Unfortunately, researchers do not yet know the exact causes of vaginal cancer. They have,
however, identified several risk factors for developing vaginal cancer. These risk factors include:

 Age - those aged over 60 are at most risk.

 HPV infection - contracting the human papilloma virus increases risk.
 Hysterectomy - women who have had a hysterectomy are statistically more likely to get
vaginal cancer.
 Use of a vaginal pessary - use of these, such as during pelvic organ prolapse, is
associated with an increase in risk.

Staging Cancers of the Female Reproductive System*

Type Stage I Stage II Stage III Stage IV†

Endometrial Only in the upper Spread to the cervix Spread to nearby tissues, Spread to the bladder
(uterine) part of the uterus the vagina, or lymph or intestine (A) or
cancer (not in the cervix) nodes but still within the distant organs (B)
pelvis‡
Ovarian Only in one or both Spread to the Spread outside the pelvis Spread outside the
cancer ovaries uterus, fallopian to the lymph nodes, the abdomen or to the
tubes, or nearby surface of the liver, the inside of the liver
tissues within the small intestine, or the
pelvis lining of the abdomen
Cervical Only in the cervix Spread outside the Spread throughout the Spread to the bladder
cancer cervix (including pelvis (including the or rectum (A) or
the upper part of lower part of the vagina), distant organs (B)
the vagina) but still sometimes blocking the
Type Stage I Stage II Stage III Stage IV†
within the pelvis ureters and/or causing a
kidney to malfunction
Vulvar cancer Only in the vulva Spread to nearby Spread to nearby lymph Spread beyond
and/or the area tissues, such as the nodes, with or without nearby tissues to the
between the lower part of the spread to nearby tissues bladder, the upper
opening of the urethra or vagina part of the vagina or
rectum and vagina but not to nearby urethra, the rectum,
(perineum) lymph nodes or more distant
lymph nodes
Vaginal Only in the vagina Spread to nearby Spread throughout the Spread to the bladder
cancer tissues but still pelvis or rectum or outside
within the pelvis of the pelvis
Fallopian Only in one or both Spread to nearby Spread to abdominal Spread to distant
tube cancer fallopian tubes tissues but still organs (such as the organs
within the pelvis intestine and liver) or
nearby lymph nodes

*Simplified from the International Federation of Gynecology and Obstetrics Staging System.

†Stage IV is sometimes further classified as A or B depending on where the cancer has spread.

‡The pelvis refers the lowest part of the torso, the area below the abdomen and between the hip bones.
It contains the internal reproductive organs, bladder, and rectum.
Early signs of reproductive tract malignancies: Each type of reproductive cancer has
different symptoms.

o Uterine-vaginal bleeding or discharge that is not normal, pressure or pain in the pelvic area.

o Cervical-vaginal bleeding or discharge that is not normal.

o Ovarian-vaginal bleeding or discharge that is not normal, pressure or pain in the pelvic area,
belly or back, bloating.

o Vaginal-vaginal bleeding or discharge that is not normal.

o Vulvar-pressure or pain in the pelvic area, itching, burning, rash, or sores around the opening of
the vagina.
 SCREENING & DIAGNOSIS:

Among all three of these reproductive-system cancers, early detection is crucial. But detection
can be very difficult, especially in the early stages.

o Regular pelvic examinations and (Pap) tests or other similar tests can lead to the early detection
of certain gynecologic cancers, especially cancer of the cervix. Such examinations can
sometimes prevent cancer by detecting precancerous changes (dysplasia) before they become
cancer.

o Regular pelvic examinations can also detect early cancers of the vagina and vulva. However,
cancers of the ovaries, uterus, and fallopian tubes are not easy for doctors to detect during a
pelvic examination.

o If cancer is suspected, a biopsy can confirm or rule out the diagnosis.

o If cancer is diagnosed, one or more procedures may be done to determine the stage of the cancer.
The stage is based on how large the cancer is and how far it has spread.

o Some commonly used procedures include ultrasonography, computed tomography (CT),

magnetic resonance imaging (MRI), chest x-rays, and positive emission tomography (PET)

TREATMENT

The treatment depends on the type of cancer.

