COLLEGE OF HEALTH SCIENCES

SCHOOL OF NURSING

COURSE CODE: NSC 313

COURSE TITLE: ACCIDENTS AND EMERGENCIES NURSING

WRITE UP ON: SCRUBBED UP CASE ON MYOMECTOMY

PRESENTED BY: NUR/15/12

SIGNATURE:

PRESENTED TO: MRS. P. BUDOTICH

DATE:23/05 /2014

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Table of ContentsLIST OF ABBREVIATIONS..........................................................................................................3

CHAPTER ONE..............................................................................................................................3

1.1 Demographic data......................................................................................................................3

1.2 Patient’s history.........................................................................................................................4

1.3 Physical examination.................................................................................................................4

1.4 Assessment of the patient using Gordon’s Functional Health Patterns.....................................4

CHAPTER TWO.............................................................................................................................5

INVESTIGATIONS........................................................................................................................5

2.1 ABDOMINAL ULTRASOUND...............................................................................................5

2.2 Full Hemogram..........................................................................................................................6

CHAPTER THREE.........................................................................................................................6

MEDICAL, SURGICAL AND NURSING MANAGEMENT.......................................................6

Admission procedure.......................................................................................................................6

Preoperative care.............................................................................................................................7

Reception of patient in theatre.........................................................................................................7

Anesthetic Area...............................................................................................................................7

SURGICAL PROCEDURE.............................................................................................................8

THE OPERATION PROCEDURE...............................................................................................10

Medico-legal Consideration...........................................................................................................10

THE POST-ANAESTHETIC CARE UNIT (PACU)...................................................................10

NURSING CARE PLAN..............................................................................................................11

CHAPTER FOUR.........................................................................................................................12

LITERATURE REVIEW..............................................................................................................12

CHAPTER FIVE...........................................................................................................................17

CONCLUSIONS AND RECOMMENDATIONS....................................................................17

REFERENCES..............................................................................................................................17

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LIST OF ABBREVIATIONSI.V : Intravenously

IVFs: intravenous fluids

I.M: intramuscular

LMNP: Last Normal Menstrual Period

MRI: Magnetic Resonance and Imaging

PACU: Post-anesthesia care unit

UEC’s: urea, electrolyte and chlorides

WHO: World Health Organisation

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CHAPTER ONE

1.1 Demographic dataName: A.K

Age: 24 years

Sex: Female

I.P No.: 0216973

Occupation: University Student

RELIGION: Christian

Marital status: Single

Residence: Kipkorgot

Date of admission: 20/12/13

Date of operation: 17/4/14

Diagnosis : Uterine Fibroids

Operation: Myomectomy

1.2 Patient’s historyHistory of presenting illness

A.K was brought the hospital out patient department with chief complains of a palpable abdominal mass for two months, excessive uterine bleeding for one week and increased bladder pressure with urinary frequency for three days.

Past medical history

This is her first admission to the hospital. She has no history of surgery or blood transfusion. She has no known history of drug and food allergy.

Family and Social history

A.K is the third born in a family of five. She is a second year university student. There is no known family history of chronic illnesses.

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Obstetric and Gynecology History

A.K is a Para 0+0 single lady. Her LMNP was on 1st Dec, 2013. She has never had any miscarriage before.

1.4 Assessment of the patient using Gordon’s Functional Health PatternsHEALTH PERCEPTION-HEALTH MANAGEMENT PATTERN.

A.K understands importance of health as an important part of life. She adheres completely to taking medications. She does not take cigarettes. She understands her condition and she is ready to maintain safe health-seeking behaviors.

NUTRITIONAL- METABOLIC PATTERN

A.K has appetite and feeds to satisfaction. She has been retaining her oral intake with no reports of vomiting.

ELIMINATION PATTERN

A.K is able to pass stool after one day and her normal bowel elimination regained.

ACTIVITY-EXERCISE PATTERN

A.K can walk and move freely as well as perform all the activities of daily living unassisted. She can bathe, feed, work and maintain her academics without any assistance.

SLEEP-REST PATTERN

A.K sleeps comfortably throughout the night after administration of analgesics.

COGNITIVE-PERCEPTUAL PATTERN

A.K is well oriented, hears, tastes and is as able to comprehend and use information.

