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Endometriosis Care Plan
Nursing Student Care Plan Example for Endometriosis
Endometriosis Nursing Care Plan Example
Pathophysiology of Endometriosis
Endometriosis is characterized by the presence of endometrial tissue in anchored to areas that extend beyond the expected location within the uterine cavity. Normally, endometrial tissue lines the interior wall of the uterine lumen and stays confined to the stratum functionalis layer. In endometriosis, the tissue migrates past the anatomical boundaries of the stratum functionalis. The most common sites of extrauterine involvement include the cervix, ovaries, and vagina; but the tissue can also migrates to areas such as the intestines, stomach, and even the thoracic cavity.
Displaced endometrium is termed as ectopic endometrial implants or endometriotic lesions. Endometriosis is staged based upon the amount of abnormal tissue that’s migrated and the severity of associated symptoms. Mild cases are termed as minimal involvement and generally do not require intervention. Advanced conditions are classified as endometriosis stage I, II, or III. The three clinical features of endometriosis include lesions, ovarian cysts, and endometriotic nodules. The effects of endometriosis often causes severe pain for patients.
Anatomy of the Uterus
The uterus is a hollow organ located within the pelvic cavity of females. It is composed of smooth muscle and is surrounded posteriorly by the rectum. The urinary bladder is positioned anteriorly to the uterus. The lumen of the uterus is lined by a bilayer of endometrium, a membranous tissue with a complex vasculature and glandular supply. An enduring stratum basalis forms the deep layer of the endometrium. The stratum functionalis, the site of embryonic implantation, composes the variable superficial endometrial layer.
The Influence of the Menstrual Cycle
Epithelial cell density alters throughout the menstrual cycle in response to changing levels of estrogen and progesterone. During menses, hormonal regulation causes the cells of the stratum functionalis to slough off; thus creating the need for tampons and maxi-pads. At the beginning of each ovulatory sequence, stratum functionalis tissue regenerates a fresh endometrial layer.
Etiology of Endometriosis
While the precise etiological mechanisms remain unknown, several theories have been developed to explain endometriosis. As endometriosis is more prevalent in certain families, genetics are believed to play a strong role. Retrograde menstruation is the most commonly implicated factor in the pathogenesis of endometriosis. This involves reflux of menstrual tissue from the fallopian tubes. Research has demonstrated a correlation with abnormal levels of the enzyme aromatase P450, which is involved in estrogen biosynthesis. Coelomic metaplasia is another factor speculated to be an etiology, especially in cases of rectovaginal disease involvement. This theory postulates that mesothelium invaginates into the ovaries, then transforms into endometrial tissue. Lymphatic or vascular dissemination is also believed to contribute to some cases. Embryonic rests is another theory, it’s based upon a notion that abnormal endometrial tissue is differentiated from Müllerian remnants located in the rectovaginal region.
Risk Factors for Endometriosis
- Family history
- Early menarche
- Shorter menstrual cycles
- Heavy bleeding during menstruation and long duration of cycles
- No or little use of hormonal contraceptives
- Von Willebrand disease
Epidemiology of Endometriosis
Prevalence of Endometriosis
Endometriosis affects approximately 1-12% of women in the U.S. It’s most commonly found in younger women. Around 10% of women who seek treatment for pelvic pain are diagnosed with endometriosis. A higher proportion of diagnoses are made in Caucasian women with above average socioeconomic status.
Why is endometriosis diagnosed more frequently in affluent white women? Researchers suspect that these women do not necessarily have a greater rate of incidence. While the precise reasons are debatable, it may be attributed to better access and quality of healthcare.
Presentation of Patients
The classic clinical presentation of endometriosis is severe pelvic and abdominal pain, accompanied by disruptions in reproductive function, including irregular menstrual cycles and impaired fertility. Nonspecific GI disturbances may occur when the bowels come into contact with unfastened endometrial tissue. Symptoms include abdominal cramping, diarrhea, constipation, and possibly obstruction.
