Group 6 Report Final


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Group 6 Report Final

  1. 1. GROUP 6 GROUP 6 GROUP 6 <ul><li>Prepared by: </li></ul><ul><ul><li>Areno, Jairah Joy </li></ul></ul><ul><ul><li>Bayhon, Jun Rey </li></ul></ul><ul><ul><li>Butalon, Michelle </li></ul></ul><ul><ul><li>Gonzales, Charisa Mae </li></ul></ul><ul><ul><li>Ponsaran, April Ann </li></ul></ul><ul><ul><li>Villanueva, Kenneth </li></ul></ul>
  3. 3. Endometriosis is a disorder in which abnormal growths of tissue, histologically resembling the endometrium, are present in locations other than the uterine lining. Although endometriosis can occur very rarely in postmenopausal women, it is found almost exclusively in women of reproductive age. All other manifestations of endometriosis exhibit a wide spectrum of expression. The lesions are usually found on the peritoneal surfaces of the reproductive organs and adjacent structures of the pelvis, but they can occur anywhere in the body . The size of the individual lesions varies from microscopic to large invasive masses that erode into underlying organs and cause extensive adhesion formation. Similarly, women with endometriosis can be completely asymptomatic or may be crippled by pelvic pain and infertility. Endometriosis
  5. 5. Etiology Experts do not know what causes endometrial tissue to grow outside your uterus. But they do know that the female hormone estrogen makes the problem worse. Women have high levels of estrogen during their childbearing years. It is during these years—usually from their teens into their 40s—that women have endometriosis. Estrogen levels drop when menstrual periods stop (menopause). Symptoms usually go away then. It is a common disease in women of reproductive age. It involves tissues of the endometrium, the inner lining of the uterus. During the menstrual cycle, built-up endometrial tissues normally are shed if pregnancy does not occur. Some endometrial cells escape from the womb into the pelvic cavity, where they attach themselves and continue their hormone stimulated growth cycle. They may also migrate to remove parts of the body . Pathophysiology
  6. 6. EXAMS AND TESTS <ul><li>Ask questions about your symptoms, your periods, your past health, and your family history. Endometriosis sometimes runs in families. </li></ul><ul><li>Do a pelvic exam . This may include checking both your vagina and rectum . </li></ul><ul><li>MRI, Ultrasound and CT Scan to check the presence of a cyst. </li></ul><ul><li>Laparoscopic surgery for the presence of endometriosis. </li></ul>
  7. 7. What are the symptoms? <ul><li>Pain. Where it hurts depends on where the implants are growing. You may have pain in your lower belly, your rectum or vagina, or your lower back. You may have pain only before and during your periods or all the time. Some women have more pain during sex, when they have a bowel movement, or when their ovaries release an egg (ovulation). </li></ul><ul><li>Abnormal bleeding. Some women have heavy periods, spotting or bleeding between periods, bleeding after sex, or blood in their urine or stool. </li></ul><ul><li>Trouble getting pregnant ( infertility ). This is the only symptom some women have. </li></ul>
  8. 8. Complications <ul><li>Internal scarring </li></ul><ul><li>Adhesions </li></ul><ul><li>Pelvic cysts </li></ul><ul><li>Ruptured cyst </li></ul><ul><li>Chocolate cysts </li></ul>
  9. 9. Nursing Diagnosis <ul><li>Acute pain related to bleeding of endometrial tissue causes local inflammation </li></ul><ul><li>Disturbed body image related to altered fertility and fears about sexuality and relationships with partner and family </li></ul><ul><li>Deficient knowledge of the perioperative aspects of hysterectomy and post-operative self care </li></ul><ul><li>Risk for situational low esteem related to perceived potential changes in femininity, effects on sexual relationships </li></ul><ul><li>Ineffective tissue perfusion related to anemia, surgical trauma, effects of anesthesia. </li></ul>
  10. 10. Medical Intervention <ul><li>Progesterone or Progestins </li></ul><ul><li>Avoid xenoestrogens </li></ul><ul><li>Hormone contraception therapy </li></ul><ul><li>Danazol (Danocrine) and gestrinone </li></ul><ul><li>Lupron depo shot </li></ul><ul><li>Aromatase </li></ul>
  11. 11. Surgical intervention Hysterectomy -is the surgical removal of the uterus to treat cancer, dysfunctional uterine bleeding, endometriosis,non malignant growth, persistent pain, pelvic relaxation and prolapse, and previous injury to the uterus. Oophorectomy - is the surgical removal of one or both ovaries. It is also called ovariectomy or ovarian ablation. If one ovary is removed, a woman may continue to menstruate and have children. If both ovaries are removed, menstruation stops and a woman loses the ability to have children.
