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Radical Hysterectomy TREATMENT FOR ADVANCEDCERVICAL CARCINOMA Pamela H. Berger, RN; Howard M. Saul, DO

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he incidence of invasive cervical carcinoma and mortality rates from the disease have decreased with the introduction of the Papanicolaou (Pap) smear in 1943.’ Use of the Pap smear has lead to an increased detection of cervical cancer in the preinvasive stage. Today, 70’3 or more of cervical disease is detected as in situ (Stage 0) or early invasive (Stage Ia) lesions.? Early detection and eradication of cervical cancer precursors decrease the incidence of death from invasive cervical cancer.’ These precursors or dysplasias are referred to as cervical intraepithelial neoplasia (CTN), defined as “epithelial cells [that] are malignant but confined to the epitheli~m.”~ Cervical intraepithelial neoplasia occurs as a c o n t i n ~ u mIt. ~begins as CIN 1 or mild dysplasia in which neoplastic cells occupy the lower third of the epithelium. It may then progress to CIN 2 or moderate dysplasia where the lower two thirds

of the epithelium is occupied by neoplastic cells. This stage can progress to CIN 3, classic severe dysplasia/carcinoma in situ, where neoplastic cells almost reach the surface of the epithelium? Abnormal cell growth begins as a slow process. The preclinical and preinvasive stages can last as long as eight to 10 years. Some cell growth stops and never goes through the transformation to invasive carcinoma. If CIN becomes microinvasive or invasive carcinoma, cell growth rate may become more rapid. If untreated, death can result from invasion and metastasis within two to three years?

Pamela H. Berger, RN. BSN CNOR, IW assisrani nurse manager for gynecologv, OR, Cooper Hospital/Universi(v Medical Center, Caniden.New Jersc:r. when this article was written. She currently is the perioperative educator, Memorial Hospital of Burlington Counfv, Mt Holly. XeIti Jersqv. She earned her associate applied science degree in nursing from Dabney S. Lancaster Communitv College, Clifton Forge, Va, and her bachelor of science degree in nursingfrom Widener Crnirersi!v.Chester, Pa.

Oncology, Cooper Hospital/University Medical Center, Camden, New Jersey. He earned his medical degreefrom the University of Osteopathic Medicine and Health Sciences College of Osteopathic Medicine and Surgeiy, Des Moines.

Howard ,M.Saul. DO, is professor of clinical ohstetnc.\/,~:l:necologl?. Division of Gynecologic 1212

Etiology, Signs, Symptom

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ervical cancer is a sexually transmitted disease.8 Its cause is unknown, but repeated insults or injuries sustained by

The authors wish to acknowledge Thomas Rocereto, MD, division head, gynecologic oncology;Ann Gerfin, RN,BSN, CNOR, OR nurse manager;Justine Busch, RN, BSN, CNOR, clinical educator, OR; and Mary Alice Smith, RN,CNOR, assistant nurse manager, OR, all at Cooper Hospital/University Medical Center, Camden,New Jersey,for their assistance with this article.

DFCFMHFR 1990 VOL 5 2 NO 6

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Patients with a diagnosis of CIN are usually asymptomatic.

the cervix seem to play a role in its de~elopment.~ Risk factors include a history of multiple male sexual partners, intercourse at an early age, cigarette smoking, and a low socioeconomic status. Recent investigations have shown that the number of female sexual partners a man has had is an important factor in the incidence of cervical cancer in his current partner.10 An increased incidence of cervical cancer has been found in second wives of men whose first wives died of the disease." Increasing evidence is implicating the human papillomaviruses (HPV) role in squamous cell neoplasms of the female anogenital tract. This would include squamous cell cancers of the cervix.12 Recent studies have shown two types of HPV to be present in 90% to 95% of the squamous cell cancers of the cervix.13 Squamous cell carcinoma is responsible for 90% of all cervical cancers.14 Patients with a diagnosis of CIN are usually asymptomatic. Cervical lesions are discovered by screening cytology only (ie, Pap smear). Occasionally, a patient will report contact bleeding after douching, placing a diaphragm, or coitus. Bleeding is the only significant early symptom. It usually begins as a thin, watery, blood-tinged vaginal discharge that may go unrecognized by the patient. This may develop into intermittent painless metrorrhagia. The bleeding episodes increase as the tumor increases in size. Pain is a late symptom and is usually the result of induration around the tumor or secondary involvement of the ureters, pelvic wall, and sciatic nerve roots.l5

