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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.
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
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