Key words non-prolapsed uterus; new transvaginal hysterectomy; Perioperative nursing
Vaginal hysterectomy with total abdominal incision does not exist, the body surface without leaving scars, trauma, intestinal disturbances less postoperative pain, the extent and incidence of postoperative low heat absorption, the use of antibiotics after a short time, patients quick recovery, short hospital stay [1]. Because there are many advantages, the domestic and growing number of hospitals to carry out this operation [2]. Our department in June 2006 in the People's Liberation Army General Hospital under the guidance of expert help in this operation, so far 168 cases have been completed, except 1 case of intraoperative bladder injury, 1 case of postoperative bleeding, the other effect than well, no complications, was discharged. Now its perioperative care are summarized below.
1 Clinical data
168 patients, aged 35 to 68 years, the average age of 48.23 years of age, parity 2.45 times, 28 cases of pelvic surgery, including the history of cesarean section in 16 cases, 2 cases of tubal ligation, appendectomy surgery in 8 cases. The diagnosis of uterine fibroids, adenomyosis, dysfunctional uterine bleeding. Anesthetic-based epidural anesthesia, according to the specific circumstances of individual patients with systemic inhalation anesthesia, body position lithotomy position for the bladder, cervix gap in the bladder, vesico-vaginal space, the junction of cervix and vagina mucosa with normal saline or 1: 1200 adrenaline saline, the bladder circular incision at the junction of the cervix cervix and vagina mucosa, sharp separation of the bladder cervical fascia, push up the bladder peritoneal fold, cut into the abdominal cavity after the dome, clamping, cutting, suturing bilateral bladder cervical ligament, sacral cardinal ligament, uterine artery and vein, followed by breaking up the organized bar uterine and ovarian ligaments, fallopian tubes, uterus completely free to peeling, broken solution, split, fibroids uterine nuclear addition to all other methods to remove probe bilateral annex, if ovarian cancer is removed, or removed as appropriate, continuous suture around the peritoneum and vaginal cuff, if the vaginal anterior and posterior wall prolapse and urinary incontinence tension, while repair of vaginal anterior and posterior wall, the other, as for menopausal women the principle of the annex at the same time underwent bilateral resection [2].
2 Care
2.1 Preoperative Care
2.1.1 The psychological care are women uterine and menstrual characteristics. 168 patients in the age structure of more than 90 years of age in the 35 to 50 worry about vaginal hysterectomy patients would influence their lives, women will lose their characteristics, premature aging, including nearly half of the patients think they have physical defects and psychological disorders , appears self-confidence shaken, sensitive, suspicious. For psychological problems, in addition to patients sincere sympathy emotional, psychological enlighten and encourage, let it feel the care and assistance, but also clearly inform patients of hysterectomy would be a temporary discomfort, menopause and cause loss of fertility, but will not affect the nature of life and the female form. To help patients build confidence and eliminate the defects and mental troubles, so that it actively cooperate with the treatment and care.
2.1.2 preoperative routine examination of patients before surgery to have a comprehensive understanding of general conditions to ensure the smooth progress of surgery. Actively help improve the heart, liver, lung, kidney function tests and blood, blood, the coagulation examination, and routine gynecological B-Preparation of blood.
2.1.3 Gastrointestinal food prepared the day before surgery light, easy to digest soft diet, oral 20% mannitol 250 ml, 1000 ml 0.9% saline, 1 hour oral finish, clean the intestinal tract. 168 patients, in addition to 11 patients can not tolerate oral administration due to the use of enema cleansing enema, the other good effect; fasted 10 hours before surgery, 4 hours forbidden to drink.
2.1.4 The day before surgery, skin surgery for skin preparation area, covering the following to the inner thigh xiphoid 1 / 3, do the umbilicus, perineum, and cleaning around the anus (for transit through the vagina to be losers open surgery or laparoscopic surgery to be ready.)
2.1.5 vaginal bacteria for the vagina is the environment, in order to prevent postoperative infection, vaginal preparation is very important. In Search of the relevant information and expert guidance, the use of the morning the day before surgery, before going to bed and on the morning of surgery with 0.5% povidone-iodine vaginal scrub 3 cervical, cervix and the vault when the attention scrub and dry with large cotton ball dipped. 168 patients no case of wound infection.
