Uterine cancer most commonly occurs in the endometrium, the mucous membrane that lines the inner surface of the uterus. Endometrial cancer, specifically adenocarcinoma (involving the glands), accounts for more than 95% of the diagnosed cases of uterine cancer. There has been an increase noted in the number of women with endometrial cancer, partly owing to women living longer and more accurate reporting. Endometrial cancer is the fourth most common cause of cancer in women, ranking behind breast, colorectal, and lung cancer. It is the most common neoplasm of the pelvic region and reproductive system of the female, and it occurs in 1 in 100 women in the United States. Other uterine tumors include adenocarcinoma with squamous metaplasia (previously referred to as adenoacanthoma), endometrial stromal sarcomas, and leiomyosarcomas.
Endometrial cancer can infiltrate the myometrium, thus resulting in an increased thickness of the uterine wall, and it can eventually infiltrate the serosa and move into the pelvic cavity and lymph nodes. It can also spread by direct extension along the endometrium into the cervical canal; pass through the fallopian tubes to the ovaries, broad ligaments, and peritoneal cavity; or move via the bloodstream and lymphatics to other areas of the body. It is a slow-growing cancer, taking 5 or more years to develop from hyperplasia to adenocarcinoma. Endometrial cancer is very responsive to treatment, provided it is detected early. Prognosis depends on the stage, uterine signs, and lymph node involvement. In 2005, 40,880 new cases of uterine cancer would be diagnosed and 7310 women would die in the United States.
The exact cause of uterine cancer is not known, although it is considered to be dependent on endogenous hormonal levels for growth. Risk factors associated with the development of uterine adenocarcinoma include age, genetic and familial factors, early menarche (before age 12), late menopause (after 52 years), hypertension, nulliparity, unopposed estrogen hormonal replacement therapy, pelvic irradiation, polycystic ovarian disease, obesity, and diabetes mellitus. Leiomyosarcomas are more common among African Americans.
Nursing care plan assessment and physical examination
Establish a history of risk factors. The major initial symptom of endometrial cancer occurring in 85% of women is abnormal, painless vaginal bleeding, either menometrorrhagia or postmenopausal. A mucoid and watery discharge may be noted several weeks to months before this bleeding. Postmenopausal women may report bleeding that began a year or more after menses stopped. A mucosanguineous, odorous vaginal discharge is noted if metastases to the vagina has occurred. Younger women may have spotting and prolonged, heavy menses. Inquire about pain, fever, and bowel/bladder dysfunction, which are late symptoms of uterine cancer. Assess the use and effectiveness of any analgesics for pain relief and also the location, onset, duration, and intensity of the pain.
Conduct a general physical and gynecologic examination. The woman should be directed to not douche or bathe for 24 hours before the examination so that tissue is not washed away. Inspection of any bleeding or vaginal discharge is imperative. The characteristics and amount of bleeding should be noted. Upon palpation, the uterus will feel enlarged and may reveal masses.
Women with the disease often exhibit depression and anger, especially if they are a nulligravida. Therefore, a thorough assessment of the woman’s perception of the disease process and her coping mechanisms is required. The family should also be included in the assessment to examine the extent of support they can provide for the patient. Family anger, ineffective coping, and role disturbances may interfere with family functioning and need careful monitoring.
Nursing care plan primary nursing diagnosis: Knowledge deficit related to treatment procedures, treatment regimens, medications, and disease process.
Nursing care plan intervention and treatment plan
If uterine cancer is detected early, the treatment of choice is surgery. A total abdominal hysterectomy (TAH) with removal of the fallopian tubes and ovaries, bilateral salpingo-oophrectomy (BSO) is generally performed. Common complications after a hysterectomy are hemorrhage, infection, and thromboembolitic disease. Premenopausal women who have a BSO become sterile and experience menopause. Hormone replacement therapy may be warranted and is appropriate. In a total pelvic exenteration (evisceration or removal of the contents of a cavity), the surgeon removes all pelvic organs, including the bladder, rectum, and vagina. This procedure is performed if the disease is contained in the areas without metastasis. If the lymph nodes are involved, this procedure is usually not curative.