  12. 12. Pre-operative management <ul><li>Lower half of the abdomen and the pubic and perineal regions maybe shaved , clean with soap and water. </li></ul><ul><li>Bladder should be empty. </li></ul><ul><li>NPO </li></ul><ul><li>An enema and antiseptic douche may be prescribed the evening before the surgery. </li></ul><ul><li>Pre-op meds maybe administered. </li></ul>
  13. 13. Post operative nursing care <ul><li>Assesses plans and evaluates the nursing care needs of the patient in the immediate post-operative or post-procedural period. </li></ul><ul><li>Provides comfort and support for post-operative patients.  </li></ul><ul><li>Evaluates responses to treatments and interventions.  </li></ul><ul><li>Carries out physician orders.  </li></ul><ul><li>Anticipates case specific needs based on knowledge of procedure and pathophysiology regarding patient and procedure.  </li></ul><ul><li>Manages pain.  </li></ul><ul><li>Administers prescribed medications and monitors vital signs.  </li></ul><ul><li>Maintains aseptic technique and actively monitors situations which could lead to breaches in aseptic technique. </li></ul><ul><li>Serves as the primary coordinator of all ancillary disciplines for well coordinated patient care.  </li></ul><ul><li>Monitors, records and communicates patient condition as appropriate, utilizing computerized documentation systems.   </li></ul><ul><li>Provides age and culturally appropriate care.  </li></ul><ul><li>Orients and mentors new staff members.  </li></ul><ul><li>Follows Standard Precautions using personal protective equipment as required </li></ul>
  14. 14. Prevention <ul><li>Prevention of endometriosis is not currently possible. Traditionally, women with relatives affected by endometriosis - or in whom the diagnosis has recently been made - are advised not to postpone childbearing. The merits of this advice have not been proved. A more thorough understanding of the pathophysiology of endometriosis is required before preventative strategies can be devised. </li></ul>
  15. 15. Ovarian cysts are small fluid-filled sacs that develop in a woman's ovaries. Most cysts are harmless, but some may cause problems such as rupturing, bleeding, or pain; and surgery may be required to remove the cyst(s). It is important to understand how these cysts may form. Women normally have two ovaries that store and release eggs. Each ovary is about the size of a walnut, and one ovary is located on each side of the uterus . One ovary produces one egg each month, and this process starts a woman's monthly menstrual cycle . The egg is enclosed in a sac called a follicle. An egg grows inside the ovary until estrogen (a hormone), signals the uterus to prepare itself for the egg. In turn, the uterus begins to thicken itself and prepare for pregnancy . This cycle occurs each month and usually ends when the egg is not fertilized. All contents of the uterus are then expelled if the egg is not fertilized. This is called a menstrual period. Ovarian Cysts
  16. 16. ovarian cyts
  17. 17. Ovarian Cysts Causes <ul><li>Oral contraceptive/birth control pill use decreases the risk of developing ovarian cysts because they prevent the ovaries from producing eggs during ovulation. The following are possible risk factors for developing ovarian cysts: </li></ul><ul><li>History of previous ovarian cysts </li></ul><ul><li>Irregular menstrual cycles </li></ul><ul><li>Increased upper body fat distribution </li></ul><ul><li>Early menstruation (11 years or younger) </li></ul><ul><li>Infertility </li></ul><ul><li>Hypothyroidism or hormonal imbalance </li></ul><ul><li>Tamoxifen therapy for breast cancer </li></ul>
  18. 18. PATHOPHYSIOLOGY <ul><li>From fetal life through a woman's reproductive life, ovarian follicles undergo varying rates of maturation and involution under the guidance of the hypopituitary axis. Multiple follicles are recruited every month during the proliferative phase of the menstrual cycle. However, only one follicle reaches maturity and produces estrogen, releasing a mature oocyte at mid cycle. The follicular cyst transforms into a corpus luteum following ovulation and produces progesterone until the beginning of the next cycle. In the absence of fertilization of the oocyte, it continues to atrophy. </li></ul><ul><li>Follicular dysgenesis occurs with hypothalamic-pituitary dysfunction or because of native anatomic defects in the reproductive system. When follicular development into a corpus luteum is arrested, a luteal ovarian cyst can result. </li></ul><ul><li>Two functional ovarian cysts may develop: follicular cysts (ie, graafian follicular cysts) occur in the first 2 weeks of the cycle, and corpus luteal cysts occur in the later half of the cycle. The rupture of the follicular cyst can lead to sharp, severe, unilateral pain of mittelschmerz (occurring mid cycle), and it is experienced by approximately 25% of menstruating women. Similarly, failure of corpus luteum degeneration leads to a luteal cyst formation. These cysts may become inflamed or spontaneously hemorrhage, producing symptoms during the later half of the menstrual cycle. </li></ul><ul><li>Carcinomatous processes of the ovary, both primary and metastatic, frequently are complicated by cystic degeneration. The formation of inclusions of the ovary's germinal epithelium may lead to cystic development. Endometriomas are cysts filled with blood from the ectopic endometrium. </li></ul>