Diagnosis

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uccessful treatment of cervical cancer depends on accurately diagnosing the extent of the disease. Once a patient has an

abnormal Pap smear, the goal is to rule out invasive carcinoma by pelvic examination, colposcopy, colposcopically directed biopsies, and endocervical curettage. If the diagnosis of CIN can be made positively at this point, the patient can be treated by local destruction of the lesion. The entire transformation zone of the cervix must be treated. This usually is done on an outpatient basis. Treatment can be by laser, cryosurgery, local excision, electrocautery, or conkation. A hysterectomy may be considered if the woman is past childbearing age. A colposcopic biopsy will indicate the need for a cone biopsy if the squamocolumnar junction cannot be visualized, the total lesion cannot be visualized, there are positive endocervical curettings, microinvasion was diagnosed on previously obtained colposcopic biopsies, or there is a large discrepancy between the Pap smear and the colposcopic biopsy. If the patient has invasive carcinoma, she must undergo further diagnostic studies to detect metastatic spread.

Staging

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ervical carcinoma spreads by direct extension into the parametria, vaginal mucosa, myometrium of the lower uterine segment, paracervical lymphatics and on to the obturator, hypogastric and external iliac lymph nodes, or to direct structures (eg, bladder, rectum).16 Staging is a comprehensive process to determine the extent of the disease. It is also used to accurately communicate between institutions. The most important function of staging is that it serves as a method of comparing treatment used in one institution with that used in an0ther.I' For these reasons, once a stage has been determined and 1213

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treatment started, it cannot be changed by later findings. Staging is done usually on an outpatient basis. The physician begins initial staging of the patient with a physical examination, including palpation of the supraclavicular and inguinal nodes and the abdomen. He or she examines the patient's pelvis with a speculum and bimanual recto-vaginal exam. The second half of the staging process involves diagnostic studies. The patient undergoes an intravenous pyelogram (IVP) to rule out hydronephrosis, which can be caused by extension of the disease process. Metastasis to the lung is ruled out by a chest x-ray. Laboratory studies include a complete blood count, serum blood urea nitrogen, creatinine. liver enzymes. and electrolytes. These serve as baseline data and also may detect possible metastases. The patient may have a cystoscopy to rule out direct extension to the bladder. This is not mandatory in stage 1 disease, however, it should be done if the lesion is more advanced. The physician may consider a proctoscopy if he or she suspects rectosigmoid extension.I * When the physician completes all components of the staging exam, a stage is assigned. Treatment options are then chosen, based on the clinical stage of the disease (Table 1).

removal of the uterus, its uterosacral and uterovesicle ligaments, the upper one third of the vagina, and all of the parametrium. This is generally done in conjunction with paraortic and pelvic lymphadenectomy. Advantages to this procedure are that it permits ovarian conservation, establishes the precise extent of the tumor, and leaves a more functional vagina. This surgery offers a psychological advantage to the patient in that the tumor mass has been removed, the treatment plan is shorter, and prognostic information may be gained. Disadvantages to this surgery include the normal risks of anesthesia, thromboembolic phenomena, urologic or bowel injury or dysfunction, hemorrhage, infection, and death. Changes that the patient may experience after radical hysterectomy include bladder hypertonicity resulting in decreased bladder capacity, difficulty initiating micturation, and the loss of sensation of the need to mi~turate.'~Normal bladder function usually returns within six months. Sensory alterations may persist indefinitely.20Patients are likely to experience alterations in body image due to shortening of the vagina and loss of reproductive capabilities as a consequence of surgery. Radiation therapy usually is considered for those patients who are over 65, are morbidly obese, or who have a cardiovascular, pulmonary, or metabolic disease.21