2.1.6 Other guidance for patients before surgery Practice deep breathing. Night before surgery should ensure that patients rest and reduce their stress and anxiety, the general stability of sedative drugs to the oral 5 to 10 mg, night shift nurses should be aware of their sleep, if necessary, once again sedatives. Half an hour before surgery to basic anesthetics.
2.2 Postoperative care
2.2.1 The role of pain after the disappearance of anesthesia care to the most obvious pain after 24 hours [3], postoperative pain is a major nursing problems, anxiety, nervous patients more sensitive to pain. In order to avoid discomfort to the patient the pain, the patient quiet and rest, get through this period, patients should be fully understood, the right to assess their pain on the basis of individual differences for pain relief to take a different approach, such as keeping the environment quiet , by listening to music, chatting, watching TV, distracting, given enough time prescribed analgesics, the application and the church controlled analgesia pump patients (after a small number of patients with analgesia pump will cause low blood pressure, blood pressure should be observed ), while the analgesic effect observed after treatment. 168 patients in more than 20 patients without use of pain medication, relaxation techniques through the guidance of this period is well spent; in 5 patients with controlled analgesia pump, no drop in blood pressure occurred in 1 case.
2.2.2 General Nursing catheter indwelling catheter 2 days, pay attention to maintaining unobstructed drainage catheter to observe the color of urine, and urine output traits. Individual suspected bladder injury or surgery were found to repair bladder injury and who need long-term catheterization after open 7 to 10 days [4], indwelling Foley catheter should be prepared during the day with 0.5% povidone-iodine scrub urethra 2 times 2 times a week replace the drainage bag to prevent retrograde infection. Catheter occlusion before extubation every 2 to 4 hours time to exercise bladder function, to assist the determination of residual urine in patients, ensuring patient was extubated.
2.2.3 perineal care to keep the perineum clean and dry, observe the situation in the perineum or vaginal exudate dressing oozing bleeding sap situation, every day with 0.5% povidone-iodine perineal scrub 2 times until discharge.
2.2.4 Notwithstanding the complications of surgical care through the vagina many advantages, but also has its natural disadvantages, namely the operative field is small, exposed the difficulties, the operation space is small, surgery may damage adjacent organs and blood vessels. If damage bladder, ureter, rectum can cause vaginal leakage of urine, fecal leakage, wound infection; such as accidental injury, vascular suture tie loose or leak can cause internal bleeding and vaginal bleeding or hemorrhagic shock, if the surgery via the vagina to detect timely repair, suture to avoid complications. Therefore, vital signs should be closely observed postoperatively, perineal dressing bleeding and vaginal bleeding sap exudate case, urine drainage situation, pay attention to listen to complaints of patients, such as patients with restlessness, cold sweats, lips cyanosis, low back pain, abdominal distension, it is likely to hemorrhage and shock, inform your doctor immediately [3]. Our department during this procedure, 1 patient had intraoperative bladder injury occurred, the repair did not result in adverse consequences in a timely manner; has 1 patient 1 hour after the end of surgery, the gradual emergence of shock symptoms, and perineal dressings clean and dry, determine the postoperative bleeding, emergency re-open the layers of vaginal suture found on the left and bleeding caused by rupture of corpus luteum, consider pulling intraoperative exploration attachment caused by the line of left ovarian luteal vaginal cystectomy, postoperative patient gradually recovered and discharged. Therefore, the vaginal surgery patients who require not only a firmer foundation, proficiency, soft, close postoperative observation, good nursing care is to prevent complications, an important measure to ensure successful operation.
2.2.5 Diet care after 6 hours into the liquid, but should avoid milk, soy milk, sugar and other gas production of food. Flatus backward semiliquid soft diet, then gradually transition to a normal diet. Encourage patients into high-protein, high in vitamins, fiber-rich foods, drink more water to meet the rehabilitation needs of the body after surgery, to prevent constipation.