o Reproductive cancers are often treated with surgery, chemotherapy (medicine to kill cancer
cells), hormone therapy (medicine to block hormones that are related to cancer growth), or
radiation.

o One or more of these treatments may be used together.

o The main treatment of endometrial or ovarian cancer is surgical removal of the tumor. Surgery
may be followed by radiation therapy or chemotherapy.
o In women with cervical cancer, radiation therapy may be external (using a large machine) or
internal (using radioactive implants placed directly on the cancer). External radiation therapy is
usually given several days a week for several weeks. Internal radiation therapy involves staying
in the hospital for several days while the implants are in place.

o Chemotherapy may be given by injection, by mouth, or through a catheter inserted into the
abdomen (intraperitoneally). How often chemotherapy is given depends on the type of cancer.
Sometimes women have to remain at the hospital while they receive chemotherapy.

o When a gynecologic cancer is very advanced and a cure is not possible, radiation therapy or
chemotherapy may still be recommended to reduce the size of the cancer or its metastases and to
relieve pain and other symptoms.

o Appropriate drugs can be used to relieve the anxiety and pain commonly experienced by people
with incurable cancer.

EVIDENCE BASED MANAGEMENT:

o (Cervical) Combination Therapy: There was a major advance in the treatment of cervical
cancer when five NCI-sponsored clinical trials showed that patients with advanced cervical
cancer who were treated with combination chemo based on the drug cisplatin, together with
radiation therapy, survived significantly longer than patients who were treated with radiation
therapy alone. The overall results from these trials showed that the risk of death from cervical
cancer was decreased by about 30 percent — down to a 50 percent risk of death — with the use
of this concurrent "chemoradiation" therapy. In light of these findings, NCI issued a clinical
announcement to thousands of physicians stating that strong consideration should be given to
adding chemotherapy to radiation therapy in the treatment of invasive cervical cancer.

o (Cervical) HPV vaccine: Another major advance in the management of cervical cancer was the
FDA's approval of a vaccine designed specifically to prevent this disease. The results of several
studies have shown that in women who had not already been infected, the approved HPV vaccine
was nearly 100 percent effective in preventing precancerous cervical lesions, precancerous
vaginal and vulvar lesions, and genital warts caused by infection with the types of human
papilloma virus (HPV) targeted by the vaccine.

o (Ovarian) Combined Treatment: In 2006, NCI announced an advance in the treatment of

advanced ovarian cancer. Based on the results of eight clinical trials, NCI encouraged doctors to
use a combination of two chemo delivery methods — intravenous (by vein) and intraperitoneal
(into the abdomen) — after surgery to remove as much of the ovarian cancer as possible. The
combined drug-delivery approach, though it had more side effects, extended overall survival for
women with advanced ovarian cancer by about a year compared to intravenous drug delivery
alone.

PREVENTION

KEY POINTS

 Avoiding risk factors and increasing protective factors may help prevent cancer.

o Avoiding cancer risk factors may help prevent certain cancers. Risk factors include
smoking, being overweight, and not getting enough exercise. Increasing protective
factors such as quitting smoking and exercising may also help prevent some cancers.
o Education regarding the significance of irregular bleeding per vagina in
perimenopausal and postmenopausal period.
o Screening of high risk women at least in menopausal period to detect the premalignant
or early carcinoma is a positive step.
The following protective factors decrease the risk of cancer:

-Avoiding sexual activity

-Getting an HPV vaccine

-Using barrier protection during sexual activity

PELVIC INFLAMMATORY DISEASE:

DEFINITION: Pelvic inflammatory disease, or PID, is a disease of the upper genital tract. It is a
spectrum of infection and inflammation of the upper genital tract organs typically involving the
uterus, ovaries, fallopian tubes, and cervix. It’s usually caused by a sexually transmitted infection
(STI), like chlamydia or gonorrhea, and is treated with antibiotics.
CAUSES

Many types of bacteria can cause PID, but gonorrhea or chlamydia infections are the most
common. These bacteria are usually acquired during unprotected sex. The bacteria first enter the
vagina and cause an infection. As time passes, this infection can move into the pelvic organs.PID
can become extremely dangerous, even life-threatening, if the infection spreads to your blood.

