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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

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Collaborative Management

• Symptomatic management
• Hormonal manipulation
• Drug therapyvitamins C, E, and B complex
• Diuretics
• Avoidance of caffeine
• Reduction of dietary fat
• Mild analgesics

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Collaborative Management (Contd)

• 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

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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

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Intraductal Papilloma (Contd)

• Trauma and erosion within the duct, resulting in
  bloody or serous nipple discharge
• Diagnosis aimed first at ruling out breast cancer

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Gynecomastia

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

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Gynecomastia (Contd)

• Underlying disease causing estrogen excess
• Androgen deficiency
• Breast cancer

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Breast Cancer

• Types of breast cancer
• Complications include
• Invasion of lymph channels causing skin edema
• Metastasis to lymph nodes
• Bone, lungs, brain, and liversites of metastatic
  disease from breast cancer
• Ulceration of overlying skin

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Nipple Retraction
13
Peau dorange
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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.

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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
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Breast Care

• Clinical breast examination
• Cancer surveillance
• Prophylactic mastectomy
• Chemoprevention

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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.

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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.

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Potential for Metastasis (Contd)

• 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.

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Surgical Management
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Surgical Management (Contd)

• Removal of the mass
• Neoadjuvant therapy
• Axillary node dissection
• Sentinel lymph node biopsy
• Breast-conserving surgery
• Modified radical mastectomy

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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

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Adjuvant Therapy

• To decrease the risk of recurrence, adjuvant
  therapy consists of
• Radiation therapy
• Chemotherapy
• Hormonal therapy
• Stem cell transplantation
• Targeted therapy

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This is chapter 74

• Care of Patients with Gynecologic Problems

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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

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Premenstrual Syndrome

• A collection of symptoms that are cyclic in
  nature
• Nutrition therapy
• Drug therapyhormonal therapy. Oral
  contraceptives, gonadotropin-releasing hormone,
  serotonin-reuptake inhibitors
• Complementary and alternative therapies

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Endometriosis

• Endometriosis is endometrial tissue implantation
  outside the uterine cavity.

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Interventions

• Drug therapy
• Complementary and alternative therapy
• Surgical management

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Dysfunctional Uterine Bleeding

• Bleeding that is excessive or abnormal in amount
  or frequency

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Dysfunctional Uterine Bleeding (Contd)

• Associated with
• Endocrine disturbances
• Polycystic ovary disease
• Stress
• Obesity or underweight
• Long-term drug use
• Anatomic abnormalities

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Collaborative Management

• Nonsurgical management includes hormone
  manipulation.
• Surgical management includes
• Dilation and curettage procedure
• Laser or balloon endometrial ablation
• Myomectomy
• Hysterectomy

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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

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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

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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

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Uterine Prolapse (Contd)
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Cystocele and Rectocele
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Fistulas

• Abnormal opening between two adjacent organs or
  structures
• Urethrovaginal fistula
• Vesicovaginal fistula
• Rectovaginal fistula
• Management

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Benign Neoplasms

• Ovarian cyst
• Uterine leiomyoma
• Nonsurgical management
• Surgical management

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Uterine Leiomyomas
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Cervical Polyps

• Pedunculated tumors (on stalks) arising from the
  mucosa and extending to the opening of the
  cervical os
• Polyp removala simple office procedure

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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

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Endometrial (Uterine) Cancer (Contd)

• Possible testing for gene causing HNPCC
• IV pyelography
• Barium enema
• CT of the pelvis
• Liver and bone scans
• Hysteroscopic examination of the uterus
• Proctosigmoidoscopy

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Surgical Management

• Total hysterectomy and bilateral
  salpingectomy/oophorectomy

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Surgical Management (Contd)

• Total abdominal hysterectomy and bilateral
  salpingo-oophorectomy
• Radical hysterectomy with bilateral pelvic lymph
  node dissection for stage II cancer

