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Lyra May Dalayon BSN, RN.Staff Nurse OB-I

A Case Presentation of

Pelvic Endometriosis Stage 4

PATIENT: 198****AGE: 39 YEARS OLDGENDER: FEMALENATIONALITY: FILIPINODATE OF ADMISSION: MARCH 11, 2013

DIAGNOSIS: ENDOMETRIAL CYST RIGHT OVARY

DEMOGRAPHIC DATA

SKIN:

Warm to touch, medium brown complexion, with good skin turgor

No edema and lesion notedHair is thick, black and equally distributed; no infestation.

Nails are healthy, no clubbing and deformities

HEAD-NECK:

Head- symmetricalScalp- no tenderness, lesions or mass noted

Eyes- PERLA, sclera- whiteEars- no hearing disorder

Nose- no congestion and drainage, nostrils are patentThroat and neck- no pain, good ROM

 

PHYSICAL ASSESSMENT

CHEST/LUNGS: Clear breath sounds

No wheezes, no cracklesRR: 24

CARDIOVASCULAR:Normal rate regular rhythm

No murmurPulse Rate: 103 bpm – regularBlood Pressure: 130/90 mmhg

O2 Saturation: 98%

MUSKULOSKELETAL:No paralysis and deformities

Active range of movementAble to perform activities of daily living

independently

NEUROLOGIC:Oriented to time place and person

Behavior is appropriate and cooperativeNo abnormalities in speech pattern

Appropriate verbal and motor responseReactive and Equal pupils

ABDOMEN: (+) palpable mass at right lower quadrant with

direct tenderness upon palpation

GENITO-URINARY: Pubic hair equally distributed. Voided freely

VAGINAL EXAM:(+) brownish vaginal discharge,

Non foul smelling

3 DAYS PRIOR TO ADMISSION, PATIENT HAD VOMITING WITH EPIGASTRIC PAIN TO RIGHT LOWER QUADRANT AREA RADIATING TO BACK.

FEW HOURS PRIOR TO ADMISSION PATIENT COMPLAINT OF INCREASED PAIN AT RIGHT LOWER QUADRANT AREA WITH EPISODES OF VOMITING, ULTRASOUND DONE BY A RADIOLOGIST AT AL AQSA CLINIC WHERE PATIENT IS CURRENTLY WORKING AND DIAGNOSED AS ECTOPIC PREGNANCY HENCE WENT TO AAH FOR SECOND OPINION.

PRESENT MEDICAL HISTORY

EXAMINE BY OB-GYNE DOCTOR AT AAH EMERGENCY ROOM PHYSICAL ASSESSMENT AND BLOOD WORKS MADE:LMP: MARCH 07, 2013TEMPERATURE: 38.6˚CBP: 130/90bpmRR:24cpmPR: 103bpm

BLOOD WORKS:CBC: HGB: 11.5G/DL (11.2-15.7) WBC: 12.12 (3.98-10.04) PLT: 338 (182-369)BLOOD GROUP: O POSITIVEURINALYSIS: PUS CELLS: 0-2/HPF

(WITHIN NORMAL) RBC: 15-20/HPFBETA HCG QUANTITATIVE: <2.39 (44.71-256,740) 1-10

WEEKS

VAGINAL EXAMINATION:BROWNISH MINIMAL DISCHARGES

CERVIX CLOSED

TVS : SUGGESTIVE FINDINGS OF

ENDOMETRIAL CYST, RIGHT OVARY

2013- DIAGNOSED WITH KIDNEY STONE ON ORAL MEDICATION

2011- HISTORY OF HYDROSALPINX GIVEN UNRECALLED ANTIBIOTIC BUT WITHOUT ANY FOLLOW UP

2010- LAPAROTOMY DUE TO OVARIAN CYST AT LEFT

2003-LAPAROSCOPY DUE TO OVARIAN CYST

PAST MEDICAL AND SURGICAL HISTORY

ENDOMETRIOSIS- is the abnormal growth of extra uterine endometrial cells, often in the cul-de-sac of the peritoneal cavity or on the uterine ligaments or ovaries.

- is a benign, usually progressive and sometimes recurrent disease that invades locally and disseminates widely.

- the incidence of endometriosis is 30% to 45% in women with infertility.

TOPIC PRESENTATION

STAGES OF ENDOMETRIOSISStage 1: Just a few endometrial implant; mostly found in the cul-de-sac and pelvic area.

Stage 2: Mild levels of endometriosis to moderate levels that not only affect the above areas but can now affect the ovaries

Stage 3: Moderate amount of disease and in extensive places around the pelvic cavity, with adhesions

Stage 4: Extensive endometrial implants sprinkled all throughout the pelvic cavity with adhesions; higher probability of infertility, involving bladder and bowel.

Anatomy and Physiology

PREDISPOSING FACTOR

Pathophysiology

AGE

GENETIC

NULLIGRAVID

IRREGULAR HEAVY PERIOD

PRECIPITATING FACTOR

backflow of menstruation

attached to the sorrounding tissue

cause irritation to the area where it attached

after successive menstrual cycle

displaced section of endometrial tissue

bleed

Produced web like growth of scar tissue

adhesion

Bands to fibrous tissue

Cyst

1. Cyclic pelvic pain- related to swelling and extravasations of blood and menstrual debris into the surrounding tissue.

2. Dyspareunia- direct pressure on areas of endometriosis in the cul-de-sac.

3. Irregular and heavy menstrual flow- due to ovulatory dysfunction.

* Endometriosis often asymptomatic*

Signs and Symptoms

ACTUAL:Laparoscopy guided oophorocystectomy with adhesiolysis

INTRAOPERATIVE FINDING:

Shows severe adhesions to the mass by bowels and bladder. Mass seen anteriorly measuring approximately 12 cm. Uterus both fallopian tubes and left ovary not properly visualized due to the mass and severe adhesions.