RISK FACTORS

A number of factors might increase the risk of pelvic inflammatory disease, including:

 Being a sexually active woman younger than 25 years old

  Having multiple sexual partners

 Being in a sexual relationship with a person who has more than one sex partner

 Absence of contraceptive pill use.

 Douching regularly, which upsets the balance of good versus harmful bacteria in the
vagina and might mask symptoms

 Having a history of pelvic inflammatory disease or a sexually transmitted infection

CLINICAL FEATURES OF PELVIC INFLAMMATORY DISEASE

Signs and symptoms of pelvic inflammatory disease might include:

 Bilateral lower abdominal and pelvic pain which is dull in nature.

 Heavy vaginal discharge with an unpleasant odor

 Abnormal uterine bleeding, especially during or after intercourse, or between menstrual

cycles

 Pain or bleeding during intercourse

 Fever, sometimes with chills

 Painful or difficult urination

PID might cause only mild signs and symptoms or none at all. When severe, PID might cause
fever, chills, severe lower abdominal or pelvic pain — especially during a pelvic exam — and
bowel discomfort.

CLINICAL DIAGNOSTIC CRITERIA OF PID

Minimum criteria:
  Lower abdominal tenderness
 Cervical motion tenderness

Additional criteria:

 Oral temperature > 38.3 celcius

 Laboratory documentation of positive cervical infection with Gonorrhoea.

Definitive criteria

 Histological evidence of endometritis on biopsy.

 Laproscopic evidence of PID

INVESTIGATIONS:

 Blood and urine tests. These tests will measure your white blood cell count, which
might indicate an infection, and markers that suggest inflammation. Your doctor also
might recommend tests for HIV and sexually transmitted infections, which are sometimes
associated with PID.

 Ultrasound. This test uses sound waves to create images of your reproductive organs.

 Laparoscopy. Laproscopy is considered the “gold standard”. While it is the most reliable
aid to support the clinical diagnosis.

COMPLICATIONS OF PID:

Immediate:
 1. Pelvic
2. Septicemia – producing arthritis or myocarditis.

Late:

 Ectopic pregnancy. PID is a major cause of tubal (ectopic) pregnancy. In an ectopic

pregnancy, the scar tissue from PID prevents the fertilized egg from making its way
through the fallopian tube to implant in the uterus. Ectopic pregnancies can cause massive,
life-threatening bleeding and require emergency medical attention.

 Infertility. PID might damage your reproductive organs and cause infertility — the
inability to become pregnant. The more times you've had PID, the greater your risk of
infertility. Delaying treatment for PID also dramatically increases your risk of infertility.

 Chronic pelvic pain. Pelvic inflammatory disease can cause pelvic pain that might last for
months or years. Scarring in your fallopian tubes and other pelvic organs can cause pain
during intercourse and ovulation.

 Tubo-ovarian abscess. PID might cause an abscess — a collection of pus — to form in

your uterine tube and ovaries. If left untreated, you could develop a life-threatening
infection.
TREATMENT FOR PELVIC INFLAMMATORY DISEASE INCLUDE:

 Bed rest is imposed, analgesic and Antibiotic therapy is recommended.

 Oral feeding is restricted. Dehydration and acidosis are to be corrected by intravenous

fluid.

 Temporary abstinence. Avoid sexual intercourse until treatment is completed

PREVENTION

To reduce your risk of pelvic inflammatory disease, essential steps in the prevention are:
  Community based approach to increase public health awareness.

 Prevention of sexually transmitted diseases with the knowledge of healthy and safe sex.

 Liberal use of contraceptive.

 Routine screening of high risk population.

POTENTIAL NURSING DIAGNOSIS FOR PELVIC INFLAMMATORY DISEASE

1. Risk for infection
2. Acute pain
3. Hyperthermia
4. Risk for situational low self-esteem
5. Knowledge deficient regarding cause/complications of condition, therapy needs, and
transmission of disease to others

Nursing Diagnosis : Alteration of comfort,related to inflammation,edema, secondary to pelvic

inflammatory disease

Plan : At the end of the shiftthe patient will be ableto report a decrease of pain.