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Nonsurgical Management

• Radiation therapy
• Intracavitary radiation (brachytherapy)
• External radiation
• Drug therapy
• Chemotherapy
• Hormone therapy
• Complementary and alternative therapies

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Cervical Cancer

• Disorder is a progressionfrom 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

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Health Promotion and Maintenance

• HPV vaccine (Gardasil)

51
Clinical Manifestations

• Patient often asymptomatic
• Classic symptompainless vaginal bleeding
• Watery, blood-tinged vaginal discharge that may
  become dark and foul-smelling as the disease
  progresses

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Clinical Manifestations (Contd)

• Leg pain
• Flank pain
• Unexplained weight loss, pelvic pain, dysuria,
  hematuria, rectal bleeding, chest pain, and cough

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Diagnostic Assessment

• Pap smear
• Squamous atypia, inflammatory atypia, or minor
  atypia abnormalities
• Bethesda system
• Colposcopic examination
• Endocervical curettage

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Early Surgical Procedures

• Loop electrosurgical excision procedure
• Laser therapy
• Cryotherapy

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Surgical Procedures

• Hysterectomy
• Pelvic exenteration

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Ovarian Cancer

• Most common typeserous 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

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Nonsurgical Management

• Chemotherapy with agents such as cisplatin,
  carboplatin, and paclitaxel
• Radiation therapy

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Surgical Management

• Total abdominal hysterectomy and bilateral
  salpingo-oophorectomy
• Staging

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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.

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Management

• Laser therapy
• Radiation therapy
• Surgical managementvulvectomy or skinning
  vulvectomy or radical vulvectomy

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Vulvectomy
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Postoperative Care

• Providing wound care
• Promoting urinary and bowel elimination
• Managing pain
• Addressing sexuality

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Vaginal Cancer

• Rare
• Treatment with any of these
• Laser therapy
• Wide excision
• Partial or total vaginectomy
• Topical chemotherapy
• Radiation therapy

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Fallopian Tube Cancer

• Rarest of all gynecologic cancers
• Most common symptomspostmenopausal bleeding,
  increased abdominal pain, watery vaginal
  discharge, leukorrhea
• Treatmenttotal abdominal hysterectomy and
  bilateral salpingo-oophorectomy with omentectomy

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This is chapter 75

• Care of Male Patients with Reproductive Problems

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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

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BPH
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Potential Complications of BPH
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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

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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

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Other Nonsurgical Measures

• Thermotherapy

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Surgical Procedures

• Transurethral resection of the prostate (TURP)
• Suprapubic prostatectomy
• Retropubic prostatectomy
• Perineal prostatectomy

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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 patients abdomen or thigh
• Uncomfortable urge to void continuously
• Antispasmodic medications

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CBI
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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.

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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

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Prostate Cancer (Contd)

• Digital rectal examination
• Prostate-specific antigen
• Biopsy necessary to confirm suspected prostatic
  cancer

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Prostate Cancer (Contd)
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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

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Postoperative Care of Radical Prostatectomy
(Contd)

• 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.

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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.
• Nongerm 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

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Potential for Metastasis

• Interventions include
• Surgical management
• Preoperative care
• Operative proceduresradical retroperitoneal
  lymph node dissection, orchiectomy

98
Potential for Metastasis (Contd)

• 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 infancyalmost always eliminates
  the possibility of penile cancer
• Painless, wartlike growth or ulcer
• Excisional biopsy
• Radiation therapy
• Penectomy

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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 (Contd)

• Diabetes mellitus
• Malignancies
• Abnormal reflex
• Some drug effects
• Recreational drugs
• Prolonged sexual activity

107
Collaborative Management

• Urologic emergency
• Goal of interventionto 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
• Treatmentbedrest with scrotum elevated on a
  towel, scrotal support when ambulating
• Comfort measures
• Epididymectomy

110
Orchitis

• Acute testicular inflammation resulting from
  trauma or infection
• Treatmentbedrest with scrotal elevation,
  application of ice, and administration of
  analgesics and antibiotics
• Mumps orchitis