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This Presentation will Start Soon:. Lyra May Dalayon BSN, RN. Staff Nurse OB-I. A Case P resentation of Pelvic Endometriosis Stage 4. DEMOGRAPHIC DATA. PATIENT: 198**** AGE: 39 YEARS OLD GENDER: FEMALE NATIONALITY: FILIPINO DATE OF ADMISSION: MARCH 11, 2013

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  1. This Presentation will Start Soon: Lyra May Dalayon BSN, RN. Staff Nurse OB-I

  2. A Case Presentationof Pelvic Endometriosis Stage 4

  3. DEMOGRAPHIC DATA PATIENT: 198**** AGE: 39 YEARS OLD GENDER: FEMALE NATIONALITY: FILIPINO DATE OF ADMISSION: MARCH 11, 2013 DIAGNOSIS: ENDOMETRIAL CYST RIGHT OVARY

  4. PHYSICAL ASSESSMENT 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

  5. 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%

  6. 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

  7. 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

  8. PRESENT MEDICAL HISTORY 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.

  9. 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

  10. 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

  11. VAGINAL EXAMINATION: BROWNISH MINIMAL DISCHARGES CERVIX CLOSED TVS : SUGGESTIVE FINDINGS OF ENDOMETRIAL CYST, RIGHT OVARY

  12. PAST MEDICAL AND SURGICAL HISTORY 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

  13. TOPIC PRESENTATION 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.

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

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

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

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

  18. Anatomy and Physiology

  19. PRECIPITATING FACTOR Pathophysiology NULLIGRAVID AGE IRREGULAR HEAVY PERIOD GENETIC PREDISPOSINGFACTOR backflow of menstruation

  20. 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

  21. adhesion Bands to fibrous tissue Cyst

  22. Signs and Symptoms Cyclic pelvic pain- related to swelling and extravasations of blood and menstrual debris into the surrounding tissue. Dyspareunia- direct pressure on areas of endometriosis in the cul-de-sac. Irregular and heavy menstrual flow- due to ovulatory dysfunction. * Endometriosis often asymptomatic*

  23. Treatment • 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.

  24. IDEAL: 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.

  25. Diagnostic test • 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.

  26. CAUSES 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.

  27. ◊ 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

  28. COMPLICATIONS: 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

  29. NURSING PROBLEM PRIORITIZAION1. Hyperthermia related to infection2. Pain3. Anxiety4. Deficient knowledge (diagnosis and treatment)5. Disturbed body image6. Sexual dysfunction

  30. Health teaching • Assess the woman’s cultural and ethnicinfluences, which will play a part in her understanding and subsequent copingwithendometriosis. • Be emotionally supportive. Provide interested couples withinformationEndometriosisAssociation, Resolve (a support, education, research group for infertile couples), and newer techniques forinfertilitymanagement. 4.

  31. 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 anydiscomfortduring sexual intercourse to minimize misunderstandings. • 4. Encourage the couple to try different positions during sexual intercourse to find those most comfortable for the woman.

  32. NURSING CARE PLAN

  33. 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.

  34. 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.

  35. CONCLUSION • 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.

  36. 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.

  37. BIBLIOGRAPHY • 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? BaillieresClinObstetGynaecol 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

  38. THANK YOU

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