SELF PERCEPTION-SELF CONCEPT PATTERN

She has strong self-esteem despite of her condition.

ROLE-RELATIONSHIP PATTERN

A.K is a 24-year-old single lady without children. She was assisting the family in daily activities and casual labor to generate income for the family. Her condition has really separated her from the family and also has impacted negatively on the family’s source of income.

VALUE-BELIEF PATTERN.

A.K is a Christian and believes in God as a supernatural healer. She has no conflicts between treatment and beliefs. She always reports to hospital when not able to cope with a condition.

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COPING-STRESS TOLERANCE PATTERN

A.K is able to cope with stress and live comfortably. She is always ready to share experiences and seek for advice.

SEXUALITY-REPRODUCTIVE PATTERN

A.K is a Para 3+1 and 27 years. She had her menarche when she was 13 years. She can’t remember her last normal menstrual period (LMNP).

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CHAPTER TWO

INVESTIGATIONS

2.1 Abdominal Ultrasound Showed well-defined solid masses in the submucosal lining of the endometrium making the uterus appear bulky with rugged surfaces.

2.2 Full HemogramParameter Results Reference Range CommentWBC 5.1 x109/L 4.0-11.0 NormalLymph # 2.8 x 109/L 0.8-4.0 NormalMid 0.2 X 109/L 0.1-0.9 NormalGran 2.1 x 199/L 2.0-7.0 NormalLymph % 54.1 20.0-40.0 HighHGB 11.6g/dl 11.0-15.0 NormalRBC 4.15 x 1012 3.00-5.00 NormalHCT 33.5 37.0-48.0 LowMCV 80.8FL 82.0-95.0 LowMCH 27.9pg 27.0-31.0 NormalMCHC 34.6g/dl 32.0-36.0 NormalPCT 0.261 0.108-0.282 Normal

2.3. UEC’s on 15th April 2014Parameter Result unit Reference range commentCREA JaffeGen 2 comp

20µM/L 44-80µM/L Low

Chloride indirect 103.1 mmol/L 98-107.0 mmol/L NormalK indirect 4.10 mmol/L 3.5-5.10 mmol/L NormalNa indirect 131.9 mmol/L 136.0-145.0 mmol/L LowUrea 3.43 mmol /L 0.00-8.30 mmol/L Normal

2.4. Grouping and cross-matchingBlood grouping done showed that she was blood group O Rhesus positive.

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CHAPTER THREE

MEDICAL, SURGICAL AND NURSING MANAGEMENT

Admission procedureThe patient was brought to MTRH by her mother , several investigations were done and she was admitted to Faraja ward for pre-operative management awaiting theatre.

Preoperative careThe patient was informed of her condition and the type of operation she was to undergo, it’s advantages and the risks involved and later the patient signed consent. Her blood sample was taken for grouping and cross-matching in readiness for transfusion if need arises. The blood electrolytes level and hemoglobin level were taken as well. She was then starved for six hours before operation.

Reception of patient in theatreThe nurse at the recieving area recieved the patient to the theatre unit who was accompanied by the ward nurse. The two nurses discussed and confirmed before handing over the patient’s file.The following was discussed and confirmed before the patient was transferred to theatre trolley.

a) Identification band, the name on file and her IP number.b) The pre-operative preparation of the patient as indicated by ticking and signing on the

operative checklist.c) The validity of the consent was confirmed.d) The patient’s haemoglobin was checked and was 12.9 g/dl.e) Serology test was Non-reactive.f) The patient’s blood group was checked and was found to be Group O rhesus +ve.g) The patient’s vital signs were taken and was found to be within normal ranges.

Anesthetic AreaThe anesthetic room nurse received the patient in to the anesthetic corner. She confirmed that the patient’s pre-operative checklist was fine. The anesthetist with the help of anesthetic room nurse administered the following anaesthetizing drugs:

1) Suxamethonium 200 mg I.M : A nerve blocker given to prolong the action of pancuronium thus maintaining the muscle paralysis and state of anesthesia.

2) Atropine 1.2 mg I.M: used to decrease saliva and phlegm and to control stomach/intestinal spasms.

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3) Halothane: is indicated for the induction and maintenance of general anesthesia.4) Pancuronium: indicated as an adjunct to general anesthesia, to facilitate tracheal

intubation and to provide skeletal muscle relaxation during surgery or mechanical ventilation.