Treatment

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reatment for stage 0 is conization and progresses to total hysterectomy, either abdominal or vaginal, for stage Ial. Stage Ia2, when the depth of invasion is less than 3 mm and there is no lymph/vascular space involvement, may be treated by an extrafascial or modified radical hysterectomy. Stage Ia2 lesions with invasion deeper than 3 mm or with lymph/vascular space involvement, Stage Ib, and IIa lesions (Fig 1) can be treated by either a radical hysterectomy and paraortic and pelvic lymphadenectomy or radiation therapy. Since the cure rate of the disease at this stage is the same whether surgery or radiation is done, the decision is made on an individual basis. Radical hysterectomy is defined as wide

Preoperative Preparation

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reparing the patient for radical hysterectomy begins in the physician's office with a discussion of the surgical procedure. Body changes that will occur, in particular the shortened vagina and sterility, are discussed with the patient. The physician allows adequate opportunity for the patient to discuss her feelings about surgery and the diagnosis of cancer. If necessary, the physician gives the patient the names of other patients who have been through similar surgery and who are willing to discuss their feelings and experiences. At this time, the physician should discuss the changes that will occur in bladder function because of the surgery. The majority of patients scheduled for radical

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Table 1

International Classification of Cancer of the Cervix Stage 0 Stage I

Stage Ia

Stage Ial Stage Ia2

Stage Ib

Carcinoma in situ. The carcinoma is strictly confined to the cervix (extension to the corpus should be disregarded). Preclinical carcinomas of the cervix; that is, those diagnosed only by microscopy. Minimal microscopically evident stromal invasion. Lesions detected microscopically that can be measured. The upper limit of the measurement should not show a depth of invasion of more than 5 mm taken from the base of the epithelium, either surface or glandular, from which it originates, and a second dimension, the horizontal spread, must not exceed 7 mm. Larger lesions should be staged as Ib. Lesions of greater dimensions than Stage Ia2, whether seen clinically or not. Preformed space involvement should not alter the staging but should be specifically recorded so as to determine whether it should affect treatment decisions in the future.

Stage I1

Involvement of the vagina but not the lower third, or infiltration of the parametria but not out to the side wall. Stage IIa Involvement of the vagina but no evidence of parametrial involvement. Stage IIb Infiltration of the parametria but not out to the side wall. Stage 111 Involvement of the lower third of the vagina or extension to the pelvic side wall. Stage IIIa Involvement of the lower third of the vagina but not out to the pelvic side wall if the parametria are involved. Stage IIIb Involvement of one or both parametria out to the side wall. Stage 111 Obstruction of one or both ureters on intravenous (urinary) pyelogram without the other criteria for Stage 111 disease. Stage IV Extension outside the reproductive tract. Stage IVa Involvement of the mucosa of the bladder or rectum. Stage IVb Distant metastasis or disease outside the true pelvis.

(Reprintedfrom Clinical Gynecologic Oncology, 3rd ed, (1989), P J DiSaia, W T Cremman, with permksion from The C V Mosby Co, St Louis)

hysterectomies at Cooper HospitalAJniversity Medical Center (CHAJMC), Camden, NJ, are admitted the day before surgery. On the afternoon of admission the anesthesiologist will visit the patient and discuss the proposed anesthesia. The patient also will be visited by the perioperative nurse. The preoperative visit is an important part of the patient’s preoperative preparation. It allows the patient a chance to ask questions that may be on her mind, thus decreasing the fear of the unknown. The nurse takes time to develop a

rapport with the patient, ensuring that when the patient arrives in the operating room, she will be greeted by a familiar person. These measures all help to decrease the normal preoperative anxiety. During the visit, the perioperative nurse discusses the operating room routine with the patient. The nurse also gives the patient time to ask questions about the proposed surgery. If the patient’s family is present, the nurse explains about the family waiting area, the average length of the procedure, the scheduled time of the surgery, when the patient will leave her room, and the 1215

