TAHBSO-NCP

Total abdominal hysterectomy bilateral salpingo oophorectomy (TAHBSO) is the removal of entire uterus, the ovaries, fallopian tubes and the cervix. TAHBSO is usually performed in the case of uterine and cervical cancer. This is the most common kind of hysterectomy. Removal of the ovaries eliminates the main source of the hormone estrogen, so menopause occurs immediately.

Postoperative Care

Main Article: TAHBSO Surgical Procedure and Perioperative Management

  1. Determines patient’s immediate response to surgical intervention.
  2. Monitor patient’s physiologic status.
  3. Assess patient’s pain level and administers appropriate pain relief measures.
  4. Maintains patient’s safety(airway, circulation, prevention of injury)
  5. Administer medication, fluid and blood component therapy, if prescribed.
  6. Assess patient’s readiness for transfer to in hospital unit or for discharge home based on institutional policy.

Nursing Care Plans

Here are the 9 TAHBSO nursing care plans:

Acute Pain

Nursing Diagnosis: Acute Pain secondary to surgical procedure

Due to surgical procedure done that needs a surgical incision there will be presence of trauma in the area that signals an actual tissue damage and inflammation, this damage will cause an inflammation of the nerves when the nerves are affected, there will be the presence of pain.

Possibly evidenced by

  • irritability
  • impaired physical mobility
  • disturbed sleep pattern
  • facial mask
  • diaphoresis
  • restlessness
  • facial grimaces

Desired Outcomes

  • Report pain is relieved/controlled.
  • Verbalize methods that provide relief.
  • Demonstrate use of relaxation skills and diversional activities.

Nursing Interventions

Nursing Interventions Rationale
1. Establish rapport 1. To gain trust
2. Emphasize ordered diet 2. To encourage patient not to eat untolerated food
3. Monitor vital signs 3. To obtain baseline data
4. Provide comfort measures 4. To satisfy the confinement of patient
5. Encourage deep breathing 5. To inhibit pain
6. Provide safety measure 6. To prevent from injury
7. Develop communication review procedures/expectations and tell client when treatment will hurt 7. To alter pain and diminish emotional stress
8. Administer analgesics as indicated to maximal dosage as needed 8. To reduce concern of unknown and associated muscle tension & To maintain acceptable level of pain.

Hypothermia

Hypothermia is the sudden decrease of temperature. It is due to different factors such as exposure to cool environment, aging or medications. In a surgical procedure hypothermia occurs due to exposure to the cool environment in the OR. Anesthesia also affects body temperature. Inadequate clothing like the OR gown also contributes to heat loss.

Possibly evidenced by

  • reduction in body temperature below normal range
  • shivering
  • cool skin
  • pallor
  • slow capillary refill
  • cyanotic nail beds
  • hypertension
  • tachycardia

Desired Outcomes

  • Patient will display core temperature within normal range
  • Patient will demonstrate behaviors to monitor and promote normothermia

Nursing Interventions

Nursing Interventions Rationale
1. Establish rapport 1. To gain trust
2. Monitor  vital signs 2. To obtain baseline data
3. Remove wet clothing and prevent pooling of antiseptic solutions under client in OR 3. These measures protect patient from heat loss
4. Wrap in warm blanket 4. To promote heat
5. Avoid use of heat clamps or hot water bottles 5. Surface rewarming can lead to rewarming  shock due to surface vasodilation
6. Administer medications to prevent shivering 6. To avoid increasing in temperature
7. Use hyperthermia blanket 7. To warm patient
8. Administer fluids during rewarming 8. To prevent hypovolemic shock
9. Keep client quiet 9. To reduce potential for fibrillation in cold heart
10. Provide well-balance high calorie diet 10. To replenish glycogen stores and nutritional balance
11. Perform range-of-motion exercises, provide support hose, reposition, do cough/deep breathing exercises, avoid restrictive clothing 11. To reduce circulatory stasis
12. Protect skin by repositioning, applying lotion and avoid direct contact with heating appliance or blanket 12. impaired circulation can result in severe tissue damage
13. Provide patent airway with humidified oxygen when used 13. To provide heat

Hyperthermia

Organisms release endotoxin which stimulates the release of pyrogens from the leukocytes resetting the body’s internal thermostat to febrile level then there will be activation of hypothalamus which will result to an increase in epinephrine and heparin, vasoconstriction of cutaneous vessels. Then heat will be produce as peripheral vasodilation results in skin flushing and skin which is warm to touch.