The following additional drugs were given :

i. Ceftriaxone 720 mg I.Mii. I.V drips Normosaline 1500 mls.

SURGICAL PROCEDURE Operating room

Scrubbing

I prepared for the procedure through: tucked in my top of the theatre suit tightly; I rolled the sleeves three inches above the elbow. I wore a cap and face mask and removed my wrist watch as well as the jewellery and ensured my nails were cut short with no any wound ready for the procedure.

SCRUBBING PROCEDURE

Using the wall clock, I timed myself. I wet my hands and arms to the elbow , picked the soap and made a lot of lather on the hands and arms( the soap remained in hands until the point of drop off latter).

Social wash: washed the hands for one minute. Keeping the fingertips uppermost all the time, I rinsed the hands to my elbow. Using the elbow, I pressed the hutch of the dispenser and picked one sterile brush, lathered it and keeping the tablet of the soap at the back of the brush between the palm and brush in the right arm.

Starting with the left hand, put my fingers together to scrub the fingernails, moved to fingers, hand and then palm using a circular motion. I also took extra time at folds of the wrist. I scrubbed six times rinsing after each starting from fingertips to the wrists. I change over to the right hand and did the same.

I dropped the brush into the receptacle provided keeping the soap still in hand. I lathered the hands and washed up to the wrist for another one minute. Rinsed the soap and dropped it back into the soapy dish.

I took all the necessary the cautions not to touch the the tap handles during the exercises as not to contaminate the hands.

I rinsed the hands and arms thoroughly in one direction starting from the fingertips downwards systematically to the elbow.

The circulating nurse helped me remove the mackintosh.

Drying

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After the circulating nurse opened the cover for the gowns, I picked up the towel and stepped back. Starting the left hand, I blotted dry the fingers, webs of the hand and palm as well. The moved to the back of the hand, the forearm using a circular motion to the elbows. Change the left hand with the wet against the left palm. Using the dry part of the towel, repeat the same procedure on the other arm. When you get to the elbow, discard the towel in the dispenser provided.

Gowning

I followed this procedure while gowning:

1. Pick a gown and step back.2. Hold the neck band and let the bottom of hem drop.3. Open the gown and slide both hands in through the arms hole.4. The runner nurse will first tie the neck and shoulder bands then wrist bands without

touching the gown.

Gloving

The following procedure was adhered to:

1. Arrange gloves on the trolley with glove finger portion away from you.2. Pick the glove with left hand holding at the folded part and slip in your right hand. Fold

the tip of the sleeve on right hand and pass the glove over.3. Using the gloved hand slip your fingers beneath the folded area of the remaining glove

and slip in the left hand into the glove.4. Unroll the cuff of the glove covering the cuff of the sleeve.5. Do the same for the opposite hand using the same technique.6. Ensure you do not contaminate any area that will come into contact with the sterile field.

Operation set

The set contained the following equipment:

Backhaus towel clips(5), sponge holding forceps(4), blade holder no 3 and 4, Addison’s needle holder, mayo needle holder( short, medium and long), Addison’s dissecting forceps, mayo scissors(2 curved and one straight), artery forceps (5 curved and 5 straight), dissecting forceps, Armiteges haemostatic forceps (6), lens tissue forceps (2), Littlewoods tissue holding forceps (2), Allis tissue forceps (2 short and 2 long) , suction tube, gallipots and kidney dishes (large and medium), 10 pieces of guazes and 5 abdominal packs.

Positioning the patient

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The patient was brought to the operation room and placed in a supine position. She was draped and operation remained accessible.

Management of the airwaya. An anesthetic mask was put in place to ensure precise delivery of gases.b. Oral airway was inserted to ensure airway patency.c. Endotracheal intubation was put in place across the vocal cords in to the trachea to

guarantee a clear upper airway free from airway aspiration. Draping and skin preparation: The patient’s skin was draped with sterile material

covering every area except the incision area as a measure of infection prevention. The incision site was swabbed severally starting from the sides then to the middle in and upward motion with spirit then betadine.