  19. 19. Ovarian Cysts Symptoms <ul><li>Lower abdominal or pelvic pain, which may start and stop and may be severe, sudden, and sharp </li></ul><ul><li>Irregular menstrual periods </li></ul><ul><li>Feeling of lower abdominal or pelvic pressure or fullness </li></ul><ul><li>Long-term pelvic pain during menstrual period that may also be felt in the lower back </li></ul><ul><li>Pelvic pain after strenuous exercise or sexual intercourse </li></ul><ul><li>Pain or pressure with urination or bowel movements </li></ul><ul><li>Nausea and vomiting </li></ul><ul><li>Vaginal pain or spots of blood from vagina </li></ul><ul><li>Infertility </li></ul>
  20. 20. DIAGNOSTIC EXAMS <ul><li>Endovaginal ultrasound: This type of imaging test is a special form of ultrasound developed to examine the pelvic organs and is the best test for diagnosing an ovarian cyst. </li></ul><ul><li>Other imaging: CT scanning aids in assessing the extent of the condition. MRI scanning may also be used to clarify results of an ultrasound. </li></ul><ul><li>Laparoscopic surgery : The surgeon fills a woman's abdomen with a gas and makes small incisions through which a thin scope (laparoscope) can pass into the abdomen. The surgeon identifies the cyst through the scope and may remove the cyst or take a biopsy from it. </li></ul><ul><li>Hormone levels: A blood test to check LH, FSH, estradiol , and testosterone levels may indicate potential problems concerning these hormone levels. </li></ul><ul><li>Pregnancy testing : The treatment of ovarian cysts is different for a pregnant woman than it is for a nonpregnant woman. An ectopic pregnancy (pregnancy outside the uterus) must be ruled out because some of the symptoms of ectopic pregnancy may be similar to those of ovarian cysts. </li></ul><ul><li>Culdocentesis : This test involves taking a fluid sample from the pelvis with a needle inserted through the vaginal wall behind the uterine cervix. </li></ul>
  21. 21. COMPLICATIONS <ul><li>Dermoid cysts. These cysts may contain tissue such as hair, skin or teeth because they form from cells that produce human eggs. They are rarely cancerous, but they can become large and cause painful twisting of your ovary. </li></ul><ul><li>Endometriomas. These cysts develop as a result of endometriosis, a condition in which uterine cells grow outside your uterus. Some of that tissue may attach to your ovary and form a growth. </li></ul><ul><li>Cystadenomas. These cysts develop from ovarian tissue and may be filled with a watery liquid or a mucous material. They can become large — 12 inches or more in diameter — and cause twisting of your ovary. </li></ul>
  22. 22. NURSING DIAGNOSIS <ul><li>Risk for situational low self esteem related to effect on sexual relationship </li></ul><ul><li>Ineffective tissue perfusion related to effects of anesthesia </li></ul><ul><li>Constipation related to weakening of abdominal muscle </li></ul><ul><li>Risk for infection related to surgical procedure </li></ul><ul><li>Deficient knowledge related to self care practices regarding their condition </li></ul>
  23. 23. Medical intervention <ul><li>Ultrasonic observation or endovaginal ultrasound are used repeatedly and frequently to monitor the growth of the cyst. </li></ul>Medications <ul><li>Oral contraceptives: Birth control pills may be helpful to regulate the menstrual cycle, prevent the formation of follicles that can turn into cysts, and possibly reduce the size of an existing cyst. </li></ul><ul><li>Pain relievers: Anti-inflammatories such as ibuprofen (for example, Advil) may help reduce pelvic pain. Narcotic pain medications by prescription may relieve severe pain caused by ovarian cysts. </li></ul>
  24. 24. Surgical intervention Laparoscopic surgery: The surgeon fills a woman's abdomen with a gas and makes small incisions through which a thin scope (laparoscope) can pass into the abdomen. The surgeon identifies the cyst through the scope and may remove the cyst or take a sample from it. Laparotomy : This is a more invasive surgery in which an incision is made through the abdominal wall in order to remove a cyst. Surgery for ovarian torsion: An ovarian cyst may twist and cause severe abdominal pain as well as nausea and vomiting. This is an emergency, surgery is necessary to correct it. Cystectomy : This is like taking a clam out of the shell. The thinned out ovarian tissue is cut open, and the cyst is gently peeled away from inside the ovary. The cyst fluid is then removed with a suction device. The cyst now looks like a deflated balloon and can easily be removed through the small laparoscopy incision.
