Ovarian cancer is the primary cause of death from reproductive system malignancies in women. The American Cancer Society estimated that in 2005 in the United States, 22,220 new cases of ovarian cancer would be diagnosed, and it would take the life of 16,200 women. Only 77% have a 1-year survival rate, 44% have a 5-year survival rate. Only 19% of the cases are diagnosed before metastasis has occurred. Because of the lack of early detection and the rapid progression of the disease, the number of deaths caused by ovarian cancer has risen. No longterm improvement in the survival rate has occurred in the past 30 years.
Three types of ovarian cancers exist owing to the three types of tissue in the ovary: primary epithelial tumors, germ cell tumors, and gonadal stromal (sex cord) tumors. Primary epithelial tumors compose approximately 90% of all ovarian cancers and include serous and mucinous cystadenocarcinomas, endometrioid tumors, and mesonephric tumors. They arise in the ovarian epithelium (known as müllerian epithelium). Germ cell tumors, which arise from an ovum, include endodermal sinus malignant tumors, embryonal carcinoma, immature teratomas, and dysgerminoma. Sex cord tumors, which arise from the ovarian stroma (the foundational support tissues of an organ), include granulosa cell tumors, thecomas, and arrhenoblastomas.
Ovarian cancers grow and spread silently until they affect the surrounding organs or cause abdominal distension. At the appearance of these symptoms, metastases to the fallopian tubes, uterus, ligaments, and other intraperitoneal organs occur. Tumors can spread through the lymph system and blood into the chest cavity.
As the disease progresses, the patient experiences multiple system complications. Peripheral edema, ascites, and intestinal obstruction can complicate the course of the disease. Patients develop severe nutritional deficiencies, electrolyte disturbances, and cachexia. If the lungs are involved, the patient develops malignant recurrent pleural effusions.
Although several theories exist, the exact cause of ovarian cancer is unknown; many factors, however, seem to play a role in its development. A family history of ovarian cancer places the patient at risk, as does a diet high in saturated fats. It appears that ovarian cancer occurs in women who have more menstrual cycles (i.e., early menarche, late menopause, nulliparity, infertilty, and celibacy). Women who live in industrialized countries have a higher risk than do those in underdeveloped countries, where women have high parities. Exposure to asbestos and talc may place the patient at risk. Late menarche, early menopause, pregnancy, and oral contraception may offer a protective benefit by effecting ovulation suppression.
Nursing care plan assessment and physical examination
Elicit a detailed family history of all cancer-related illnesses, paying particular attention to the history of female relatives. The patient’s descriptions of the signs and symptoms vary with the tumor’s size and location; symptoms usually do not occur until after tumor metastasis. The symptoms patients most commonly report are back pain, fatigue, bloating, constipation, abodominal pain and urinary urgency. Most patients with ovarian cancer have at least two of these symptoms. Other symptoms include urinary frequency, abdominal distension, pelvic pressure, vaginal bleeding, leg pain, and weight loss. Pelvic discomfort and acute pelvic pain may occur, and if infection, tumor rupture, or torsion has resulted, the pain may resemble that of acute appendicitis.
The patient often appears thin and chronically ill. Her abdomen may be grossly distended, but her extremities are thin and even wasted. When you palpate the abdominal organs, you may be able to feel masses. During the vaginal examination, you may be able to palpate an ovary in postmenopausal women that feels like the size of an ovary in premenopausal women. An ovarian tumor may feel hard like a rock or pebble, may feel rubbery, or may have a cystlike quality. Palpation of an irregular, nodular (“handful of knuckles”), insensitive bilateral mass in the pelvis strongly suggests the presence of an ovarian tumor.
If the patient is a young woman who needs to undergo surgery and loses her childbearing ability, determine the meaning of children to her and her partner. Consider the patient’s developmental level, financial resources, job responsibilities, home care responsibilities, and the degree of independence of any children. If the patient is a child, determine whether or not her parents have told her she has cancer. If the prognosis of the patient’s cancer is poor, determine the patient’s degree of understanding of the gravity of the prognosis. Determine the effect of the patient’s religion and spirituality on the course of the disease.
Nursing care plan primary nursing diagnosis: Pain (acute) related to tumor invasion, tissue destruction, and organ compression.
Nursing care plan intervention and treatment plan
Aggressive surgical treatment is usually used. If there is a desire to preserve the fertility of young women or girls, however, a conservative approach may be used if they have a unilateral encapsulated tumor. In this approach, the surgeon may resect the ovary, biopsy structures such as the omentum and uninvolved ovary, and perform peritoneal washings for cytologic examination of pelvic fluid. These patients need careful follow-up with periodic diagnostic tests to determine if the tumor is metastasizing.