2.2.6 Rehabilitation Guidance (1) General Director: Zhu Huanzhe home, pay attention to maintaining genital cleansing in general should rest for 3 months. Report of 7 to 14 days after gut absorption phase, should be more bed rest, there may be some vaginal bleeding, if the amount of menstrual bleeding more than should be timely treatment; 6 weeks before the ban bath, anti retrograde infection; 3 months to avoid heavy manual labor and increase abdominal pressure, attention gradually increase activity. (2) psychological guidance: re-explain the surgical procedure and the possible impact of telling patients and the female form with the sexual life is closely related to the vagina and the ovarian secretion of estrogen, in order to eliminate the defects and mental troubles. It is best to let her husband, accompanied by lectures, in order to obtain her husband's understanding and recognition. Encourage patients to participate in social activities after discharge and more, through integration into the community to regulate emotions, increase marital relations, quality of life.
2.2.7 sex guide 3 months after surgery vaginal stump complete wound healing, scar gradually softening, can be gradually restored sex life. The first time life can be applied to vaginal lubricants, for the first time after psychological stress of life can play the natural relaxing effect [5] clearly advertised on the sexual life of patients can not be a long period of panic, so that the adverse physical and mental rehabilitation, but also a long time influence their emotions lead to family discord. In order to improve the quality of life, 1 month after gradual functional exercise to strengthen pelvic floor muscles support the pelvic floor muscles and vaginal tightening degree of care ability to explain and teach pelvic floor muscle training methods were applied methods to encourage patients to qualified hospitals pelvic floor muscle rehabilitation devices and rehabilitation treatment for vaginal, vaginal tightening by increasing the degree to improve the quality of life.
3 body will be
3.1 With the progress of human civilization and the rapid development of science and technology, the majority of women on the increasing demand for quality of life, requiring a minimum of trauma to achieve the best therapeutic effect. Vaginal hysterectomy is almost entirely extraperitoneal surgery, peritoneal operation less disturbance of the abdominal organs, a very low incidence of postoperative bowel obstruction, trauma, postoperative pain, no abdominal scar but also to meet the needs of women's beauty and after you can get out of bed earlier, faster recovery of intestinal function can be consumed as soon as possible, on the lung function is smaller, therefore, the overall rapid recovery, surgery costs, after the application of antibiotics and complications of treatment costs are reduced, patients are generally satisfied. In addition, shorter operation time, trauma, anesthesia time and the depth of the corresponding decrease in medical complications in elderly patients and patients can better tolerate surgery, thus, more and more patients choose this surgery. However, vaginal hysterectomy because of its natural disadvantages, namely the operative field is small, exposed the difficulties, the operation space is small, too large for the uterus, pelvic adhesions, a malignancy may need a large ovarian tumor removed at the same time, you need both exploratory abdominal and those who are not mothers, not be suitable for the procedure [6].
3.2 New non-prolapsed uterus transvaginal hysterectomy for the treatment of gynecological diseases, new technologies, the surgery is difficult, technically demanding, but also of care put forward higher requirements. Good preoperative preparation, especially the preparation of the vagina and postoperative complications of observation care, physical and psychological rehabilitation guidance is particularly important, conventional surgery three days before the vaginal preparation is used 1:5000 potassium permanganate, 0.2 ‰ iodine flushing the vagina, This not only increased the suffering of the patients, but also extended hospital stay, increased costs, access to relevant information and expert guidance, 168 patients preoperatively with a 0.5% povidone-iodine scrub cervix and vagina, no infection occurred in 1 case . Transvaginal surgery may damage its natural disadvantages adjacent organs and blood vessels. Therefore, postoperative changes should be closely observed to detect complications of the disease threatened, close observation and timely treatment of complications after surgery can effectively ensure the safety and success. With the increasing demand on quality of life, good sex life after the bounden duty of the guidance to become nurses, were followed up for more than 40 patients, the majority of women using a vaginal lubricant, but because of shorter hospital stay on the basin floor muscle exercise method of control is not good, which need to be to strengthen women's health in the community. With the treatment of gynecological diseases, development of new technology and people required to improve the quality of life, requiring nurses to learn new business, new technologies, be diligent in their work to develop the habit of thinking, so careful observation, intensive care to meet patients with a wide range of needs.