Intervention:

-Determine / document presence of possible patophysiological causesof pain.

- Encourage adequaterest periods to preventfatigue.

- Discuss impact of painon lifestyle /independence and waysto maximize level of functioning.

- Identify specific signs /symptoms and changesin pain characteristicsrequiring medical follow up.

UTERINE FIBROID:

Fibroids are muscular tumors that grow in the wall of the uterus (womb). Another medical term
for fibroids is “leiomyoma” (leye-oh-meye-OHmuh) or just “myoma”. Fibroids are almost
always benign (not cancerous). Fibroids can grow as a single tumor, or there can be many of
them in the uterus. They can be as small as an apple seed or as big as a grapefruit. In unusual
cases they can become very large.

DEFINITION: Uterine fibroids, also known as uterine leiomyomas or fibroids, are benign
smoothmuscle tumors of the uterus. Most women have no symptoms while others may have
painful or heavy periods. If large enough, they may push on the bladder causing a frequent need
to urinate. They may also cause pain during sex or lower back pain. A woman can have one
uterine fibroid or many of them. Occasionally, fibroids may make it difficult to get pregnant,
although this is uncommon.

Incidence: About 20% to 80% of women develop fibroids by the age of 50. In 2013, it was
estimated that 171 million women were affected. They are typically found during the middle and
later reproductive years. After menopause, they usually decrease in size. In the United States,
uterine fibroids are a common reason for surgical removal of the uterus.
 Location and classification

Growth and location are the main factors that determine if a fibroid leads to symptoms and
problems. A small lesion can be symptomatic if located within the uterine cavity while a large
lesion on the outside of the uterus may go unnoticed. Different locations are classified as
follows:

 Intramural fibroids are located within the wall of the uterus and are the most common
type; unless large, they may be asymptomatic.
 Subserosal fibroids are located underneath the peritoneal surface of the uterus and can
become very large.
 Submucosal fibroids are located in the muscle beneath the endometrium of the uterus
and distort the uterine cavity; even small lesions in this location may lead to bleeding and
infertility.
 Cervical fibroids are located in the wall of the cervix (neck of the uterus). Rarely,
fibroids are found in the supporting structures of the uterus that also contain smooth
muscle tissue.

Fibroids may be single or multiple. Most fibroids start in the muscular wall of the uterus. With
further growth, some lesions may develop towards the outside of the uterus or towards the
internal cavity. Secondary changes that may develop within fibroids are hemorrhage, necrosis,
calcification, and cystic changes. They tend to calcify after menopause.

If the uterus contains too many to count, it is referred to as diffuse uterine leiomyomatosis.
Pathophysiology:
An enucleated uterine leiomyoma – external surface on left, cut surface on right.

Fibroids are a type of uterine leiomyoma. Fibroids grossly appear as round, well circumscribed
solid nodules that are white or tan, and show whorled appearance on histological section. The
size varies, from microscopic to lesions of considerable size. Typically lesions the size of a
grapefruit or bigger are felt by the patient herself through the abdominal wall.

ETIOLOGY: The exact cause is generally unknown but certain predisposing factors are
responsible.
Predisposing factors includes:
Obesity
Hereditary
Genetic Disorder

CLINICAL MANIFESTATION:

(1) Uterine bleeding

(2) heavy or painful periods

(3) abdominal discomfort or bloating

(4) painful defecation

(5) back ache

(6) infertility

(7) interference with the position of the fetus

(8) urinary frequency

(9) fundal height more than the gestational age.

CLINICAL PRESENTATION:
 uterine size is much bigger than the period of amenorrhoea
 less foetal movements
 foetal heart not felt easily

Diagnostic Evaluation: Abdominal Palpation

 pelvic examination
 Ultrasonography
 MRI, CTG
 Weight monitoring.
 Sonohysterography Hysterosalpingography
 Hematological assessment

MEDICAL MANAGEMENT:

Most fibroids do not require treatment unless they are causing symptoms. After menopause
fibroids shrink and it is unusual for them to cause problems.