Possibly evidenced by

  • increase in body temperature above normal range
  • flushed skin, warm to touch
  • tachycardia
  • seizures or convulsions

Desired Outcomes

  • Patient will maintain core temperature within normal range
  • Patient will be free from complications of hyperthermia

Nursing Interventions

Nursing Interventions Rationale
1. Establish rapport 1. To gain trust
2. Monitor  vital signs 2. To obtain baseline data
3. Monitor body temperature every 4 hours or more often if indicated 3. To evaluate effectiveness of interventions
4. Loosen patient’s clothingand remove blankets 4. To promote heat loss through radiation and conduction
5. Apply ice bags to axilla or groin and do TSB 5. To promote heat loss through evaporation
6. Administer antipyretic as ordered 6. To reduce fever
7. Observe patient for confusion or disorientation 7. Changes LOC may result from tissue hypoxia
8. Determine patient’s preference for liquids 8. Offering patient liquids he prefers promotes adequate hydration
9. Keep liquids at bedside and within reach 9. To allow patient easy access
10. Monitor intake and output accurately 10. To identify changes and progress of the treatment
11. Administer I.V fluid as ordered 11. These measure prevents excessive loss of water, sodium chloride and potassium
12. Give patient oresol 12. To replace loss fluid and electrolytes
13. Provide supplement oxygen 13. To offset increase oxygen demands and consumption

Anxiety

Due to upcoming surgical procedure patients are usually experiencing anxiety. The brain signals our body part to initiate responses such as fatigue, nausea and abdominal pain.

Possibly Evidenced By

  • Patient may raise concerns due to change in life event
  • fear
  • nausea
  • abdominal pain
  • fatigue
  • sleep disturbance
  • urinary hesitancy
  • poor eye contact
  • extraneous movement
  • restlessness
  • irritability
  • anorexia
  • insomnia
  • impaired attention
  • Trembling, hand tremors

Desired Outcomes

  • Patient will verbalized awareness of feelings of anxiety
  • Patient will appear relaxed and report anxiety is reduced to a manageable level

Nursing Interventions

Nursing Interventions Rationale
1. Establish rapport 1. To gain trust
2. Monitor  vital signs 2. To obtain baseline data
3. Listen attentively; allow patient to express feelings verbally 3. To allow patient to identify anxious behaviors and discover source of anxiety
4. Identify and reduce as many environment stressors 4. Anxiety commonly results from lack of trust in the environment
5. Provide accurate information about the situation 5. Helps the patient what is reality based
6. Provide comfort measures like back rub and soft music 6. To decrease autonomic response to anxiety
7. Use cognitive therapy 7. To correct faulty catastrophic interpretations of physical symptoms
8. Refer patient to professional mental health resources 8. To provide ongoing mental health assistance

Fatigue

Due to poor physical condition after surgical procedure, body insist demands of nutrition and oxygen that results to fatigue

Possibly Evidenced By

  • Pale skin
  • Impaired physical mobility
  • Irritability
  • Weakness
  • Pain
  • Activity intolerance
  • Stress

Desired Outcomes

  • patient will demonstrate an increase energy output with presence of fatigue
  • patient will perform activities of daily living and participate in desired activities at level of ability

Nursing Interventions

Nursing Interventions Rationale
1. Establish rapport 1. To gain trust
2. Monitor vital signs 2. To obtain maintenance data
3. Evaluate the need for individual assistance and discuss lifestyle changes imposed by fatigue state 3. To determine degree of fatigue
4. Establish realistic activity goals with client 4. Enhance commitment in promoting optimal outcomes
5. Instruct client in ways to monitor responses to activity and significant signs and symptoms 5. To indicate the need to alter activity level

Sexual Dysfunction

Dysfunction of the female reproductive system can produce depression and even anxiety. The patient experiences this due to deficient knowledge about the dysfunction and the decrease in sexual desire.