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Fig 1. Cervical intraepithelial neoplasia, Stage IIa. approximate length of stay in the postanesthesia care unit (PACU). The nurse explains to the patient and family that the patient will be in the holding area for a period of time before she is taken to the operating room. In discussing the holding area routine, the perioperative nurse describes the intravenous line that will be started, the questions that the holding room nurse will ask the patient, and the paper cap that will cover the patient’s hair. While she is talking with the patient, the perioperative nurse can assess the patient for the presence of problems or conditions that might require adaptations of the normal operative routine or equipment (ie, an allergy or chronic low back pain). The patient is told that she will be allowed nothing to eat or drink after midnight. The perioperative nurse instructs the patient to remove all jewelry and to give it to a relative for safe keeping. The nurse explains the necessity of removal of contact lenses and dentures before coming to the operating room. The risks of thromboembolic phenomena and measures taken by the surgeons at CH/UMC to prevent them are discussed with the patient. These measures include a preoperative injection of heparin and the wearing of thigh-high antiem1216

bolism hose. Intraoperatively, the nurse places sequential compression stockings on the patient. The morning of the surgery, the perioperative nurse prepares the OR for the proposed surgery. The patient’s temperature is maintained during the surgery by the use of a warming blanket on the bed. The nurse prepares specimen slips for the frozen sections and peritoneal washings that are sent during the case. Instrumentation for this procedure includes normal instrumentation for a hysterectomy, long instruments, and extra deep retractors (Fig 2). An extra large self-retaining abdominal retractor often is needed. If during the preoperative visit and assessment the perioperative nurse noted that adaptations would need to be made, they are made at this time. The nurse goes to the holding room where he or she greets the patient. At this time the nurse verifies the patient’s identity. assesses the patient, and checks the chart for a valid operative permit, required paperwork, and laboratory studies. Any discrepancies are noted and reported to the appropriate individuals. If all is in order, the nurse accompanies the patient to the operating suite and assists her in transferring to the operating room bed. He or she places a safety strap across the patient’s thighs and covers her with warm blankets.

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Fzg 2. Deep instruments used for radical hysterectomy include four Lemon retractors (a), two Deaver retractors (b), long vein retractor (c) , long Russian and DeBakey forceps (d), ring forcep (e) , long regular and Heaney needle holders 03,long straight and curved Allis clamps (g) , long right angles (h), and long scissors (0.

Intraoperative Phase

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s the induction of anesthesia is begun, the circulating nurse is present at the side of the patient. She holds the patient’s hand and ensura that OR noise level is kept to a minimum. Comfort measures along with the preanesthesia drugs that have been given help to decrease the preoperative anxiety level of the patient. The nurse assists anesthesia personnel as necessary during induction. After the induction of anesthesia and intubation, the nurse places the patient in a frog-legged position. To confirm the stage of the disease, the surgeon may perform a bimanual recto-vaginal examination under anesthesia. Following this, the nurse preps the vagina with povidone-iodine and inserts a Foley catheter. The catheter is connected to a gravity drainage/collection system. The nurse then repositions the patient in the supine position and thigh-high sequential compression stockings are applied over the antiembolism hose on both legs. After the nurse completes a routine abdominal prep, he or she applies an 1218

electrocautery grounding pad to the patient on the surface of a large muscle mass, usually the anterior lateral thigh. The surgical team then drapes in a routine fashion for a laparotomy. The surgeon makes a midline incision from above the umbilicus to the symphysis pubis to allow for adequate exposure. A transverse incision such as a Maylard may be an acceptable alternative, depending on the patient’s body configuration. The patient’s abdomen is opened in routine fashion and the surgeon begins peritoneal washings for cytology immediately upon dissecting into the peritoneal cavity. He or she explores the abdominal cavity for signs of metastatic disease and begins paraortic, common iliac, and pelvic lymphadenectomy. The nurse sends specimens retrieved by the surgical team for frozen section. Figure 3 shows the normal location of the paraortic, common iliac, and pelvic lymph nodes. If the specimens are positive for metastatic disease, the surgeon abandons the radical hysterectomy. The surgeon suspends the ovaries to the lateral sidewall cephalad to the iliac crest.