Vaginal hysterectomy with total abdominal incision does not exist, the body surface without leaving scars, trauma, intestinal disturbances less postoperative pain, the extent and incidence of postoperative low heat absorption, the use of antibiotics after a short time, patients quick recovery, short hospital stay [1]. Because there are many advantages, the domestic and growing number of hospitals to carry out this operation [2]. Our department in June 2006 in the People's Liberation Army General Hospital under the guidance of expert help in this operation, so far 168 cases have been completed, except 1 case of intraoperative bladder injury, 1 case of postoperative bleeding, the other effect than well, no complications, was discharged. Now its perioperative care are summarized below.
1 Clinical data
168 patients, aged 35 to 68 years, the average age of 48.23 years of age, parity 2.45 times, 28 cases of pelvic surgery, including the history of cesarean section in 16 cases, 2 cases of tubal ligation, appendectomy surgery in 8 cases. The diagnosis of uterine fibroids, adenomyosis, dysfunctional uterine bleeding. Anesthetic-based epidural anesthesia, according to the specific circumstances of individual patients with systemic inhalation anesthesia, body position lithotomy position for the bladder, cervix gap in the bladder, vesico-vaginal space, the junction of cervix and vagina mucosa with normal saline or 1: 1200 adrenaline saline, the bladder circular incision at the junction of the cervix cervix and vagina mucosa, sharp separation of the bladder cervical fascia, push up the bladder peritoneal fold, cut into the abdominal cavity after the dome, clamping, cutting, suturing bilateral bladder cervical ligament, sacral cardinal ligament, uterine artery and vein, followed by breaking up the organized bar uterine and ovarian ligaments, fallopian tubes, uterus completely free to peeling, broken solution, split, fibroids uterine nuclear addition to all other methods to remove probe bilateral annex, if ovarian cancer is removed, or removed as appropriate, continuous suture around the peritoneum and vaginal cuff, if the vaginal anterior and posterior wall prolapse and urinary incontinence tension, while repair of vaginal anterior and posterior wall, the other, as for menopausal women the principle of the annex at the same time underwent bilateral resection [2].
2 Care
2.1 Preoperative Care
2.1.1 The psychological care are women uterine and menstrual characteristics. 168 patients in the age structure of more than 90 years of age in the 35 to 50 worry about vaginal hysterectomy patients would influence their lives, women will lose their characteristics, premature aging, including nearly half of the patients think they have physical defects and psychological disorders , appears self-confidence shaken, sensitive, suspicious. For psychological problems, in addition to patients sincere sympathy emotional, psychological enlighten and encourage, let it feel the care and assistance, but also clearly inform patients of hysterectomy would be a temporary discomfort, menopause and cause loss of fertility, but will not affect the nature of life and the female form. To help patients build confidence and eliminate the defects and mental troubles, so that it actively cooperate with the treatment and care.
2.1.2 preoperative routine examination of patients before surgery to have a comprehensive understanding of general conditions to ensure the smooth progress of surgery. Actively help improve the heart, liver, lung, kidney function tests and blood, blood, the coagulation examination, and routine gynecological B-Preparation of blood.
2.1.3 Gastrointestinal food prepared the day before surgery light, easy to digest soft diet, oral 20% mannitol 250 ml, 1000 ml 0.9% saline, 1 hour oral finish, clean the intestinal tract. 168 patients, in addition to 11 patients can not tolerate oral administration due to the use of enema cleansing enema, the other good effect; fasted 10 hours before surgery, 4 hours forbidden to drink.
2.1.4 The day before surgery, skin surgery for skin preparation area, covering the following to the inner thigh xiphoid 1 / 3, do the umbilicus, perineum, and cleaning around the anus (for transit through the vagina to be losers open surgery or laparoscopic surgery to be ready.)
2.1.5 vaginal bacteria for the vagina is the environment, in order to prevent postoperative infection, vaginal preparation is very important. In Search of the relevant information and expert guidance, the use of the morning the day before surgery, before going to bed and on the morning of surgery with 0.5% povidone-iodine vaginal scrub 3 cervical, cervix and the vault when the attention scrub and dry with large cotton ball dipped. 168 patients no case of wound infection.