Radiation therapy may also be given in combination with the surgery (before or after) or it may be used alone, depending on the staging of the disease, whether the tumor is not well differentiated, or whether the carcinoma is extensive. Radiation may be the treatment of choice for the very elderly woman with an advanced stage of endometrial cancer for whom surgery would not improve quality of life. With radiation, the possible complications are hemorrhage, cystitis, urethral stricture, rectal ulceration, or proctitis. Intracavity radiation or external radiation therapy may be given 6 weeks before surgery to limit recurrence or to improve the chance of survival. An internal radiation device may be implanted during surgery (preloaded) or at the patient’s bedside (afterloaded). If the device is inserted during the surgical procedure, the postoperative management needs to include radiation precautions. Provide a private room for the patient and follow the key principle to protect against radiation exposure: distance, time, and shielding. The greater the distance from the radiation source, the less exposure to ionizing rays. The less time spent providing care, the less radiation exposure. The source of radiation determines if lead shields are necessary to provide care. All healthcare workers coming in contact with a “hot” patient (a patient with an internal radiation implant) need to monitor their exposure with a monitoring device such as a film badge.
The major emphasis is prevention, either primary by reduction of risk factors or secondary by early detection. Encourage women to seek regular medical checkups, which should include gynecologic examination. Discuss risk factors associated with the development of endometrial cancer, particularly as they apply or do not apply to the particular woman. Encourage the older menopausal woman to continue with regular examinations. If the woman is bleeding heavily, monitor her closely for signs of dehydration and shock (dry mucous membranes, rapid and thready pulses, delayed capillary refill, restlessness, and mental status changes). Encourage her to drink liberal amounts of fluids, and have the equipment available for intravenous hydration if necessary. A balanced diet promotes wound healing and maintains good skin integrity.
Patients require careful instruction before radiation therapy or surgery. Explain the procedures carefully, and notify the patient what to expect after the procedure. For surgical candidates, teach coughing and deep-breathing exercises. Fit the patient with antiembolism stockings. If the patient is premenopausal, explain that removal of her ovaries induces menopause. Unless she undergoes a total pelvic exenteration, her vagina is intact and sexual intercourse remains possible. During external radiation therapy, the patient needs to know the expected side effects (diarrhea, skin irritation) and the importance of adequate rest and nutrition. Explain that she should not remove ink markings on the skin because they direct the location for radiation. If a preloaded radiation implant is used, the patient has a preoperative hospital stay that includes bowel preparation, douches, an indwelling urinary catheter, and diet restrictions the day before surgery.
If the woman has pain from either the surgical procedure or the disease process, teach her pain-relief techniques such as imagery and deep breathing. Encourage her to express her anger and feelings without fear of being judged. Note that surgery and radiation may profoundly affect the patient’s and partner’s sexuality. Answer any questions honestly, provide information on alternatives to traditional sexual intercourse if appropriate, and encourage the couple to seek
counseling if needed. If the woman’s support systems and coping mechanisms are insufficient to
meet her needs, help her find others. Provide a list of support groups that may be helpful.
Nursing care plan discharge and home health care guidelines
Teach the need for regular gynecologic examinations, even though she had a hysterectomy. Teach the patient to report any abnormal vaginal bleeding to the healthcare provider. The woman who has had a TAH with BSO is at risk for developing osteoporosis. Recommend a daily intake of up to 1500 mg of calcium through diet and supplements. Recommend vitamin D supplements to enable the body to use the calcium. Stress the need for regular exercise, particularly weight-bearing exercise. Discuss the exercise schedule and type with the patient in light of her treatment and expected recovery time.
Ensure that the patient understands the dosage, route, action, and side effects of any medication she is to take at home. Note that, to monitor her response, some of the medications require her to have routine laboratory tests following discharge from the hospital.
Discuss any incisional care. Encourage the patient to notify the surgeon for any unexpected wound discharge, bleeding, poor healing, or odor. Teach the patient to avoid heavy lifting, sexual intercourse, and driving until the surgeon recommends resumption.
To decrease bulk, teach the patient to maintain a diet high in protein and carbohydrates and low in residue. If diarrhea remains a problem, instruct the patient to notify the physician or clinic because antidiarrheal agents can be prescribed. Encourage the patient to limit her exposure to others with colds because radiation tends to decrease the ability to fight infections. To decrease skin irritation, encourage the patient to wear loose-fitting clothing and avoid using heating pads, rubbing alcohol, and irritating skin preparations.
Teach the patient appropriate self-care for her specific treatment. Teach the patient to be able to identify where she can obtain assistance should postoperative or posttreatment complications occur. Make sure that the significant others are aware of the expectations of a normal convalescence and whom to call should concerns arise.