Common Symptoms of Endometriosis
- Back pain
- Sharp pelvic pain
- Abdominal cramping
- Cyclical abdominal bloating
- Dysfunctional uterine bleeding
- Dysmenorrhea (painful menstruation)
- Gastrointestinal disturbances, diarrhea or constipation
- Heavy blood flow during menses
- Infertility or reduced fertility
- Dyspareunia (painful intercourse)
- Nonmenstrual and menstrual pelvic pain and cramping
- Urinary disturbances, such as incontinence, dysuria, hematuria, and oliguria
Characteristics of Endometriosis
Size and Location of Endometrial Implants
In addition to the amount of irregular endometrial growth that occurs, the presentation of symptoms are influenced by the anatomical location in which tissue becomes anchored, and how deep it adheres to it. Implants may be superficial anchored, deep, or even unattached. The most common, yet complex form is adenomyosis, a condition in which the endometrial cells grow abnormally thick and move within the myometrium or outer uterine wall. However, endometrial tissue may migrate beyond the uterus. Serious and life threatening complications may occur if deep implants impair the function of vital organs.
Endometrioma is a pelvic mass that forms as a result of endometriosis. They appear as chocolate-colored hemorrhagic material. Serious compilations may occur if ruptured (Takeuchi et al., 2008).
Around 10% of cases involve the bowels. If endometrial tissue advances into the bowels, it may obstruct rectal organs. These cases tend to be complex and manifest disruption of digestive function. In this form of the condition, the patient may present with a wide variety of serious gastrointestinal disturbances. Generally (but no always), the patient will have already received treatment for a non-complicated case. The clinician will suspect bowel involvement when unexplained (as in not attributable to any known factors associated with the GI system) gastrointestinal symptoms appear after the primary uterine adenomyosis has identified and corrected.
If the endometrial implants invade the urinary tract, pressure may be placed upon structures such as the bladder and ureters. These structures can become obstructed and possibly even displaced or retracted as a result. Symptoms such as dysuria and incontinence may manifest.
Diagnosis of Endometriosis
The Road to a Diagnosis
Diagnosis is often a long and frustrating process for the patient. Endometriosis is initially suspected through a physical examination upon classic complaints of menstrual difficulties, abdominal pain, other non-specific gastrointestinal disturbances, and possible issues with fertility. A pelvic exam should be performed. The first line approach to diagnosis is a process of elimination. This begins by ruling out other etiologies consistent with the patient’s specific symptoms, such as inflammatory bowel disease, pelvic inflammatory disease, thyroid disorders, hemorrhoids, and perirectal abscess. Once these pathologies have been eliminated, the clinician must initiate diagnostic imaging and procedures to conduct an evaluation.
Imaging, including ultrasonography of the pelvic area, provides data that can be supportive of a diagnosis. However, the only true method for a confirmative diagnosis is to examine the tissue. The least invasive method to obtain a sample is through laparoscopy.
The patient’s perspective: Diagnosis of endometriosis is often a long and frustrating process for the patient. She may spend years seeking out the cause of her chronic pain, fatigue, erratic periods, and difficulty conceiving. Friends and family often do not understand her plight. Many patients must bear through multiple misdiagnoses before receiving the correct one. As nurses, we need to be aware of the patient’s journey.
Laparoscopy (for the Uterus)
- Laparoscopy is a procedure that utilizes a hallow tube equipped with a scope (tiny camera) to provide real-time video footage of internal structures. It serves both diagnostic and therapeutic (as in treatment) purposes. It’s used for exploratory purposes as it allows for direct visualization of tissue structures. Attachments added to the scope enables tissue biopsy, which are used to evaluate for the presence of endometrial cells. The biopsy results obtained from the laparoscopy provide for a definitive diagnosis of the condition. During exploration, the provider may be able to remove endometrial implants by placing a special attachment through the scope.