  25. 25. Pre-op nursing care <ul><li>Informed consent </li></ul><ul><li>Assess client’s level of understanding of surgical procedure and its implications. </li></ul><ul><li>Explain routine pre and post-op procedure and any special equipment used. </li></ul><ul><li>Obtain history of past medical conditions surgical procedures, allergies, dietary restrictions and medications. </li></ul><ul><li>Perform baseline head-to-toe assessment, including vital signs, height, and weight. </li></ul><ul><li>Remain NPO </li></ul><ul><li>Cleanse the skin with antibacterial soap as ordered. </li></ul><ul><li>Promote adequate rest and sleep. </li></ul><ul><li>Ensure that the ff. are performed as ordered: </li></ul><ul><li>CBC, electrolytes, PT/PTT(prothrombin time; partial thromboplstin time, urinalysis, ECG, type and crossmatch, chest x-ray </li></ul>
  26. 26. Post-op nursing care <ul><li>Assess for and maintain patent airway. </li></ul><ul><li>Administer oxygen as ordered. </li></ul><ul><li>Assess rate, depth, and quality of respirations. </li></ul><ul><li>Check vital signs every 15 min. until stable, then every 30 min. </li></ul><ul><li>Note level of consciousness. </li></ul><ul><li>Monitor IV infusion: condition of site and amount of fluid being infused and flow rate. </li></ul><ul><li>Assess drainage for intactness, drainage and hemorrhage. </li></ul><ul><li>Measure intake and output. </li></ul>
  27. 27. Nursing care <ul><li>Allow woman (and partner) to verbalize concerns about sexuality post surgery. </li></ul><ul><li>Support woman and family through procedure. </li></ul><ul><li>Provide discharge teaching. </li></ul>
  28. 28. Dysmenorrhea Dysmenorrhea refers to the syndrome of painful menstruation. Primary dysmenorrhea occurs in the absence of pelvic pathology, whereas secondary dysmenorrhea results from identifiable organic diseases, most typically endometriosis, uterine fibroids, uterine adenomyosis, or chronic pelvic inflammatory disease. The prevalence of dysmenorrhea is estimated to be between 45 and 95% among reproductive-aged women. Although not life threatening, dysmenorrhea can be debilitating and psychologically taxing for many women and is one of the leading causes of absenteeism from work and school.
  29. 29. Types of Dysmenorrhea <ul><li>This is called dysmenorrhea. There are two types of dysmenorrheal — primary or secondary. </li></ul><ul><li>Primary Dysmenorrhea Primary dysmenorrhea is pelvic pain that comes from having your period and the natural production of prostaglandins. Often it begins soon after a pre-teen or teen starts having periods. </li></ul><ul><li>Secondary Dysmenorrhea Secondary dysmenorrhea has causes other than menstruation and the natural production of prostaglandins. It may begin later in life than primary dysmenorrhea. This type of pain often lasts longer than normal cramps. Some of the most common causes of secondary dysmenorrhea are: </li></ul><ul><li>Endometriosis </li></ul><ul><li>Fibroids </li></ul>
  30. 30. etiology <ul><li>age of less than 30 years </li></ul><ul><li>a low body mass index </li></ul><ul><li>Smoking </li></ul><ul><li>earlier menarche(< 12 years) </li></ul><ul><li>longer menstrual cycles </li></ul><ul><li>Heavy menstrual flow </li></ul><ul><li>Nulliparity </li></ul><ul><li>premenstrual syndrome </li></ul><ul><li>Sterilization </li></ul><ul><li>clinically suspected pelvic inflammatory disease </li></ul><ul><li>sexual abuse </li></ul><ul><li>Psychological symptoms were associated with dysmenorrhea. </li></ul>
  31. 31. Pathophysiology Prostaglandins are released during menstruation, due to the destruction of the endometrial cells, and the resultant release of their contents. Release of prostaglandins and other inflammatory mediators in the uterus is thought to be a major factor in primary dysmenorrhea. Females with primary dysmenorrhea have increased activity of the uterine muscle with increased contractility and increased frequency of contractions.