2.1.6 Other guidance for patients before surgery Practice deep breathing. Night before surgery should ensure that patients rest and reduce their stress and anxiety, the general stability of sedative drugs to the oral 5 to 10 mg, night shift nurses should be aware of their sleep, if necessary, once again sedatives. Half an hour before surgery to basic anesthetics.
2.2 Postoperative care
2.2.1 The role of pain after the disappearance of anesthesia care to the most obvious pain after 24 hours [3], postoperative pain is a major nursing problems, anxiety, nervous patients more sensitive to pain. In order to avoid discomfort to the patient the pain, the patient quiet and rest, get through this period, patients should be fully understood, the right to assess their pain on the basis of individual differences for pain relief to take a different approach, such as keeping the environment quiet , by listening to music, chatting, watching TV, distracting, given enough time prescribed analgesics, the application and the church controlled analgesia pump patients (after a small number of patients with analgesia pump will cause low blood pressure, blood pressure should be observed ), while the analgesic effect observed after treatment. 168 patients in more than 20 patients without use of pain medication, relaxation techniques through the guidance of this period is well spent; in 5 patients with controlled analgesia pump, no drop in blood pressure occurred in 1 case.
2.2.2 General Nursing catheter indwelling catheter 2 days, pay attention to maintaining unobstructed drainage catheter to observe the color of urine, and urine output traits. Individual suspected bladder injury or surgery were found to repair bladder injury and who need long-term catheterization after open 7 to 10 days [4], indwelling Foley catheter should be prepared during the day with 0.5% povidone-iodine scrub urethra 2 times 2 times a week replace the drainage bag to prevent retrograde infection. Catheter occlusion before extubation every 2 to 4 hours time to exercise bladder function, to assist the determination of residual urine in patients, ensuring patient was extubated.
2.2.3 perineal care to keep the perineum clean and dry, observe the situation in the perineum or vaginal exudate dressing oozing bleeding sap situation, every day with 0.5% povidone-iodine perineal scrub 2 times until discharge.
2.2.4 Notwithstanding the complications of surgical care through the vagina many advantages, but also has its natural disadvantages, namely the operative field is small, exposed the difficulties, the operation space is small, surgery may damage adjacent organs and blood vessels. If damage bladder, ureter, rectum can cause vaginal leakage of urine, fecal leakage, wound infection; such as accidental injury, vascular suture tie loose or leak can cause internal bleeding and vaginal bleeding or hemorrhagic shock, if the surgery via the vagina to detect timely repair, suture to avoid complications. Therefore, vital signs should be closely observed postoperatively, perineal dressing bleeding and vaginal bleeding sap exudate case, urine drainage situation, pay attention to listen to complaints of patients, such as patients with restlessness, cold sweats, lips cyanosis, low back pain, abdominal distension, it is likely to hemorrhage and shock, inform your doctor immediately [3]. Our department during this procedure, 1 patient had intraoperative bladder injury occurred, the repair did not result in adverse consequences in a timely manner; has 1 patient 1 hour after the end of surgery, the gradual emergence of shock symptoms, and perineal dressings clean and dry, determine the postoperative bleeding, emergency re-open the layers of vaginal suture found on the left and bleeding caused by rupture of corpus luteum, consider pulling intraoperative exploration attachment caused by the line of left ovarian luteal vaginal cystectomy, postoperative patient gradually recovered and discharged. Therefore, the vaginal surgery patients who require not only a firmer foundation, proficiency, soft, close postoperative observation, good nursing care is to prevent complications, an important measure to ensure successful operation.
2.2.5 Diet care after 6 hours into the liquid, but should avoid milk, soy milk, sugar and other gas production of food. Flatus backward semiliquid soft diet, then gradually transition to a normal diet. Encourage patients into high-protein, high in vitamins, fiber-rich foods, drink more water to meet the rehabilitation needs of the body after surgery, to prevent constipation.