Symptomatic uterine fibroids can be treated by:

 medication to control symptoms

 medication aimed at shrinking tumors
 ultrasound fibroid destruction
 myomectomy or radio frequency ablation
 hysterectomy
 uterine artery embolization

Medication:

 NSAIDs: To reduce painful menstrual periods

 Oral contraceptive pills: to reduce uterine bleeding and cramps
 Levonorgestrel intrauterine devices: to limit menstrual blood flow
 Danazol: to shrink fibroids and control symptoms
 Uterine artery embolization(UAE): is a noninvasive procedure that blocks of blood
flow to fibroids and thus can treat them. Uterine artery ligation, sometimes also
laparoscopic occlusion of uterine arteries are minimally invasive methods to limit blood
 supply of the uterus by a small surgery that can be performed transvaginally or
laparoscopically.
 Myomectomy: is a surgery to remove one or more fibroids. It is usually recommended
when more conservative treatment options fail for women who want fertility preserving
surgery or who want to retain the uterus. Submucosal fibroid in hysteroscopy

Treatment of an intramural fibroid by laparoscopic surgery

After treatment of an intramural fibroid by laparoscopic surgery

Hysterectomy: was the classical method of treating fibroids. Although it is now recommended
only as last option, fibroids are still the leading cause of hysterectomies in the US.

Radiofrequency ablation: is a technique in which the fibroid is shrunk by inserting a needle-

like device into the fibroid through the abdomen and heating it with radio-frequency (RF)
electrical energy to cause necrosis of cells.
COMPLICATIONS:

 cord compression
 musculoskeletal abnormalities
  hydro nephrosis
 intrauterine growth restriction
 prolonged labour

NURSING MANAGEMENT:-

Assessment of patient who is having uterine fibroid is usually based on clinical manifestations
that usually occur. The nursing interventions required by the patient with uterine fibroid vary
greatly depending on the severity of the disease. Nursing intervention is based on nursing
process.
Nursing Diagnosis:

Subjective assessment: Objective assessment:

Feeling thirsty Dry lips

Feeling discomfort in spine position uterine height more than the gestational age

Easy fatigability looking pale due to anemia

Worried about pregnancy outcome anxiety related to diagnosis

Nursing Diagnosis:

 Deficient Fluid Volume related to deficient fluid intake

 Altered position related to gravid uterus and fibroid
 Easy fatigability related to anemia
 Anxiety related to diagnosis and concern for self.

Nursing Diagnosis I: Fluid volume deficit related to deficient fluid intake

Plan: to monitor vital signs, observe skin color, Oxygen saturation, skin temperature and loss of
consciousness, evaluate the amount of vaginal bleeding.
Intervention:
  Take plenty of fluids and fruits containing good content of water like watermelon.
 Monitor intake and output strictly; notify health care provider if urine output is less than
30 mL/hour.
 Monitor vital signs every hour.
Evaluation: Client’s vital signs were normal.

Nursing Diagnosis II: Altered position related to gravid uterus and fibroid

Plan: To keep the patient in Comfortable Position

Intervention:
 Lie on lateral position
 Avoid being confined to bed
 Do light exercises like walking
Evaluation: Patient feels comfortable.

Nursing Diagnosis III: Anxiety related to diagnosis and concern for self care.
Plan: To Decrease Anxiety and Increase Knowledge.

Intervention:

 Provide psychological Support.

 Reassure mother about foetal well-being.
 Provide information about modern treatments.
 Advice client to take enough of fluids.

BREAST CARCINOMA

Worldwide, breast cancer is the most frequently diagnosed life-threatening cancer in women. In
less-developed countries, it is the leading cause of cancer death in women. In developed
countries, however, it has been surpassed by lung cancer as a cause of cancer death in women. In
the United States, breast cancer accounts for 29% of all cancers in women and is second only to
lung cancer as a cause of cancer deaths. (For discussion of male breast cancer, see Breast Cancer
in Men.)
Breast carcinoma is a cancer that develops from breast tissue. Early breast carcinomas are
asymptomatic; pain or discomfort is not usually a symptom of breast cancer. Breast cancer is
often first detected as an abnormality on a mammogram before it is felt by the patient or
healthcare provider.
The general approach to evaluation of breast cancer has become formalized as triple assessment:
clinical examination, imaging (usually mammography, ultrasonography, or both), and needle
biopsy. Increased public awareness and improved screening have led to earlier diagnosis, at
stages amenable to complete surgical resection and curative therapies. Improvements in therapy
and screening have led to improved survival rates for women diagnosed with breast cancer.