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Fig 3. Anatomy of the pelvic lymph/vascular structures. Shown are the ureters (a), paraortic lymph nodes (b), inferior vena cava (c), aorta (d), right common iliac nodes (e), left common iliac nodes 03, presacral nodes (g), right external iliac nodes (h), left external iliac nodes (i), hypogastric nodes f j ) , hypogastric artery (k), obturator nodes (I), and obturator nerve (m). (Figure adapted with permission from illustration by Howard Saul, DO)

This prevents them from being damaged by subsequent radiation therapy, which would result in early menopause for the patient. The surgeon closes the incision in the normal fashion. Postoperatively, the patient is referred for radiation therapy. If the pathologist finds the lymph nodes are negative, the surgeon begins developing the avascular paravesical and pararectal spaces and any suspicious parametrial area is biopsied and sent for frozen section. If the results of the frozen sections confirm that the patient’s tumor is still confined to the cervix or upper vagina, the surgeon completes the radical hysterectomy. He or she dissects the ureters out of the parametrial tunnel and ligates the uterine arteries at their origin from the internal iliac artery. The surgeon ligates the parametrial tissues at the pelvic sidewall and the uterosacral ligaments at their origin and removes the upper one third of the vagina. At the completion of the procedure, he or she places retroperitoneal drains and closes 1220

the abdomen in a normal fashion. The circulating nurse’s responsibility during the surgery is to provide needed sterile supplies to the operative field. He or she assists the operative team in maintaining aseptic technique and receives specimens from the field, labels them, and sends them to pathology. The circulating nurse also assists anesthesia personnel in the calculation of fluid loss by weighing sponges and monitoring suction cannisters. If blood replacement is necessary, the circulating nurse obtains the needed blood and assists anesthesia personnel in proper identgcation of the blood product and the patient. As the retroperitoneum is closed, the perioperative nurses complete a sponge count. The nurses count sponges, needles, sharp, and instruments at the closure of the parietal peritoneum and the fascia. A fmal sponge, needle, and sharps count is taken as the skin is closed. Transient hypertonic bladder occurs following this surgery, therefore a suprapubic catheter is needed. The circulating nurse assists in the insertion

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of this catheter. Using aseptic technique, he or she disconnects the Foley catheter from its drainage system and instills approximately 400 mL of warm normal saline solution into the bladder through the catheter, which is then clamped. This distends the bladder to allow for easy insertion of the suprapubic catheter. The surgeon inserts the catheter and connects it to a gravity drainage/ collection system. This empties the bladder of the saline solution and the Foley catheter can then be removed. The nurse washes any residual prep solution from the patient’s abdomen to prevent skin irritation and applies tape to the dressings. The nurse notifies the PACU of the patient’s impending arrival and condition. He or she assists anesthesia personnel with extubation of the patient and accompanies the anesthesia/surgical team and the patient to the PACU. When the PACU and anesthesia staff consider the patient stable and adequately recovered from the anesthesia, they transfer the patient to the gynecology floor.

Postoperative Period

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ypical postoperative hospital stays last between 10 and 14 days until the patient’s bladder function has returned o r is adequate for discharge. The nurse encourages the patient to ambulate on the first postoperative day. The patient receives subcutaneous heparin and wears antiembolism hose for five postoperative days. The patient is NPO until normal bowel sounds return. Retroperitoneal drains remain in place until drainage drops to less than 50 mL per drain per day. The patient undergoes an IVP at approximately day seven, and the nurse encourages the patient to try to void on day 10. If residual urine after voiding is less than 100 mL, the nurse removes the suprapubic catheter. If postvoiding residuals remain high, the nurse instructs the patient in the catheter’s use and care, and the patient is discharged with the catheter in place. The physician can remove the catheter in the ofice when indicated. The patient is seen for follow-up visits every two months for six months, every three months for the next year and a half, and then every six months for life. Cancer recurrence rates for patients treated with l222