2.2.6 Rehabilitation Guidance (1) General Director: Zhu Huanzhe home, pay attention to maintaining genital cleansing in general should rest for 3 months. Report of 7 to 14 days after gut absorption phase, should be more bed rest, there may be some vaginal bleeding, if the amount of menstrual bleeding more than should be timely treatment; 6 weeks before the ban bath, anti retrograde infection; 3 months to avoid heavy manual labor and increase abdominal pressure, attention gradually increase activity. (2) psychological guidance: re-explain the surgical procedure and the possible impact of telling patients and the female form with the sexual life is closely related to the vagina and the ovarian secretion of estrogen, in order to eliminate the defects and mental troubles. It is best to let her husband, accompanied by lectures, in order to obtain her husband's understanding and recognition. Encourage patients to participate in social activities after discharge and more, through integration into the community to regulate emotions, increase marital relations, quality of life.
2.2.7 sex guide 3 months after surgery vaginal stump complete wound healing, scar gradually softening, can be gradually restored sex life. The first time life can be applied to vaginal lubricants, for the first time after psychological stress of life can play the natural relaxing effect [5] clearly advertised on the sexual life of patients can not be a long period of panic, so that the adverse physical and mental rehabilitation, but also a long time influence their emotions lead to family discord. In order to improve the quality of life, 1 month after gradual functional exercise to strengthen pelvic floor muscles support the pelvic floor muscles and vaginal tightening degree of care ability to explain and teach pelvic floor muscle training methods were applied methods to encourage patients to qualified hospitals pelvic floor muscle rehabilitation devices and rehabilitation treatment for vaginal, vaginal tightening by increasing the degree to improve the quality of life.
3 body will be
3.1 With the progress of human civilization and the rapid development of science and technology, the majority of women on the increasing demand for quality of life, requiring a minimum of trauma to achieve the best therapeutic effect. Vaginal hysterectomy is almost entirely extraperitoneal surgery, peritoneal operation less disturbance of the abdominal organs, a very low incidence of postoperative bowel obstruction, trauma, postoperative pain, no abdominal scar but also to meet the needs of women's beauty and after you can get out of bed earlier, faster recovery of intestinal function can be consumed as soon as possible, on the lung function is smaller, therefore, the overall rapid recovery, surgery costs, after the application of antibiotics and complications of treatment costs are reduced, patients are generally satisfied. In addition, shorter operation time, trauma, anesthesia time and the depth of the corresponding decrease in medical complications in elderly patients and patients can better tolerate surgery, thus, more and more patients choose this surgery. However, vaginal hysterectomy because of its natural disadvantages, namely the operative field is small, exposed the difficulties, the operation space is small, too large for the uterus, pelvic adhesions, a malignancy may need a large ovarian tumor removed at the same time, you need both exploratory abdominal and those who are not mothers, not be suitable for the procedure [6].
3.2 New non-prolapsed uterus transvaginal hysterectomy for the treatment of gynecological diseases, new technologies, the surgery is difficult, technically demanding, but also of care put forward higher requirements. Good preoperative preparation, especially the preparation of the vagina and postoperative complications of observation care, physical and psychological rehabilitation guidance is particularly important, conventional surgery three days before the vaginal preparation is used 1:5000 potassium permanganate, 0.2 ‰ iodine flushing the vagina, This not only increased the suffering of the patients, but also extended hospital stay, increased costs, access to relevant information and expert guidance, 168 patients preoperatively with a 0.5% povidone-iodine scrub cervix and vagina, no infection occurred in 1 case . Transvaginal surgery may damage its natural disadvantages adjacent organs and blood vessels. Therefore, postoperative changes should be closely observed to detect complications of the disease threatened, close observation and timely treatment of complications after surgery can effectively ensure the safety and success. With the increasing demand on quality of life, good sex life after the bounden duty of the guidance to become nurses, were followed up for more than 40 patients, the majority of women using a vaginal lubricant, but because of shorter hospital stay on the basin floor muscle exercise method of control is not good, which need to be to strengthen women's health in the community. With the treatment of gynecological diseases, development of new technology and people required to improve the quality of life, requiring nurses to learn new business, new technologies, be diligent in their work to develop the habit of thinking, so careful observation, intensive care to meet patients with a wide range of needs.