This Presentation will Start Soon:

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 — endometriosis- associated adenocarcinoma — can develop later in life in women who have had endometriosis

1. 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 DIAGNOSES PLANNING INTERVENTION RATIONALE EVALUATIO N

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) 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   Gain trust and cooperation Baseline status  Tepid sponge bath for 3o minutes  To reduce the temperature  Encouraged Increase oral fluid intake  To rehydrate Goal met as evidenced by temperatur e fall to 37.3˚C RR: 20cpm PR: 92bpm

ASSESSMENT NURSING DIAGNOSIS PLANNING NURSING INTERVENTION RATIONALE OUTCOME

DEPENDENT:  Administer Paracetamol IV 1gram every 4 hours  Antipyretic effect  Administer Ceftriaxone 1 gram IV every 8 hours for 24 hours  Bactericidal activity of ceftriaxone results from inhibition of bacterial cell wall synthesis  IV fluid RL 500 ml @ 125cc/hr  To hydrate and for fluid replacement

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