Treatment

For mild cases:Hormonal: 1. Combination Oral Contraceptive Pills

(COCP)- to regulate hormones

For moderate to severe cases, common surgical treatments are:

1. Hysterectomy is the removal of the uterus and is the only permanent cure for cysts*

2. In UFE’s, gel or plastic particles are injected into the blood vessels feeding blood to the cysts. Once the blood supply is blocked, the cysts shrink.

IDEAL:

1. Ultrasound scanning is an excellent way of diagnosing chocolate cysts and can pick up cysts which are very small. -However, it's not possible to make a

definitive diagnosis of endometriosis on ultrasound scanning, as many other conditions can also produce cysts in the ovary. The diagnosis can be confirmed either by aspirating the cyst under ultrasound guidance ( and finding the typical dark old blood which is diagnostic of endometriosis); or by doing a laparoscopy.

Diagnostic test

Several theories exist as to how endometriosis begins.

◊ Retrograde menstruation – abnormal backflow, which almost all women experience, yet only some will develop the disease; this outdated theory does

not explain endometriosis adequately

◊ Immunologic dysfunction – “broken” immune system allows for inappropriate implantation of retrograde debris.

CAUSES

◊ Genetics – a 7‐10 fold risk exists in women and girls whose mother or relative has disease

◊ Environmental Toxicants – pollutants cause cell changes, which allow for implantation and errant immune response

1. InfertilityThe main complication of endometriosis is impaired fertility. Approximately one-third to one-half of women with endometriosis have difficulty getting pregnant.

2. Ovarian cancerOvarian cancer does occur at higher than expected rates in women with endometriosis. But the overall lifetime risk of ovarian cancer is low to begin with. Although rare, another type of cancer — endometriosis-associated adenocarcinoma — can develop later in life in women who have had endometriosis

COMPLICATIONS:

NURSING PROBLEM PRIORITIZAION

1. Hyperthermia related to infection2. Pain3. Anxiety4. Deficient knowledge (diagnosis and treatment)5. Disturbed body image6. Sexual dysfunction

4.

Health teaching1. Assess the woman’s cultural and ethnic

influences, which will play a part in her understanding and subsequent coping with endometriosis.

2. Be emotionally supportive. Provide interested couples with information Endometriosis Association, Resolve (a support, education, research group for infertile couples), and newer techniques for infertility management.

3. Encourage the couple to talk openly about the disease and its effects on their sexual compatibility, and urge the woman to tell her partner about any discomfort during sexual intercourse to minimize misunderstandings.

4. Encourage the couple to try different

positions during sexual intercourse to find those most comfortable for the woman.

ASESSMENT NURSING DIAGNOSE

S

PLANNING INTERVENTION RATIONALE EVALUATION

SUBJECTIVE:“I FEEL SO HOT” as verbalized by the pateint

OBJECTIVE:Temp:38.6°CPR: 103bpmRR: 24cpmWBC: 12.12 (3.98-10.04)

Hyperthermia related to infection as evidenced fever of 38.6˚C

After 4 hours of nursing intervention temperature decrease to normal range 36.5˚C to 37.5˚C.

INDEPENDENT: Establish rapport

Check vital signs every 4 hours

Tepid sponge bath for 3o minutes

Encouraged Increase oral fluid intake

Gain trust and cooperation

Baseline status

To reduce the temperature

To rehydrate

Goal met as evidenced by temperature fall to 37.3˚CRR: 20cpmPR: 92bpm

NURSING CARE PLAN

ASSESSMENT

NURSING DIAGNOSIS

PLANNING NURSING INTERVENTION

RATIONALE OUTCOME

DEPENDENT:Administer Paracetamol IV 1gram every 4 hours

Administer Ceftriaxone 1 gram IV every 8 hours for 24 hours

IV fluid RL 500 ml @ 125cc/hr

Antipyretic effect

Bactericidal activity of ceftriaxone results from inhibition of bacterial cell wall synthesis

To hydrate and for fluid replacement

1. Ensure that the patient understands the dosage, route, action, and side effects of discharge medicine before going home.

2.Encourage the patient to be alert to her emotions, behavior, physical symptoms, diet, and rest and exercise.

 

Discharge and Home Health Care Guidelines

3.Encourage the patient to maintain open communication with her significant other and her family to discuss concerns she may have about the disease process.

Endometriosis is a challenging disease specially for a nulligravid women due to its complication, one of it is infertility. Endometriosis commonly affect women ages 15- 49 years of age and commonly the treatment ended in surgical procedures and in worst scenario hysterectomy. It is the reason why early detection is always the best idea of managing this disease. The only way to obtain a definitive diagnosis of endometriosis is through surgery called Laparoscopy.

CONCLUSION

Though symptoms and/or diagnostic testing may give rise to “informed suspicion”, only surgery permits the requisite visual and more importantly, histological diagnosis.Laparoscopy also facilitates treatment of the disease. Alternative therapies, such as diet and nutrition, acupuncture, physical therapy, and other complementary treatments can be helpful at effectively managing symptoms on a non‐invasive basis.

Kennedy S. Berggvist A, Chapron C, D’ Hooghe Group for Endometriosis and Endometrium Guideline Development Group. ESHRE guideline for the diagnosis and treatment of Endometriosis. Hum Reprod. 2005 oct. 20 (10): 2698-2704

Wardle P. Hull MGR. Is endometriosis a disease? Baillieres Clin Obstet Gynaecol 1993 Dec: 7(4): 673-85

Sasson IE, Taylor HS. Stem cells and the

pathogenesis of endometriosis. Ann N Y Acad Sci. 2008 Apr; 1127: 106-15

BIBLIOGRAPHY

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