THE OPERATION PROCEDURE

Medico-legal ConsiderationThe following legal issues were considered ;

a) Confirmation of the patient’s consentb) Counting of the swabs and needles used during the operation ; I did this in presence of

my circulating nurse.c) Adherence to the hospital protocols as well as the WHO protocols in performing

myomectomy.

THE POST-ANAESTHETIC CARE UNIT (PACU)After the operation the patient was transferred to the P.ACU by the anesthetist. During handing over to the P.A.C.U nurse on duty, the anesthetist briefly discussed the type of operation done. The PACU nurse did quick head to toe examination noting the following :

a) The airway was patent and maintenance of patency initiated in order to ensure a patent airway.

b) The breathing mechanism was checked for quality and rate established.c) Circulation and patient’s state of consciousness was assessed.d) The patency of the I.V line was checked to ensure that it was running with an aim of

supporting circulation.e) The condition of the surgical site : it was well bandaged and clean with no bleeding or

oozing observed.

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Pethidine 100mg was administered to control pain. After ensuring that the patient was fit enough for recovery in P.A.C.U, THE vital signs were monitored and recorded after every 15 minutes till recovery. When the patient was fully awake, vitals were taken 1 hourly for 2 hours.

When the patient was stable and fully recovered , she was transferred to the ward for further post-operative management.

NURSING CARE PLANASSESMENT NURSING

DIAGNOSISEXPECTED OUTCOMES

INTERVENTIONS

RATIONALE EVALUATION

Patient complains of pain at incision site at a score of 8 in a scale of 1-10 with 0 representing low pain and 10 representing severe pain.

Acute pain related to surgical procedure as evidenced by the patient’s verbal report.

The patient verbalizes decreased pain to a tolerable level within 30 minutes.

Position the patient comfortably in bed.Administer analgesics e.g morphine 10mls 4-hourly.

To avoid straining the incision site which may exacerbate pain.

Goal fully attained.

All the abdominal swabs, packs are soaked with blood. The patient’s pulse is 120 bpm while blood pressures is 89/50 mmHg.

Risk for ineffective tissue perfusion related to blood loss during the surgical procedure.

The patient will demonstrate adequate perfusion within 30 minutes , as evidenced by stable vital signs, palpable pulses, good capillary refill, usual mental status, individually adequate -urinary output.

Administer oxygen therapy via face mask.Administer IVFs as prescribed.Transfuse with whole blood.Monitor blood pressure, SpO2 and pulse 1 hourly.Apply anti embolism stockings.

To increase oxygen perfusion within tissues.To control hypovolemia and prevent shock.To monitor blood oxygen saturation .Aids in venous return; reduces stasis and risk of thrombosis.

 Goal fully attained.

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The patient feels that she will not get married due to the myomectomy procedure.

Low self-esteem related to concerns about effect on sexual relationship as evidenced by fear of rejection or reaction to her status after myomectomy.

That the patient verbalizes concerns and indicate healthy ways of dealing with them.

Verbalizes acceptance of self in situation and adaptation to change in body/self-image.

Provide time to listen to concerns and fears of patient and SO. Discuss patient’s perceptions of self related to anticipated changes and her specific lifestyle.Provide accurate information, reinforcing information previously given.

Conveys interest and concern; provides opportunity to correct misconception.Provides opportunity for patient to question and assimilate information.

The patient expresses optimism in life.

The patient enquires about her role in the post-operative care.

Knowledge deficitrelated to post-operative care as evidenced by request for information.

The patient verbalizes understanding of condition and potential complications ; Identifies relationship of signs/symptoms related to surgical procedure and actions to deal with them.

Verbalizes understanding of therapeutic needs.

Explain thoroughly to the regarding post-operative care.Involve the patient in her care during operative period.

Builds up patient’s knowledge and confidence towards recovery.

The patient is ready to participate in her daily care.

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CHAPTER FOUR

LITERATURE REVIEWIntroduction

Uterine fibroids are noncancerous growths of the uterus that often appear during childbearing years. Also called leiomyomas (lie-o-my-O-muhs) or myomas. They are benign growths in the wall of the uterus , they can prolapse through the cervix or may be confused for an ovarian mass. They can also cause problems in pregnancy, and, in some patients, myomas are thought to be linked to infertility.