  32. 32. Signs and symptoms <ul><li>The main symptom of dysmenorrhea is pain concentrated in the lower abdomen , in the umbilical region or the suprapubic region of the abdomen. It is also commonly felt in the right or left abdomen. It may radiate to the thighs and lower back . </li></ul><ul><li>nausea </li></ul><ul><li>Vomiting </li></ul><ul><li>diarrhea </li></ul><ul><li>Headache </li></ul><ul><li>fainting </li></ul><ul><li>fatigue </li></ul><ul><li>Symptoms of dysmenorrhea usually begin a few hours before the start of menstruation, and may continue for a few days. </li></ul>
  33. 33. Exams and tests <ul><li>Evaluating female’s medical history </li></ul><ul><li>Complete physical examination including pelvic examination </li></ul><ul><li>Ultrasonography </li></ul><ul><li>Laparoscopy </li></ul><ul><li>hysteroscopy </li></ul><ul><li>using MRI, visible features of the uterus were compared in dysmenorrheic and eumenorrheic (normal) participants. </li></ul>
  34. 34. complications <ul><li>Fainting- from severe menstrual cramps. </li></ul><ul><li>Abdominal pain </li></ul><ul><li>Back pain </li></ul>
  35. 35. Nursing diagnosis <ul><li>Acute pain related to bleeding of the endometrial lining tissue </li></ul><ul><li>Sleep pattern disturbance related to severe menstrual cramps </li></ul>
  36. 36. Medical intervention <ul><li>NSAIDs (non-steroidal anti-inflammatory drugs), block the body from making prostaglandins. This makes cramps less severe. </li></ul><ul><li>Hormonal Contraception Hormonal contraception, such as birth control pills, patches, and vaginal rings, also reduce menstrual pain. In some cases, the hormonal intrauterine device (IUD) may be recommended. </li></ul><ul><li>prostaglandin inhibitors (i.e., nonsteroidal anti-inflammatory medications, or NSAIDs, such as aspirin, ibuprofen) - to reduce pain </li></ul><ul><li>acetaminophen </li></ul><ul><li>oral contraceptives (ovulation inhibitors) </li></ul><ul><li>progesterone (hormone treatment) </li></ul><ul><li>Surgery If fibroids are causing the pain, your doctor may suggest surgery or uterine artery embolization. During surgery, the fibroid or the entire uterus may be removed(hysterectomy). </li></ul>
  37. 37. Nursing care <ul><li>May help ease pain, although they do not prevent it: </li></ul><ul><li>Taking a vitamin B or magnesium supplement </li></ul><ul><li>Acupuncture or acupressure </li></ul><ul><li>dietary modifications (to increase protein and decrease sugar and caffeine intake) </li></ul><ul><li>vitamin supplements </li></ul><ul><li>regular exercise </li></ul><ul><li>heating pad across the abdomen </li></ul><ul><li>hot bath or shower </li></ul><ul><li>abdominal massage </li></ul>
  38. 38. Post menstrual dysmorphic syndrome <ul><li>Post menstrual dysmorphic syndrome can occur between the ages of 44 and 55 and the standard definition is when menstrual periods have completely stopped for more than 12 months. Postmenopause syndrome can also be surgically induced by hysterectomy at any age and afterward you can no longer have children or menstrual periods. </li></ul><ul><li>After the menopause. Postmenopausal is defined formally as the time after which a woman has experienced twelve (12) consecutive months of amenorrhea (lack of menstruation ) without a period. </li></ul><ul><li>ETIOLOGY: </li></ul><ul><li>Post-menstrual syndrome is due to opposite factors wherein there may be a high </li></ul><ul><li>progesterone level relative to estrogens. </li></ul>
  39. 39. Signs and symptoms <ul><li>Vaginal Dryness and Itching </li></ul><ul><li>hot flashes , irritability </li></ul><ul><li>bleeding irregularities </li></ul><ul><li>mood swings </li></ul><ul><li>urinary incontinence </li></ul><ul><li>weight gain </li></ul><ul><li>low sex drive </li></ul><ul><li>higher risk for breast cancer </li></ul><ul><li>heart disease or osteoporosis </li></ul><ul><li>Others may have to deal with uterine fibroid tumors as a result of hormone imbalance. </li></ul>
  40. 40. Diagnostics <ul><li>There are no recommended labs for menopause or post-menopause . As and when your menstrual cycle stops, pituitary gland starts secreting follicle stimulating hormone. Increased levels of this hormone will automatically shutdown your ovaries. It can be easily tested with simple blood test. </li></ul><ul><li>COMPLICATIONS: </li></ul><ul><li>Osteoporosis </li></ul><ul><li>Fibroid tumor </li></ul>
  41. 41. Nursing diagnosis <ul><li>Risk for injury related to one fragility and microarchilectural deterioration of bone tissue secondary to osteoporosis </li></ul><ul><li>Knowledge deficit related to self-care practices </li></ul><ul><li>Anxiety related to infertility </li></ul><ul><li>Sleep pattern disturbance related to different irritants, discomfort and feelings of panic </li></ul><ul><li>Acute pain related to vaginal secretions decreases thus causing dyspaurenia (pain during intercourse) </li></ul>
