1. Dr. Aida Abd El-Razek

2. Definition Hysterectomy is the surgical removal of the uterus. 65% of these procedures occur during reproductive years.

3. Indication   Obstetric Indication *Uncontrollable P.P.H *Rupture of uterus *Placenta accreta *Couvelaire uterus *Gross uterine infection.

4. Gynaecological Indication *Uterine Conditions *Vaginal conditions *Tubal conditions *Ovarian conditions

6. *Abdominal *Laparoscopic * Vaginal

7. * Types of Abdominal   Subtotal: body of the uterus is removed, but cervical stump remains.   Total: body and cervix are removed.

8. ◘ Total hysterectomy with bilateral salpingo- oophorectomy: entire uterus, tubes, and ovaries are removed.

10. Advantages of Subtotal Hys EEEEasy and takes a short time LLLLess liability to injure the bladder, ureter & rectum. LLLLess risk of pelvic infection because the vagina is not opened. IIIIt is not followed by dyspareunia

11. Disadvantages of Subtotal Hys  Carcinoma may develop in cervical stump.  Menstruation can occur with high subtotal hysterectomy.  Poor drainage of the pelvis after operation because the vagina is not opened & so haematoma formation is more common.

12. Advantages of Total Hys  It Avoid the risk of stump carcinoma.  Good drainage of the pelvis because the vagina is opened & haematoma formation is less common.

13. Disadvantages of Total Hys  O O O Operation is difficult.  T T T Takes a longer time.  M M M More liability to injure bladder, ureter & rectum.  ↑ ↑ ↑ ↑ risk of pelvic infection.  D D D Dyspareunia

14. *Vaginal hysterectomy: Removal of uterus through the cervix and vagina; cervical stump may remain

15. Indications of Vaginal hysterectomy  Uterine prolapse.  Chronic inversion of uterus.  Dysfunctional uterine bleeding.  Fibroid uterus the size of the uterus is not more than 10 weeks pregnancy.

16. Preoperative Management Determine if patient knows reason for hysterectomy, what the procedure involves, and what to expect postoperatively. Patient must remain NPO from midnight the night before surgery and void before surgery.

17. *Administer an enema *Perform vaginal irrigation. *Skin prep is done if ordered. *Administer preoperative medication to help the patient relax. *Administer an enema *Perform vaginal irrigation. *Skin prep is done if ordered. *Administer preoperative medication to help the patient relax.

18. Postoperative Management Postoperatively, assess for: Wound appearance and drainage Vital signs, level of consciousness Level of pain Vaginal drainage (serous, bloody) Intake and output Urge to void, bladder distention, residual urine (if appropriate) Clarity, color, and sediment of urine

19. Promote exercise and ambulation to prevent thromboembolus, facilitate voiding, and stimulate peristalsis.

21. During operation * Primary haemorrhage. *Injury to the bladder, ureter, and intestines *Anesthetic complications

22. Postoperative complications CC ardiovascular: reactionary & secondary haemorrhage, venous thrombosis and pulmonary embolism PP ulmonary: bronchitis, pneumonia.

23. Gastrointestinal tract: distension, vomiting, acute gastric dilatation and paralytic ileus. Peritonitis Urinary tract: UTI, retention of urine Abdominal wound. Infection, burst abdomen

24. *Vaginal discharge due to infection of the vault. *Formation of granulation tissue in the vaginal vault *Premature menopause

25. NURSING CARE PLAN

26. Nursing Diagnoses 1.Pain related to surgical procedure 2.Altered Pattern of Urinary Elimination related to decreased bladder sensation 3.Risk for Infection related to surgical procedure 4.Self-Esteem Disturbance related to alteration in female organs 5.Sexual Dysfunction related to alteration in reproductive organs and function

27. Nursing Interventions A.Relieving Pain 1.Assess pain location, level, and characteristics. 2.Administer prescribed pain medications. 3.Encourage patient to splint incision when moving. 4.Encourage patient to ambulate as soon as possible to decrease flatus and abdominal distention. 5.Institute sitz baths or ice packs as prescribed to alleviate perineal discomfort.

28. B.Promoting Urinary Elimination 1.Monitor intake and output, bladder distention, signs and symptoms of bladder infection. 2.Maintain patency of indwelling catheter if one is in place. 3.Catheterize patient intermittently if uncomfortable or has not voided in 8 hours. 4.Check for residual urine after patient voids; should be less than 100 mL. Continue to check if more than 100 mL or bladder infection may develop. 5.Encourage patient to empty bladder around the clock, not only when feeling the urge, due to loss of sensation of bladder fullness. 6.Encourage fluid intake to decrease risk of urinary infection.

29. C.Preventing Infection 1.Assess vaginal drainage for amount, color, and odor, assess incision site and temperature. 2.Administer antibiotics as prescribed. 3.Assist use of incentive spirometer, coughing and deep breathing, and ambulation to decrease risk of pulmonary infection.

30. D.Strengthening Self-Esteem 1.Allow patient to discuss her feelings about herself as a woman. 2.Reassure patient she is still feminine. 3.Encourage patient to discuss her feelings with her spouse or significant other. 4.Reassure patient that she will not go through premature menopause if her ovaries were not removed.

31. E.Regaining Sexual Function 1.Discuss changes regarding sexual functioning such as shortened vagina and possible dyspareunia due to dryness. 2.Offer suggestions to improve sexual functioning. A.Use of water soluble lubricants B.Change position female dominant offers more control of depth of penetration.

32. Patient Education/Health Maintenance

33. *Total hysterectomy produces a surgical menopause. *Advise her against sitting too long at one time, as in driving long distances, because of the possibility of pooling of blood in the pelvis and causing thromboembolism.

34. *Tell the patient to expect a tired feeling for the first few days at home and, therefore, not to plan too many activities for the first week. She will be able to perform most of her usual daily activities within a month, and feel herself again within 2 months.

35. Emphasize the importance of follow-up and routine physical and gynecologic examinations.

36. *Instructions about intercourse, douching, and use of tampons, which are usually discouraged for 4 to 6 weeks. Sexual intercourse should be resumed cautiously to prevent injury and discomfort.

37. Evaluation

38. *Verbalizes decreased pain *Voids every 8 hours of sufficient quantity *Absence of fever and signs of infection

39. *Verbalizes positive statements about self and positive outlook on recovery *Verbalizes understanding of possible changes in sexual functioning and what to do about it