Etiology

There are no know the cause of uterine fibroids, but research and clinical experience point to these factors:

Genetic changes. Many fibroids contain changes in genes that differ from those in normal uterine muscle cells. There's also some evidence that fibroids run in families and that identical twins are more likely to both have fibroids than non-identical twins.

Hormones. Estrogen and progesterone, two hormones that stimulate development of the uterine lining during each menstrual cycle in preparation for pregnancy, appear to promote the growth of fibroids. Fibroids contain more estrogen and progesterone receptors than normal uterine muscle cells do. Fibroids tend to shrink after menopause due to a decrease in hormone production.

Other growth factors. Substances that help the body maintain tissues, such as insulin-like growth factor, may affect fibroid growth.

Risk factors

There are few known risk factors for uterine fibroids, other than being a woman of reproductive age. Other factors that can have an impact on fibroid development include:

Heredity. If the mother or sister had fibroids, one is at increased risk of developing them.

Race. Black women are more likely to have fibroids than women of other racial groups. In addition, black women have fibroids at younger ages, and they're also likely to have more or larger fibroids.

Other factors. Onset of menstruation at an early age, having a diet higher in red meat and lower in green vegetables and fruit, and drinking alcohol, including beer, appear to increase the risk of developing fibroids.

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Pathophysiology

In general, myoma growth is a result of the stimulation of estrogen, which is present until menopause. Over time, previously asymptomatic myomas may grow and become symptomatic. Conversely, many myomas begin to shrink as menopause removes the estrogen stimulation and many myoma-related symptoms resolve spontaneously shortly after menopause.

Myomas are generally categorized by location. Intramural myomas are entirely or mostly contained within the myometrium. Subserosal myomas project outward from the uterus. Submucosal myomas project into the endometrial cavity . Pedunculated myomas are attached to the uterine wall by stalks and can be directed into either the peritoneal or the uterine cavity.

Pelvic pressure and pain symptoms are usually the result of mass effect. This can occur either from a single large myoma or from a combination of multiple smaller myomas. A fibroid uterus can grow to be quite large, at times reaching the size of a term gravid uterus. Interestingly, perhaps due to the slow growth and accommodation by the patient, some extremely large uteri are well tolerated by patients and do not require intervention. Some large myomas that impinge on the ureters can cause hydronephrosis and, very rarely, ureteral obstruction.

Bleeding abnormalities are usually the result of distortion of the endometrial cavity by myomas. Unlike pain, which is usually caused by large or multiple myomas, some patients have significant intermenstrual bleeding or menorrhagia from a single, small, strategically placed myoma. A submucosal myoma sometimes can prolapse through the cervix and may cause no symptoms or may cause significant bleeding.

Acute pain resulting from myomas is uncommon and usually stems from 1 of 2 possibilities. Some pedunculated myomas can undergo torsion, causing the same severe pain as torsion of the ovary. Large myomas can also outgrow their blood supply, leading to infarction (degenerating myoma), which can be extremely painful.

Although general agreement is lacking on the mechanism, myomas are also thought to be related to infertility, fetal malpresentations, preterm labor, and IUGR. Possible mechanisms for infertility include distortion of the endometrial cavity and abnormal endometrial surface, thereby affecting both sperm transport and embryo implantation.

Very rarely, myomas can be associated with erythrocytosis. This triad of myomatous uterus, erythrocytosis, and restoration and maintenance of normal hematologic values after hysterectomy is called myomatous erythrocytosis syndrome.A number of etiologies have been hypothesized, but alterations in erythropoietin levels seem likely.

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Presentation

The most common symptoms of uterine fibroids include:

Heavy menstrual bleeding Prolonged menstrual periods — seven days or more of menstrual bleeding Pelvic pressure or pain Frequent urination Difficulty emptying the bladder Constipation Backache or leg pains

DIAGNOSIS

Routine pelvic exam: irregularities in the shape of the uterus, suggesting the presence of fibroids.

If one have symptoms of uterine fibroids, the doctor may order these tests:

Ultrasound. If confirmation is needed, the doctor may order an ultrasound. It uses sound waves to get a picture of the uterus to confirm the diagnosis and to map and measure fibroids. A doctor or technician moves the ultrasound device (transducer) over the abdomen (transabdominal) or places it inside the vagina (transvaginal) to get images of the uterus.