CAUSES OF BREAST CANCER

The origin of breast cancer is a complex interaction between the biologic and endocrine
properties of the person and the environmental exposures that may precipitate mutation of cells
to a malignancy. Despite known hereditary risk factors, the majority of breast cancers are
diagnosed in women with no such risk factors. Although 10% to 20% of breast cancer patients
have a family history suggestive of a hereditary susceptibility, only 5% of all breast cancers can
be attributed to a known genetic defect

RISK FACTORS:

 Age and gender

 Family history of breast cancer

 Reproductive factors and steroid hormones

 Lifestyle risk factors e.g. Obesity, Sedentary lifestyle

 Environmental risk factors: Tobacco smoke (both active and passive exposure),Alcohol
consumption, Environmental carcinogens (eg, exposure to pesticides, radiation, and
environmental and dietary estrogens).
SIGNS AND SYMPTOMS:

Signs of breast cancer may include a lump in the breast, a change in breast shape, dimpling of the
skin, fluid coming from the nipple, or a red scaly patch of skin. In those with distant spread of
the disease, there may be bone pain, swollen lymph nodes, shortness of breath, or yellow skin.

Breast cancer

Breast cancer showing an inverted nipple, lump, and skin dimpling.

The first noticeable symptom of breast cancer is typically a lump that feels different from the rest
of the breast tissue. Indications of breast cancer other than a lump may include thickening
different from the other breast tissue, one breast becoming larger or lower, a nipple changing
position or shape or becoming inverted, skin puckering or dimpling, a rash on or around a nipple,
discharge from nipple/s, constant pain in part of the breast or armpit, and swelling beneath the
armpit or around the collarbone.
DIAGNOSIS:

Most types of breast cancer are easy to diagnose by microscopic analysis of a sample—
or biopsy—of the affected area of the breast.

 Screening and early detection: Mammography, Breast examinations, High-risk patients

 Mammogram.
 Ultrasound of the breast
 Biopsy

PREVENTION
Life-style
Women may reduce their risk of breast cancer by maintaining a healthy weight, drinking less
alcohol, being physically active and breastfeeding their children. Strategies that encourage
regular physical activity and reduce obesity could also have other benefits, such as reduced risks
of cardiovascular disease and diabetes. High intake of citrus fruit has been associated with a 10%
reduction in the risk of breast cancer.

Medications
The selective estrogen receptor modulators (such as tamoxifen) reduce the risk of breast cancer
but increase the risk of thromboembolism and endometrial cancer.[100][100] There is no overall
change in the risk of death. They are thus not recommended for the prevention of breast cancer in
women at average risk but may be offered for those at high risk.

Treatment for Breast Cancer

Depends on the stage and type of Breast Cancer

 Stage I size less 2 cm No node involvement, no metastasis

 Stage II Size Up to 5 cm May have axillary’s node involvement, no metastasis
 Stage III Varied (any size) Extended to skin or chest wall, nodes involved (immovable
axillary node)
 Stage IV Varied Distant metastasis with ipsilateral supraclavicular nodes
Therapy may include a combination of surgery, radiation, chemotherapy, and hormone therapy
Surgical. The goal of surgery is control of cancer in the breast and the axillaries nodes
 Lumpectomy
 Partial mastectomy (also known as segmental mastectomy or quadrantectomy) removes one-
quarter or more of the breast.
 Simple or total mastectomy is the removal of the breast but not the lymph nodes or pectoral
muscles.
 Modified radical mastectomy is the removal of the breast and some of the axillary lymph
nodes.
 Radical mastectomy is the removal of the breast, pectoralis major and minor, and axillary
lymph nodes. The use of this surgery has declined.