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radical hysterectomy and bilateral lymphadenectomy is between 10%and 20%.22 For the majority of the patients, surgery is a curative procedure and allows them to continue to lead a normal life with minimal or no alterations in their life-style. 0 Notes 1. R F Mattingly, J D Thompson, TeLinde’s Operafive Gynecology, sixth ed (Philadelphia: J B Lippincott Co, 1985) 759. 2. Ibid. 3. J H Nelson, Jr, H E Averette, R M Richart, “Cervical intraepithelial neoplasia (dysplasia and carcinoma in situ) and early invasive cervical carcinoma,” CA-A Cancer Journal for Clinicians 39 (May/June 1989) 157. 4. P J Disaia, W T Creasman, Clinical Gynecology Oncology third ed (St Louis: The C V Mosby Co, 1989) 5. 5. Nelson, Averette, Richart, “Cervical intraepithelial neoplasia (dysplasia and carcinoma in situ) and early invasive cervical carcinoma,”l57. 6. hid, 170. 7. S B Gusberg, H M Shingleton, G Deppe, eds, Female Genital Cancer (New York: Churchill Livingstone, 1988) 275. 8. Nelson, Averette, Richart, “Cervical intraepithelial neoplasia (dysplasia and carcinoma in situ) and early invasive cervical carcinoma,” 163. 9. DiSaia, Creasman, Clinical Gynecologic Oncology, 67. 10. Nelson, Averette, Richart, “Cervical intraepithelial neoplasia (dysplasia and carcinoma in situ) and eariy invasive cervical carcinoma,” 166. 11. I I Kesler, “Veneral factors in human cervical cancer: Evidence from martital clusters,’’ Cancer 39 (April 1977) 1912-1919. 12. Nelson, Averette, Richart, “Cervical intraepithelial neoplasia (dysplasia and carcinoma in situ) and early invasive cervical carcinoma,” 167. 13. DiSaia, Creasman, Clinical Gynecologic Oncology, 11. 14. Ibd 79. 15. Ibid 75. 16. Nelson, Averette, Richart, “Cervical intraepithelial neoplasia (dysplasia and carcinoma in situ) and early invasive cervical carcinoma,” 168. 17. DiSaia, Creasman, Clinical Gynecologic Oncology, 75. 18. hd,82. 19. K M OLaughlin, “Changes in bladder function in the woman undergoing radical hysterectomy for cervical cancer,” Journal of Obstemc, Gynecologic,and Neonad Nursing, 15 (September/October 1986) 38 1. 20. hid. 2 1. Gusberg, 536.

22. DiSaia, 107.

AORN JOURNAL

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Lxamination HOMESTUDYPROGRAM

1. Cervical intraepithelial neoplasia (CIN) encompasses all dysplasias of the cervix. Which of the following is thought to contribute to cancer of the cervix? 1. multiple sexual partners 2. intercourse at an early age 3. cigarette smoking 4. human papilloma virus (HPV) a. 1 and 2 b. 2 a n d 3 c. 1, 2, and 3 d. all of the above 2. The cause of CIN is unknown, but repeated insults or injuries to the cervix play a role in the development of cervical cancer. a. true b. false 3. What role does the sexual history of a man play in transmission of CIN? 1. no role 2. HPV exposure can put the man’s partner at risk for CIN 3. Previous female partners who have died of CIN place current female partner at risk for CIN. 4. The man’s role in CIN transmission has not been explored a. 1 only b. 2 and 3 c. 3 only d. 4 only 4. In 1943, what test played a major part in diagnosing and thus reducing mortality from cancer of the cervix? a. conization of the cervix

b. culposcopy c. Papanicolaou smear d. routine pelvic exam 5. Early diagnosis of CIN is made by cytology screening only (Pap smear). a. true b. false 6. What can a woman do to increase early diagnosis of CIN? 1. nothing 2. undergo routine pelvic exams 3. have Pap smears on a routine basis 4. engage in positive thinking a. all of the above b. 1 only c. 4 only d. 2and 3 7. Patients with CIN usually are asymptomatic. a. true b. false 8. When CIN becomes symptomatic, patients may experience 1. abdominal pain 2. changes in the menstrual cycle 3. occasional bleeding following douching, coitus or insertion of a diaphragm 4. hot flashes a. 1 and 3 b. 3 and 4 c. 1,2, and 3 d. all of the above 9. CIN develops slowly and on a continuum. Which of the following statements are true? 1. Preclinical and preinvasive stages can last for eight to 10 years. 1223

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10.