  42. 42. n Medical intervention Consult the doctor once you find these symptoms in you and take the measurement of your follicle stimulating hormone for confirming yourself whether you are in menopause or post menopause stage.
  43. 43. n Nursing care Consult the doctor once you find these symptoms in you and take the measurement of your follicle stimulating hormone for confirming yourself whether you are in menopause or post menopause stage.
  44. 44. What is a vaginal fistula? . A fistula is a passage or hole that has formed between: -Two organs in your body. -An organ in your body and your skin. A fistula that has formed in the wall of the vagina is called a vaginal fistula. A vaginal fistula that opens into the urinary tract is called a vesicovaginal fistula . A vaginal fistula that opens into the rectum is called a rectovaginal fistula . A vaginal fistula that opens into the colon is called a colovaginal fistula . A vaginal fistula that opens into the small bowel is called a enterovaginal fistula .
  45. 45. vaginal fistula
  46. 46. What causes a vaginal fistula? <ul><li>A vaginal fistula starts with some kind of tissue </li></ul><ul><li>damage. After days to years of tissue breakdown, a fistula opens up. Vaginal fistulas are not a common problem in developed countries.But a fistula does sometimes happen after: </li></ul><ul><ul><li>Surgery of the back wall of the vagina, the perineum, anus, or rectum. Open hysterectomy is linked to most vaginal-urinary tract fistulas. </li></ul></ul><ul><ul><li>Radiation treatment for pelvic cancer. </li></ul></ul><ul><ul><li>A period of inflammatory bowel disease (including Crohn’s disease and ulcerative colitis ) or diverticulitis . </li></ul></ul><ul><ul><li>A deep tear in the perineum or an infected episiotomy after childbirth. </li></ul></ul>
  47. 47. Vaginal fistulas are classified into four types; treatment varies for each : <ul><li>Vesicovaginal fistulas, also called bladder fistulas, occur between the vagina and urinary bladder. This is the most common type of vaginal fistula. </li></ul><ul><li>Uterovaginal fistulas occur between the vagina and distal ureter (ureters are ducts that carry urine from the kidney to the bladder) </li></ul><ul><li>Urethrovaginal fistulas, also called urethral fistulas, occur between the vagina and urethra (tube that carries urine out of the body) </li></ul><ul><li>Rectovaginal fistulas, also called rectal fistulas, occur between the vagina and the rectum </li></ul>
  48. 48. What are the causes? <ul><li>Most rectovaginal fistulas are acquired although congenital abnormalities do exist. The acquired fistulas will be the focus here and include etiologies such as: </li></ul><ul><li>trauma (including operative, obstetric, and traumatic injuries) </li></ul><ul><li>infection </li></ul><ul><li>inflammatory bowel disease </li></ul><ul><li>Carcinoma </li></ul><ul><li>radiation </li></ul>
  49. 49. What are the symptoms of a vaginal fistula? <ul><li>A vaginal fistula is painless. But a fistula lets urine or feces pass into your vagina. This is called incontinence, and it causes embarrassing soiling problems that you cannot control. </li></ul><ul><li>If you have a vesicovaginal fistula, you most likely have fluid leaking or flowing out of your vagina. </li></ul><ul><li>If you have a rectovaginal, colovaginal, or enterovaginal fistula, you most likely have foul-smelling discharge or gas coming from your vagina. </li></ul><ul><li>Your genital area may get infected or sore. </li></ul>
  50. 50. Diagnostics <ul><li>Dye test — The bladder is filled with a dyed solution and the patient is asked to cough and bear down as the physician looks for signs of leakage in the vagina. Leakage may also be detected on a tampon after physical exercise. </li></ul><ul><li>Cytoscopy — The doctor uses a scope to inspect the vagina, ureters and bladder. </li></ul><ul><li>Retrograde pyelogram — This X-ray test is used to determine the presence of a ureterovinal fistula. Dye is injected through the bladder and into the ureters, watching for leakage between the ureter and vagina. </li></ul><ul><li>Fistulagram — This X-ray of the patient's fistula may help detect if the fistula communicates with other organs or if multiple fistulas are present. </li></ul>