- Patients are typically placed under sedation with propofol.
- Bowel laparoscopy is used in cases of confirmed or suspected bowel involvement. The scope is guided through the colon
- Imaging of the ultrasound may reveal signs of abnormal tissue growth in the pelvic area.
- It may be used in cases of suspected (to support a diagnosis) or confirmed growth of abnormal endometrial tissue (to plan for or gauge the efficacy of treatment).
- A transducer is vaginally inserted to produce video of the reproductive organs.
- While the findings do not meet independent diagnostic criteria needs, it can support the diagnosis and may help identify the location of endometritoic lesions and implants.
Rectal Endoscopic Ultrasound
- Used in cases of suspected or confirmed bowel involvement.
- Imaging of the ultrasound will reveal abnormal tissue growth located in the bowels.
Urinary Tract Imaging
- Used in cases of suspected or confirmed urinary tract involvement.
- Evaluates for the presence of endometrial tissue within the urinary tract.
In complex cases, endometrial tissue can be located in other areas. Additional imaging and diagnostic techniques are used as needed.
Treatment of Endometriosis
Forms of Treatment
Surveillance: A “Wait and See” Approach
Some cases remain asymptomatic or do not produce symptoms of a severity to warrant the risks of treatment. Subsequently, the patient and provider may decide to forge interventions for the time being. However, even if treatment is not pursued, the patient is encouraged to maintain annual pelvic examinations as recommended in order to periodically monitor status.
Pharmacological Management of Endometriosis
When the condition mandates treatment, pharmacological therapy is the first line approach. The goal of pharmaceutical therapy is to control the overgrowth of endometrial tissue and migration into extrauterine areas. Medications are not curative, but they can provide a great margin of relief for the patient. Hormonal therapy is used to suppress ovulation, which often induces a state of hypomenorrhea (reduction of menstruation) or amenorrhea (arrest of menstruation) to control the growth endometrial implants and symptoms. Pharmacological treatment involves medications such as combined oral contraceptive pills, GnRH agonists, androgen derivatives, and progestogens. The levonorgestrel intrauterine system, (LNG-IUS; Mirena, the hormonal intrauterine device or IUD) may also be used in management. Non-steroidal anti-inflammatory drugs are generally used to manage pain. Opioids may be utilized during the postoperative recovery period if surgical interventions become necessary or if symptoms are severe.
Drugs to Treat Endometriosis
- NSAIDS and other drugs to manage pain
- Hormonal contraceptives: Birth control pills, patches, and rings; hormonal intrauterine device (IUD)
- GnRH agonists and antagonists or Gonadotropin-releasing hormone analogues: GnRH analogs such as leuprolide (Lupron), goserelin (Zoladex), triptorelin (Trelstar Depot), and nafarelin (Synarel)
- Danazol (Danocrine), an androgen derivative
- Aromatase enzyme inhibitor (unlabeled use): letrozole (Femara)
- Progestogens: medroxyprogesterone acetate (Provera)
- Antiprogestogens, such as gestrinone
Birth control pills, patches, and rings are commonly prescribed as the first pharmacological treatment for endometriosis. These drugs contain progesterone or an estrogen and progesterone combination. The stratum functionalis is the uterine layer where endometrial tissue is located. Growth of the stratum functionalis is stimulated during each menstrual cycle by ovulation. By controlling ovulation, endometrial growth is creased. If other contraceptives fail, medroxyprogesterone acetate (Depo-Provera CI) may be considered. Another option is Mirena, a levonorgestrel-releasing intrauterine device.
Gn-RH Agonists and Antagonists
Gonadotropin-releasing hormone analogues (GnRHas), GnRH antagonist or GnRH agonist (GnRH-a) are used for their anovulatory effect by creating an artificial menopause. It exerts its action by blocking the release of pituitary output of tropic hormones that stimulate the release of ovarian hormones. By reducing estrogen levels, the menstrual cycle is disrupted, with a therapeutic goal of forcing endometriosis into remission.