11.

12.

13.

14.

2. CIN begins as mild dysplasia and progresses to severe dysplasia/carcinoma in situ before becoming invasive. 3. Some instances of preclinical and preinvasive cell growth never progress to an invasive carcinoma. 4. If CIN becomes microinvasive or invasive carcinoma, cell growth becomes more rapid and death can result in 2 to 3 years if untreated. a. all of the above b. 2 only c. 1, 2, and4 d. 4 only Cancer of the cervix is classified in stages designated as 0 to IV. Why is it necessary to stage carcinoma of the cervix? 1. to determine treatment 2. to describe the degree of invasion of the cancer 3. to communicate diagnoses among health care facilities 4. to evaluate treatment outcomes a. 1, 2, and 4 b. 1 and 4 c. 2 and 3 d. all of the above Staging is accomplished through a. cytologic examination b. physical examination of the abdomen, lymph nodes, and pelvis c. laboratory, radiologic, and endoscopic examination d. all of the above Staging classifications are based on the internationalclassifications for cervical cancer criteria. a. true b. false Treatment for stage 0 to Ial involves local destruction of the lesion by laser, cryosurgery, local excision, electrocautery, or conization. a. true b. false Radical hysterectomy is considered a treatment for stage Ia2 and higher and may be combined with radiation and lymphadenectomy depending on a patient’s disease stage.

DECEMBER 1990, VOL. 52, NO 6

15.

16.

17.

18.

19.

a. true b. false Radiation therapy is considered for patients who a. are over 65 b. are morbidly obese c. have cardiovascular, pulmonary, or metabolic disease. d. all of the above When frozen sections are positive and radical hysterectomy is abandoned, what treatment is offered? 1. no treatment is available 2. pelvic exoneration 3. chemotherapy 4. radiation therapy a. 1 only b. 2 a n d 3 c. 3 only d. 4 only In the preoperative interview, the perioperative nurse should prepare the patient for a. the use of anitembolism hose and preoperative subcutaneous heparin injection to prevent thrombophlebitis b. intravenous lines that will be inserted preoperative1y c. Foley and superpubic catheters d. all of the above Why are sequential compression stockings used intraoperatively? a. to assist in resuscitation measures should there be large blood losses b. to help prevent thromboembolic phenomena c. to maintain the patient’s temperature d. to prevent pressure sores Which of the following statements about frozen sections apply to radical hysterectomy? a. Frozen sections are not done. b. Frozen sections of lymph nodes and tissue are used to determine metastatic spread and whether radical hysterectomy should be pursued. c. Frozen sections are used only to stage the patient and have no impact on the surgical procedure. d. Frozen sections are based only on surgeon

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preference. 20. Both a Foley catheter and a superpubic catheter are used during radical hysterectomy. Why? 1. The Foley catheter is used to keep the bladder drained intraoperatively and to assist in insertion of a superpubic catheter. 2. Transient hypertonic bladder occurs following this surgery, and the patient requires drainage of the bladder sometimes even after discharge. 3. Catheter use is based on surgeon or hospital preference. 4. Using two catheters is a chance to charge

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the patient for extra supplies. a. 1 only b. 2 only c. 1 and 2 d. 3 and 4 Professional nurses are invited to submit clinical or managerial manuscripts for the home study program Manuscripts or queries should be sent to the Editor, AORN Journal, 101 70 E Mksksippi Ave, Denver, CO 80231. As with all manuscripts sent to the Journal, papers submitted for home study programs should not have been previously publkhed or submitted simultaneously to any other publication