  51. 51. complications <ul><li>Physical complications of vaginal fistula may include </li></ul><ul><li>incontinence, </li></ul><ul><li>problems with hygiene </li></ul><ul><li>irritation or inflammation of your vagina,perineum or the skin around your anus. </li></ul><ul><li>In some cases, a fistula may become infected and form an abscess, a problem that can become life-threatening if not treated. </li></ul>
  52. 52. Nursing diagnosis <ul><li>Risk for infection relate to surgical procedure </li></ul><ul><li>Sexual dysfunction related to abnormal structure of the vagina </li></ul><ul><li>Deficient knowledge related self care practices about the condition </li></ul>
  53. 53. Medical intervention <ul><li>If the area around your fistula is infected, you'll take a course of antibiotics before surgery. </li></ul><ul><li>Antibiotics may also be recommended for women with Crohn's disease who develop a fistula. </li></ul><ul><li>infliximab (Remicade). This drug blocks the action of an immune system protein called tumor necrosis factor-alpha (TNF-alpha), which causes inflammation. </li></ul>
  54. 54. Medical-surgical management <ul><li>The diagnosis an treatment of a vaginal fistula maybe difficult. Treatment varies with the location, extent, and cause of the fistula and the clients general help. Occasionally, a fistula heals spontaneously. Medical management is used first to treat infection because surgical management is rarely successful especially when an infection is present. On occasion, temporary colostomy maybe necessary to treat a rectovaginal fistula, and a suprapubic catheter must be inserted to prevent bladder distention after a repair of a vesicovaginal fistula. </li></ul><ul><li>Nursing care </li></ul><ul><li>Increase fluid intake to reduce the risk of infection </li></ul><ul><li>Provide perineal hygiene every four hours </li></ul><ul><li>Avoid physical stress (pre-op) </li></ul><ul><li>Keep the catheter patent and draining (post-op) </li></ul>
  55. 55. Uterine prolapse <ul><li>Uterine prolapse means your uterus has descended from its position in the pelvis farther down into your vagina. Normally, your uterus is held in place by the muscles and ligaments that make up your pelvic floor. Uterine prolapse occurs when pelvic floor muscles and ligaments stretch and weaken, providing inadequate support for the uterus. The uterus then descends into the vaginal canal. </li></ul><ul><li>Uterine prolapse often affects postmenopausal women who've had one or more vaginal deliveries. Damage sustained by supportive tissues during pregnancy and childbirth, plus the effects of gravity, loss of estrogen and repeated straining over the years, can weaken pelvic floor muscles and tissues and lead to uterine prolapse. </li></ul><ul><li>If you have mild uterine prolapse, treatment usually isn't needed. But if the condition makes you uncomfortable or disrupts your normal life, you might benefit from treatment. Options include using a supportive device (pessary), which is inserted into your vagina, or having surgery to repair the prolapse. </li></ul>
  56. 56. uterine prolapse
  57. 57. Symptoms <ul><li>Uterine prolapse varies in severity. You may have mild uterine prolapse and experience no signs or symptoms. Or you could have moderate to severe uterine prolapse. If that's the case, you may experience the following: </li></ul><ul><li>Sensation of heaviness or pulling in your pelvis </li></ul><ul><li>Tissue protruding from your vagina </li></ul><ul><li>Urinary difficulties, such as urine leakage or urge incontinence </li></ul><ul><li>Trouble having a bowel movement </li></ul><ul><li>Low back pain </li></ul><ul><li>Feeling as if you're sitting on a small ball or as if something is falling out of your vagina </li></ul><ul><li>Symptoms that are less bothersome in the morning and worsen as the day goes on </li></ul>
  58. 58. Causes <ul><li>Pregnancy and trauma incurred during childbirth, particularly with large babies or after a difficult labor and delivery, are the main causes of muscle weakness and stretching of supporting tissues leading to uterine prolapse. Loss of muscle tone associated with aging and reduced amounts of circulating estrogen after menopause also may contribute to uterine prolapse. In rare circumstances, uterine prolapse may be caused by a tumor in the pelvic cavity. </li></ul><ul><li>Genetics also may play a role. Women of Northern European descent have a higher incidence of uterine prolapse than do women of Asian and African descent. </li></ul>
  59. 59. pathophysiology Normally, your uterus is held in place by the muscles and ligaments that make up your pelvic floor. Uterine prolapse occurs when pelvic floor muscles and ligaments stretch and weaken, providing inadequate support for the uterus. The uterus then descends into the vaginal canal.