Lab tests. If one is experiencing abnormal vaginal bleeding, the doctor may order other tests to investigate potential causes. These might include a complete blood count (CBC) to determine if one have anemia because of chronic blood loss and other blood tests to rule out bleeding disorders or thyroid problems.

OTHER IMAGING TESTS

If traditional ultrasound doesn't provide enough information, the doctor may order other imaging studies, such as:

Magnetic resonance imaging (MRI). This imaging test can show the size and location of fibroids, identify different types of tumors and help determine appropriate treatment options.

Hysterosonography. Also called a saline infusion sonogram, uses sterile saline to expand the uterine cavity, making it easier to get images of the uterine cavity and endometrium. This test may be useful if one has heavy menstrual bleeding despite normal results from traditional ultrasound.

Hysterosalpingography. Uses a dye to highlight the uterine cavity and fallopian tubes on X-ray images. Recommend if infertility is a concern. In addition to revealing fibroids, it can help determine if fallopian tubes are open.

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Hysteroscopy. A small, lighted telescope called a hysteroscope is inserted through the cervix into the uterus. Then saline is injected into the uterus, expanding the uterine cavity and allowing for examination of the walls of the uterus and the openings of the fallopian tubes.

Other medications. e.g. oral contraceptives or progestins can help control menstrual bleeding, but they don't reduce fibroid size. Non-steroidal anti-inflammatory drugs (NSAIDs), which are not hormonal medications, may be effective in relieving pain related to fibroids, but they don't reduce bleeding caused by fibroids. Also intake of vitamins and iron if one has heavy menstrual bleeding and anemia.

NONINVASIVE PROCEDURE

MRI-guided focused ultrasound surgery (FUS)

MINIMALLY INVASIVE PROCEDURES

Certain procedures can destroy uterine fibroids without actually removing them through surgery. They include:

Uterine artery embolization.

Myolysis.

Laparoscopic or robotic myomectomy.

Hysteroscopic myomectomy.

Endometrial ablation and resection of submucosal fibroids.

TRADITIONAL SURGICAL PROCEDURES

Options for traditional surgical procedures include:

Abdominal myomectomy. If one have multiple fibroids, very large fibroids or very deep fibroids, the doctor may use an open abdominal surgical procedure to remove the fibroids. Many women who are told that hysterectomy is their only option can have an abdominal myomectomy instead.

Indications

Asymptomatic leiomyomata that are palpable abdominally and are a concern to the patient

Excessive uterine bleeding

o Profuse bleedingo Anemia

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Pelvic discomfort caused by myomata

o Acute and severeo Chronic lower abdominal or low back pressureo Bladder pressure with urinary frequency not due to a urinary tract infection

Hysterectomy. This surgery — the removal of the uterus — remains the only proven permanent solution for uterine fibroids. But hysterectomy is major surgery. It ends the ability to bear children. And if one also elect to have the ovaries removed, it brings on menopause and the question of whether one will take hormone replacement therapy. Most women with uterine fibroids can choose to keep their ovaries.

Complications

Known complications of fibroids include:

Red degeneration - inadequate blood supply to the centre of the lesion leading to a necrotic core with associated pain.  This is especially common in pregnancy.  

Post partum haemorrhage due to inefficient uterine contraction Abnormal lie of a foetus if the fibroid is located inferiorly Malignancy - 0.1% progress to leiomyosarcomas. Mesenteric vein thrombosis and thromboembolism Urinary retention, leading to renal failure Intestinal gangrene Acute haemorrhage

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CHAPTER FIVE

CONCLUSIONS AND RECOMMENDATIONSTheatre nursing really needs a lot of cooperation for a positive end results of surgery with no any noticeable complication. Infection-prevention measures in an outside the operating room.Scrubbing up for A.K’s case of uterine fibroids was relly a nice experience that boosted my confidence in theatre nursing.

I would recommend that more time should be allocated theatre nursing rotations for students to have a broader experience and hence boosting their confidence.

REFERENCESNursing Council of Kenya(2009). Manual of Clinical Procedures, 3rd Ed.

Gynecology by Ten Teachers, 18th Edition, Goodreads, Hodder Publication, 2006.

Pathologic Basis of Disease, Robbins and Contran, April 2011.

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