Chest after right breast mastectomy

Medication:

Drugs used after and in addition to surgery are called adjuvant therapy. Chemotherapy or other
types of therapy prior to surgery are called neoadjuvant therapy. Aspirin may reduce mortality
from breast cancer.

There are currently three main groups of medications used for adjuvant breast cancer treatment:
hormone-blocking agents, chemotherapy, and monoclonal antibodies.

NURSING CARE PLAN FOR BREAST CANCER

 Patient History. Assess the patient’s and family’s previous medical history of breast cancer or
other Cancers.
 Palpation may identify a hard lump, mass, or thickening of breast tissue. Palpation of the
cervical supraclavicular and axillary nodes may also disclose lumps or enlargement.
 Painless lump or mass in her breast or that she noticed a thickening of breast tissue
 Examine the axillary and supraclavicular areas for enlarged nodes. You may note the tumor
is firm and immovable.
 Assess the patient for pain or tenderness at the tumor site.
 Inspect the breast skin for signs of advanced disease: the presence of inflammation, dimpling,
orange peel effect, distended vessels, and nipple changes or ulceration

NURSING DIAGNOSIS FOR BREAST CANCER:

Nursing diagnosis I: Acute pain related to Surgical procedure; tissue trauma, interruption of
nerves, dissection of muscles.

Nursing Interventions:
 Pain Management:
 Alleviation of pain or a reduction in pain to a level of comfort that is acceptable to the
patient.
 Analgesic Administration: Use of pharmacologic agents to reduce or eliminate pain.
 Environmental Management: Comfort: Manipulation of the patient’s surroundings for
promotion of optimal comfort

Evaluation:

 Patient will Communicate feelings of comfort and decreased pain.

Nursing diagnosis II: Anxiety related to change of body image; scarring, loss of body part,
sexual attractiveness extent of disease, impact on others; uncertainty of prognosis; denial of own
mortality Situational crisis.
Nursing Interventions:
 Anxiety Reduction: Minimizing apprehension, dread, foreboding, or uneasiness related to
an unidentified source or anticipated danger.
  Calming Technique: Reducing anxiety in patient experiencing acute distress
 Evaluation: Express that she feels less anxious.

Nursing diagnosis III: Impaired skin integrity related to surgical removal of skin and tissue;
altered circulation, presence of edema, drainage; changes in skin elasticity, sensation; tissue
destruction of radiation therapy.

Nursing interventions:
 Wound Care: Prevention of wound complications and promotion of wound healing.
 Incision Site Care: Cleansing, monitoring, and promotion of healing in a wound that is
closed with sutures, clips, or staples.
 Pressure Ulcer Care: Facilitation of healing in pressure ulcers

Evlauation:
 Participate in her own care at the highest level possible within the limitations of her
illness.
 Express positive feelings about self.

Patient Teaching and Home Healthcare Guidelines for Breast Cancer

 Teach precautions to prevent lymphedema after node dissection, to help prevent

lymphedema,
  instructs the patient to exercise her hand and arm on the affected side regularly and to
avoid activities that might allow infection of this hand or arm. Tell her that infection
increases the risk of lymphedema.

 Request no blood pressure or blood samples from affected arm.

 Urge the patient to avoid activities that could injure her arm and hand on the side of her
surgery. Caution her not to let blood be drawn from or allow injections into that arm. She
should also refuse to have blood pressure taken or I.V. therapy administered on the
affected arm.

REFERENCES:

1. Dutta,D.C, Textbook of Gynecology, 7 th edn. New central Book Agency, Kolkata,

2004.page no;320-70.

2. Jacob Annamma. Comprehensive textbook of midwifery and gynecological nursing,

4 th edition. Jaypee medical publishers, page no; 690-96.

3. CC Wang, Maternal and Child Health Journal,2004 .

4. Salhan Sudha, Textbook of Obstetrics, 1 st edn. Jaypee brothers Medical Publishers

ltd, New Dehli, 2007.

5. Jacob Annamma. Manual of Midwifery and gynecological Nursing, 2 nd edn. Jaypee

medical publishers, page no; 101 -106.

6. www. Scribd.com/doc/…/ Maternal and Child Health Problems.