Currently, aromatase inhibitors are considered an “unlabeled use” for therapeutic endometrial treatment. The high incidence of success in treating endometriosis has led some providers consider it for use. These drugs work by preventing the production of estrogen from precursory hormones such as testosterone. It also stops the synthesis of endometrial produced estrogen.
Danazol is an androgen derivative that causes atrophy of ectopic tissue. It blocks the action of tropic hormones send out by the pituitary gland to stimulate the release of ovarian sex hormones. Generally, it is only considered after conventional therapies have failed. This hesitation is due to the androgenic effects that may produce male characteristics such as hirsutism (facial hair growth and other effects). Other risks include weight gain, acne, and emotional disturbances.
Procedures Used to Treat Endometriosis
- Cystectomy for endometrioma: coagulation and ablation of the cyst wall with laser or electrosurgery or laser; blunt or sharp dissection removal
- Surgical excision of cysts
- Resection of endometriosis implants
- Laproscopic removal of endometrial tissue; including ablation and dissection
- Hysterectomy: simple, total, or radical
- Oophorectomy or salpingo oophorectomy: unilateral or bilateral
- Presacral neurectomy and laparoscopic uterosacral nerve ablation (LUNA) Management of Endometriosis. Practice Bulletin No. 113
If the condition remains unresponsive to medical therapies or if endometrial implants are widespread, surgical intervention is the preferred method of treatment. Surgeons attempt to treat the patient with the least invasive procedure possible. The abnormal tissue may be excised or removed through ablation in an attempt to retain fertility.
Most surgical procedures for endometriosis are preformed through laparoscopy, such as excision and ablation. Multiple surgical energy modalities are available, including electrosurgical, laser, ultrasonic, or robotic. Recently, robotically-assisted laparoscopic surgical procedures have been performed with high success.
Cystectomy is used to treat endometrioma. It involves coagulation and ablation of the cyst wall with laser or electrosurgery. It also is used for blunt or sharp dissection of endometriotic tissue.
A bilateral oophorectomy compromises ovarian reserve and results in infertility. If fertility is a concern and if preservation is possible, a unilateral oophorectomy is considered. A bilateral salpingo-oophorectomy the removal of both ovaries and the fallopian tubes. A unilateral procedure may preserve fertility by preserving the function of the remaining ovary and fallopian tube, although fertility may be more challenging as ovulation will be reduced by half.
A hysterectomy may be formed, either with or without cervix removal. A simple hysterectomy only removes the uterus. In a total hysterectomy, the uterus is removed along with the cervix. The only definitive treatment of endometriosis is total abdominal hysterectomy, bilateral salpingo-oophorectomy.
If the endometrial implants have invaded the perirectal space, a bowel resection may be necessary. The patient may require a stoma and ostomy bag. The stoma is either permanent of temporary depending upon the location and the amount of tissue to be removed.
Expected Nursing Management
Incision Care and Pain Management
The goals of nursing management include the prevention of infection to the incision area and maintenance of a safe environment during the postoperative recovery phase in the acute care setting. The nurse will administer medications as ordered to provide management of pain.
Monitoring and Lab Values
The nurse will also monitor vitals to establish a baseline and assess for changes in status. Lab values will also be watched closely to identify early signs of alteration in fluid and electrolyte balances. Due to the shutdown of peristalsis related to general anesthesia and NPO status, the nurse must monitor for alteration in gastrointestinal function.
In addition to these actions, patient teaching is indicated to educate the client on diet advancement from NPO to clear liquids and following progressions. The nurse will also promote self-advocacy so the client may understand the anticipated elements of the recovery phase and follow-up treatment. All of these measures necessitate strong communication with other members of the collaborative health care team.
If fertility is impaired, the patient may be burdened with the loss of future potential to bear children. This is particularly traumatic for younger women who have not children. Additionally, the fluctuations in hormonal levels often result in an emotional rollercoaster. It’s important for the nurse to be incredibly supportive to patients who have undergone surgical procedures for endometriosis.
