Transcript A case presentation of endometriosis

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Lyra May Dalayon BSN, RN.
Staff Nurse OB-I
PATIENT: 198****
AGE: 39 YEARS OLD
GENDER: FEMALE
NATIONALITY: FILIPINO
DATE OF ADMISSION: MARCH 11, 2013
DIAGNOSIS: ENDOMETRIAL CYST
RIGHT OVARY
SKIN :
Warm to touch, medium brown complexion, with good skin turgor
No edema and lesion noted
Hair is thick, black and equally distributed; no infestation.
Nails are healthy, no clubbing and deformities
HEAD-NECK:
Head- symmetrical
Scalp- no tenderness, lesions or mass noted
Eyes- PERLA, sclera- white
Ears- no hearing disorder
Nose- no congestion and drainage, nostrils are patent
Throat and neck- no pain, good ROM
CHEST/LUNGS:
Clear breath sounds
No wheezes, no crackles
RR: 24
CARDIOVASCULAR:
Normal rate regular rhythm
No murmur
Pulse Rate: 103 bpm – regular
Blood Pressure: 130/90 mmhg
O2 Saturation: 98%
MUSKULOSKELETAL:
No paralysis and deformities
Active range of movement
Able to perform activities of daily living independently
NEUROLOGIC:
Oriented to time place and person
Behavior is appropriate and cooperative
No abnormalities in speech pattern
Appropriate verbal and motor response
Reactive 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 .
EXAMINE BY OB-GYNE DOCTOR AT AAH
EMERGENCY ROOM PHYSICAL ASSESSMENT
AND BLOOD WORKS MADE:
LMP: MARCH 07, 2013
TEMPERATURE: 38.6˚C
BP: 130/90bpm
RR:24cpm
PR: 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 POSITIVE
URINALYSIS: PUS CELLS: 0-2/HPF (WITHIN
NORMAL)
RBC: 15-20/HPF
BETA 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
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.
Stage 1: Just a few endometrial implant;
mostly found in the cul-de-sac and pelvic area.
PREDISPOSING FACTOR
AGE
GENETIC
PRECIPITATING FACTOR
NULLIGRAVID
IRREGULAR HEAVY
PERIOD
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*
 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.
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.
 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.
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.
◊ 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. Infertility
The main complication of endometriosis is
impaired fertility. Approximately one-third to
one-half of women with endometriosis have
difficulty getting pregnant.
2. Ovarian cancer
Ovarian 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 — endometriosisassociated adenocarcinoma — can
develop later in life in women who have had
endometriosis
1. Assess the woman’s cultural and ethnic influences,
4.
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
DIAGNOSES
SUBJECTIVE
:
“I FEEL SO
HOT” as
verbalized by
the pateint
Hyperther
mia related
to infection
as
evidenced
fever of
38.6˚C
OBJECTIVE:
Temp:
38.6°C
PR: 103bpm
RR: 24cpm
WBC: 12.12
(3.98-10.04)
PLANNING
After 4 hours
of nursing
intervention
temperature
decrease to
normal range
36.5˚C to
37.5˚C.
INTERVENTION
INDEPENDENT:
 Establish rapport
Check vital signs
every 4 hours
RATIONALE
 Gain trust
and
cooperation
Baseline
status
Tepid sponge bath To reduce
for 3o minutes
the
temperature
Encouraged
Increase oral fluid
intake
To rehydrate
EVALUATIO
N
Goal met as
evidenced
by
temperatur
e fall to
37.3˚C
RR: 20cpm
PR: 92bpm
ASSESSMENT
NURSING
DIAGNOSIS
PLANNING
NURSING
INTERVENTION
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
RATIONALE
Antipyretic
effect
Bactericidal
activity of
ceftriaxone
results from
inhibition of
bacterial cell
wall synthesis
 To hydrate
and for fluid
replacement
OUTCOME
Discharge and Home
Health Care Guidelines
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.
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.
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