American Dialysis Patients Have Lower Survival Rate Dialysis patients in the United States have a lower survival rate than those in other countries. From 1982 to 1987,22%more deaths occurred among American dialysis patients than European patients. Thirty-three percent more deaths occurred among American than Japanese dialysis patients. A recent international meeting compared data from five major registries in the world that track dialysis patients. The five registries (ie, Europe, Japan, Canada, AustraliajNew Zealand, United States) account for 90%of the world's dialysis patients. The data were summarized in a news release from the National Kidney Foundation, Inc. According to the report, there are several possible reasons for the poorer survival rate in the United States. First, there are simply more patients per million population as compared with other developed nations. Also, American patients may not undergo sufficient dialysis. The average dialysis in the United States is 10 hours per patient per week. This compares with 12 to 13 hours in West Germany and almost 15 hours in Japan. Questions about the adequacy of US reimbursement (eg, Medicare) for dialysis treatments are related to the amount of dialysis patients receive in the United States. West Germany pays

about twice the US amount and Japan pays almost three times the US rate. Another possibility for the poorer US survival rate may be lower compliance by patients. According to the report, up to 20% of US dialysis patients miss at least one treatment a month and 20% ask to come off their treatments early. If further investigation shows that the roles of reimbursement and compliance are major factors, changes could be initiated to help improve the survival rate of US dialysis patients.

Repeated Treatments Do Not Affect Patellar Tendons Cadaveric patellar tendons commonly are used in repair of injured anterior cruciate ligaments. Researchers have been examining the effects repeated freeze-thaw and irradiation procedures have on the tendons. According to the September 1990 issue of the American Red Cross Tissue Services Newsletter, repeated freezing and thawing do not affect material properties or mechanical strength. Irradiation at 1.95 Mrad does not significantly affect mechanical properties of the patellar tendon. Irradiation at 3 Mrad, however, adversely affects strength and flexibility. 1225

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DECEMBER 1990, VOL. 52, NO 6

Answer Sheet RADICALHYSTERECTOMY

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lease fill out the application and answer form below and the evaluation on the back of this page. Tear out the page from the Journal or make photocopies and mail to: AORN Accounting Department c/o Home Study Program 10170 E Mississippi Ave Denver, CO 80231 Session # 5494 Event # 915005 Program offered December 1990 The deadline for this program is June 30, 1991. 1. Record your identification number in the appropriate section below. 2. Completelydarken the space that indicates your answer to the examination starting with question one. 3. A score of 70% correct is required for credit. 4. Record the time required to complete the program 5. Enclose fee: Members $7; Nonmembers $14.

Mark only one answer per question 1 2 3 4 5 6

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DECEMBER 1990, VOL. 52. NO 6

Learner Evaluation The following evaluation is used to determine the extent to which this home study program met your learning needs. Rate the following items on a scale of 1 to 5. 1. Objectives. To what extent were the following

objectives of this home study program achieved? ( 1 ) Identify contributing factors in cervical cancer. (2) Identify the means of diagnosing cervical cancer. ( 3 ) Discuss the development, signs, and symptoms of cervical cancer. (4) Discuss the classifications and staging of cervical cancer. (5) Discuss the treatment for cervical cancer. ( 6 ) Identify the role of the perioperative nurse in caring for the patient requiring radical hysterectomy. 2. Content. (1) Did this article increase your knowledge of the subject matter? (2) Was the content clear and organized? (3) Did this article facilitate learning? (4) Were your individual objectives met? ( 5 ) Was the content of the article relevant to the objectives? 3. Test quesfion/answers. (1) Were they reflective of the content? (2) Were they easy to understand? (3) Did they address important points?

(Low)

(1)

(1)

(1) (1) (1)

(1)

(1) (1) (1) (1) (1) (1) (1) (1)

4. What other topics would you like to see addressed in a future home study program? Would you be interested or do you know someone who would be interested in writing an article on this topic? Topic(s) :

Author names and addresses:

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Radical hysterectomy. Treatment for advanced cervical carcinoma.

DECFMBEK 1990. VOL 52. NO 6 $ O K \ .IOI’RNAI. Radical Hysterectomy TREATMENT FOR ADVANCEDCERVICAL CARCINOMA Pamela H. Berger, RN; Howard M. Saul, D...
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