Stoma and Ostomy
If the patient undergoes a bowel resection with an associated stoma and ostomy bag placement, they will need to be educated on stoma and ostomy care. This often involves the assistance of a WOC Nurse. The primary nurse will work with the WOC Nurse and aids to help the patient deal with the tasks and emotional aspects of the stoma.
Nursing Care Plan: Postoperative
Potential Nursing Diagnoses
- Risk for infection
- Ineffective tissue perfusion related to hemorrhage
- Fluid imbalance (dehydration or fluid overload)
- Monitor for signs of hemorrhage and infection
- Monitor intake and output
- Assess the abdomen for the presence of bowel sounds and monitor elimination patterns; the client should have a bowel movement within the appropriate time frame
- Labs values for signs of dehydration, fluid overload, and electrolyte imbalances
- Pain assessment, including severity through the use of a measurable scale (such as 1-10), location, and characteristics
- Fluid and electrolyte balance: the nurse will administer fluids such as lactated ringers and electrolytes and promote
- Facilitate diet progression from NPO, clear liquids, liquid, to regular diet
- Frequently monitor the client’s status by checking vital signs
- Obtain labs throughout the day and monitor lab values, especially electrolytes such as sodium, potassium, and magnesium
- Teach the patient how to order food from the room-service menu from a list of approved clear-liquid diet selections
- Record intake of food from clear-liquid diet menu
- Ambulate as ordered to encourage urinary elimination and promote the slow return of bowel and peristaltic activity
Evaluation of Outcomes
- Did the client show evidence of a positive response to each intervention? For example, was the patient’s pain reduced to a tolerable level following administration of pain medications?
- Were these the most effective interventions for the client’s specific needs and situation?
- Can the client verbalize understanding of teaching concepts?
Resources for Nursing Students on Endometriosis
- Adamson, G. D., & Nelson, P. (1997). Surgical treatment of endometriosis. Endometriosis, 24(2), 375-408. Retrieved from http://www.fpnc.com/pdfs/research/4SurgTreatmentEndoHpn.pdf
- Bafzer, F. R. (2006). GnRH agonist and antagonist: Options for endometriosis pain management. Department of Obstetrics and Gynecology Faculty Papers. Paper 3. Retrieved from http://jdc.jefferson.edu/cgi/viewcontent.cgi?article=1002&context=obgynfp
- Bedaiwy, M. A., & Barker, N. M. (2012). Evidence based surgical management of endometriosis. Middle East Fertility Society Journal, 17(1), 57-60. Retrieved from http://www.sciencedirect.com/science/article/pii/S1110569011001348
- Bloski, T., & Pierson, R. (2008). Endometriosis and chronic pelvic pain. Nursing Womens Health, 12(5), 382-395. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3096669/
- Dhillon, P. K., & Holt, V. L. (2003). Recreational physical activity and endometrioma risk. American Journal of Epidemiology, 158(2), 156-164. Retrieved from http://aje.oxfordjournals.org/content/158/2/156.full
- Dmowski, D. P. (2008). Advances in the treatment of endometriosis: The potential of Elagolix (NBI-56418). Retrieved from http://www.endometriosisinstitute.com/pdf/US_Ob_Gyn_Advances_in_treatment_of_endo0001.pdf
- Ebrahimi, N. A. (2008). Laparoscopic excision of endometrioma. World Journal of Laparoscopic Surgery, 1(2), 44-48. Retrieved from http://worldjls.org/Journal/vol/vol2/12.pdf