Nursing Diagnosis: Sexual Dysfunction related to altered body structure and function

Possibly Evidenced By

  • problem such as loss of sexual desire
  • inability to achieved desired satisfaction
  • conflicts involving values
  • alteration in relationship with SO
  • Change of interest in self and others

Desired Outcomes

  • patient will identify stressors in lifestyle that may contribute to the dysfunction
  • patients will verbalize understanding of individual reasons for sexual problems

Nursing Interventions

  1. To gain trust
  2. To obtain maintenance data
  3. To maximize communication and understanding
  4. Sexual concerns are often disguised as humor, sarcasm, or offhand remarks
  5. These factors may be producing enough anxiety to cause depression
  6. They do not help the client
  7. To promote treatment and facilitate sharing of sensitive information
  8. To allow sexual expression for individual between partners without embarrassment

Risk for Infection

The skin considered as the first line of defense against any foreign organism when surgical procedure impaired the skin, possible entry of microorganism therefore may cause infection.

Nursing Diagnosis: Risk for infection secondary to surgical incision

Possibly Evidenced By

  • Weakness
  • Pallor-with dry and intact dressing on the area.
  • Pain over the incision
  • Irritability
  • Presence of intact dressing
  • Impaired physical mobility
  • Diaphoresis
  • Fever
  • Seizures

Desired Outcomes

  • Patient shall identify and demonstrate intervention to prevent infection
Nursing Interventions Rationale
1. Establish rapport 1. To gain trust
2. Monitor V.S. 2. To obtain baseline data
3. Note signs and symptoms of sepsis 3. To reduce complication and monitor for infection
4. Provide wound healing such as cleaning of wound 4. To reduce risk for infection
5. Provide care, change dressing as needed 5. To promote healing to the incision
6. Encourage increase intake of Vitamin C 6. To prevent infection to increase immune resistance
7. Encourage deep breathing exercise 7. To increase healing of wound

Risk for Deficient Fluid Volume

Decrease intravascular, interstitial, or intracellular fluid refers to dehydration. Fluid volume deficit or hypovolemia occurs from a loss of body fluid or the shift of fluids into the third space or reduced fluid intake. Common sources for fluid loss are the gastrointestinal tract, polyuria and increased perspiration. It also occurs to patient who underwent surgery. In an operation the patient is losing too much body fluid through blood loss that can lead to deficient fluid.

Possibly Evidenced By

  • thirst
  • weakness
  • decrease urine output
  • sudden weight loss
  • decrease skin turgor
  • dry mucous membranes
  • sunken eyeballs
  • change in mental state

Desired Outcomes

  • patient will identify risk factors and appropriate interventions
  • patients will demonstrate behaviors or lifestyle changes to prevent development of fluid volume deficit
Nursing Interventions Rationale
1. Establish rapport 1. To gain trust
2. Monitor vital signs 2. To obtain maintenance data
3. Encourage increase oral fluid intake 3. To replace lost fluids
4. Provide supplemental fluids as ordered 4. Prevents peak in fluid level
5. Monitor intake and output 5. To ensure accurate picture of fluid status
6. Provide safety measures 6. Confusion can lead to accidents
7. Encourage the use of oresol 7. To replace loss electrolyte.

6 COMMENTS

  1. very good..!!! as a nursing student, you helped me a lot. it answered my question. very good very good!!!! thank you thank you.

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