More typically, the surgeon performs a total abdominal hysterectomy and bilateral salpingooophorectomy with tumor resection. In addition, the surgeon performs an omentectomy, appendectomy, lymph node palpation with possible lymphadenectomy, and other biopsies and washings as necessary. Sometimes, the surgeon is unable to remove the tumor completely if it is wrapped around or has invaded vital organs. Monitor the patient carefully after surgery for complications such as wound infection, hemorrhage, fluid and electrolyte imbalance, and poor gas exchange.
If a young girl has had both ovaries removed, she needs hormonal replacement beginning at puberty so that she develops secondary sex characteristics. Chemotherapy after surgery prolongs survival time but is primarily palliative rather than curative, although it does provide remissions in some patients. Although radiation therapy is uncommon because it causes depression of the bone marrow, sometime patients receive it as an option to other treatments.
No matter which treatment is chosen to manage the patient’s cancer, pain management is an issue. Monitor the patient’s pain (location, duration, frequency, precipitating factors) and administer analgesics as needed. Determine the patient’s response to analgesia by asking the patient to rate her pain on a scale of 0 to 10, with 0 indicating no pain and 10 indicating the worst pain she has experienced. Collaborate with the physician to develop a painmanagement strategy that effectively keeps the patient free of pain and yet awake and alert without respiratory complications. Consider patient-controlled analgesia (PCA) as a possibility if intravenous medications are needed. If the patient’s disease is terminal, manage the pain so that the patient has a comfortable and dignified death.
Prevention and early detection are difficult in ovarian cancer because of the disease’s lack of obvious signs and symptoms. Encourage all adolescent girls and women to have regular pelvic examinations as part of an annual checkup. When the patient is diagnosed with ovarian cancer, she has to manage a host of physical and emotional problems. Help the patient manage any accompanying physical discomfort with nonpharmacologic strategies and pain medications. Teach the patient relaxation techniques or guided imagery. Explain the role of diversions as a mechanism to control pain. If the patient requires hospitalization for surgery or chemotherapy, teach her about the route, dosage, action, and complications of her analgesics so that she can manage her pain at home knowledgeably. If the patient is discharged with a PCA system, arrange for her to rent the equipment and obtain the prescriptions she needs to continue using it. If the patient’s family does not have the financial resources to manage the needed equipment, discuss her needs with a social worker or contact the American or Canadian Cancer Society for assistance.
Depression, grief, or anger is common in women who have been diagnosed with ovarian cancer. To determine the patient’s ability to cope, encourage her to discuss her feelings and monitor her for the physical signs of inability to cope, such as altered sleep patterns. Encourage her to express her feelings without fear of being judged. Note that surgery and chemotherapy may profoundly affect the patient’s and partner’s sexuality. Answer any questions honestly, provide information on alternatives to traditional sexual intercourse if appropriate, and encourage the couple to seek counseling if needed. If the woman’s support systems and coping mechanisms are insufficient to meet her needs, help her find other support systems and coping mechanisms. Provide a list of support groups.
Nursing care plan discharge and home health care guidelines
Teach the patient the need to have regular gynecologic examinations and to report any symptoms to her healthcare provider. Ensure that the patient understands the dosage, route, action, and side effects of any medication she is to take at home. Note that some of the medications require her to have routine laboratory tests following discharge to monitor her response.
Discuss with the woman helpful coping mechanisms. Encourage her to be open with her partner, her family, and her friends about her concerns. Help the patient cope with hair loss. Teach her cosmetic techniques to deal with hair and body changes. Explore alternative methods to medication to manage nausea and vomiting.
Discuss any incisional care. Encourage the patient to notify the surgeon of any unexpected wound discharge, bleeding, poor healing, or odor. Teach her to avoid heavy lifting, sexual intercourse, and driving until the surgeon recommends resumption.
Teach the patient to maintain a diet high in protein and carbohydrates and low in residue to decrease bulk. If diarrhea remains a problem, instruct the patient to notify the physician or clinic because antidiarrheal agents can be prescribed. Encourage the patient to limit her exposure to others with colds because radiation tends to decrease the ability to fight infections. To decrease skin irritation, encourage the patient to wear loose-fitting clothing and avoid using heating pads, rubbing alcohol, and irritating skin preparations.