- Hart, R. J., Hickey, M., Maouris, P., Buckett, W., & Garry, R. (2005). Excisional surgery versus ablative surgery for ovarian endometriomata: a Cochrane Review. Human Reproduction, 20(11), 3000-3007. Retrieved from http://humrep.oxfordjournals.org/content/20/11/3000.full.pdf
- Hwu, Y., Wo, F., Li, S., Sun, F., Lin, M., & Lee, R. (2011). The impact of endometrioma and laparoscopic cystectomy on serum anti-Müllerian hormone levels. Reproductive Biology and Endocrinology, 9(80). Retrieved from http://www.biomedcentral.com/content/pdf/1477-7827-9-80.pdf
- Johnson, N. (2013). The pharmacological management of endometriosis. Best Practice Journal, 52, 19-25. Retrieved from http://www.bpac.org.nz/BPJ/2013/April/docs/bpj52-pages-18-25.pdf
- Kaur, H., Krishna, D., Shetty, N., Krishnan, S., Srinivas, M. C., & Rao, K. A. (2012). Effect of pre-ovulatory single dose GnRH agonist therapy on IVF outcome in GnRH antagonist cycles; A prospective study. Journal of Reproduction and Fertility,13(4), 53. Retrieved from http://www.jri.ir/en/ShowArticle.aspx?id=514
- Luciano, A. A., LaMonica, R., & Luciano, D. E. (2011). Strategies and steps for the surgical management of endometriosis. OBG Management, 23(11). Retrieved from http://www.obgmanagement.com/home/article/strategies-and-steps-for-the-surgical-management-of-endometriosis/13bd577a787db006dfa61330d9e2ab7c.html
- Mounsey, A. L., Wilgus, A. L. & Slawson, D. C. (2006). Diagnosis and Management of Endometriosis. American Family Physician, 74(4), 594-600. Retrieved from http://www.aafp.org/afp/2006/0815/p594.html
- Patel, M. D., Feldstein, V. A., Chen, D. C., Lipson, S. D., & Filly, R. A. (1999). Endometriomas: Diagnostic performance of US. Radiology, 210, 739-745. Retrieved from http://radiology.rsna.org/content/210/3/739.long
- Rani, A. J., & Kapoor, D. (2012). Ruptured ovarian endometrioma with an extreme rise in serum CA 125 level-A case report: Ovarian endometrioma with very high CA‐125 level. Gynecologic Oncology Case Reports, 2(3), 100-101. Retrieved from http://www.sciencedirect.com/science/article/pii/S2211338X12000415
- Rivier, J., Jiang, G. C., Lahrichi, S. L., Porter, J., Koerber, S. C., Rizo, J., Corrigan, A., Gierasch, L., Hagler, A., Vale, W., & Rivier, C. (1996). Dose relationship between GnRH antagonists and pituitary suppression. Human Reproduction, 11(3). Retrieved from http://humrep.oxfordjournals.org/content/11/suppl_3/133.full.pdf
- Sheaves, C. (2013). Advances in endometriosis treatment. The Nurse Practitioner: The American Journal of Primary Health Care, 38(5), 42-47. Retrieved from http://www.nursingcenter.com/lnc/Static-Pages/Advances-in-endometriosis-treatment
Streuli, I., de Ziegler, D., Santulli, P., Marcellin, L., Borghese, B., Batteux, F., & Chapron, C. (2013). An update on the pharmacological management of endometriosis. Expert Opinion in Pharmacotherapy, 14(3), 291-305. Retrieved from http://informahealthcare.com/doi/abs/10.1517/14656566.2013.767334
Takeuchi, M., Matsuzaki, K., & Nishitani, H. (2008). Susceptibility-weighted MRI of endometrioma: Preliminary results. American Journal of Roentgenology, 191(5). Retrieved from http://www.ajronline.org/doi/full/10.2214/AJR.07.397
Vercellini, P., Crosignani, P. G., Abbiati, A., Somigliana, E., Viganò, P., & Fedele, L. (2009). The effect of surgery for symptomatic endometriosis: The other side of the story. Reproductive Update, 15(2), 177-188. Retrieved from http://humupd.oxfordjournals.org/content/15/2/177.long