  60. 60. Risk factors <ul><li>Certain factors may increase your risk of uterine prolapse: </li></ul><ul><li>One or more pregnancies and vaginal births </li></ul><ul><li>Giving birth to a large baby </li></ul><ul><li>Increasing age </li></ul><ul><li>Frequent heavy lifting </li></ul><ul><li>Chronic coughing </li></ul><ul><li>Frequent straining during bowel movements </li></ul><ul><li>Some conditions, such as obesity, chronic constipation and chronic obstructive pulmonary disease (COPD), can place a strain on the muscles and connective tissue in your pelvis and may play a role in the development of uterine prolapse. </li></ul>
  61. 61. Tests and diagnosis <ul><li>complete pelvic examination </li></ul><ul><li>ultrasound </li></ul><ul><li>magnetic resonance imaging (MRI) </li></ul>
  62. 62. Complications <ul><li>Ulcers </li></ul><ul><li>Prolapse of other pelvic organs. </li></ul><ul><li>Weakness of connective tissue overlying the rectum may result in a prolapsed rectum (rectocele) </li></ul>
  63. 63. Nursing diagnosis <ul><li>Disturbed body image related to interference with daily activities </li></ul><ul><li>Sexual dysfunction related to abnormal uterine position </li></ul><ul><li>Risk for injury related to exposed uterus </li></ul><ul><li>Risk for infection related to surgical procedure </li></ul><ul><li>Deficient knowledge related to inadequate information about prevention and treatment </li></ul>
  64. 64. Treatments and drugs <ul><li>Lifestyle changes. If you're overweight or obese, your doctor may suggest ways to achieve a healthy weight and maintain that weight. Exercises to strengthen your pelvic floor muscles (Kegel exercises) may help relieve some symptoms. Your doctor may advise you to avoid heavy lifting or straining. </li></ul><ul><li>Vaginal pessary. A vaginal pessary fits inside the vagina and is designed to hold the uterus in place. The pessary can be a temporary or permanent form of treatment. </li></ul><ul><li>Surgery to repair uterine prolapse. If lifestyle changes fail to provide relief from symptoms of uterine prolapse, or if you'd prefer not to use a pessary, surgical repair is an option. </li></ul>
  65. 65. RECTAL PROLAPSE Is a condition in which the rectum (the lower end of the colon, located just above the anus) becomes stretched out and protrudes out of the anus. Weakness of the anal sphincter muscle is often associated with rectal prolapse at this stage, resulting in leakage of stool or mucus. While the condition occurs in both sexes, it is much more common in women than men.
  67. 67. 3 TYPES OF RECTAL PROLAPSE <ul><li>Partial prolapse (also called mucosal prolapse). The lining (mucous membrane) of the rectum slides out of place and usually sticks out of the anus when you strain to have a bowel movement. </li></ul><ul><li>Complete prolapse. The entire wall of the rectum slides out of place and usually sticks out of the anus. </li></ul><ul><li>Internal prolapse ( intussusception ). One part of the wall of the large intestine (colon) or rectum may slide into or over another part, like the folding parts of a telescope. </li></ul>
  68. 68. Rectal Prolapse is caused by: <ul><li>weakening of the ligaments and muscles that hold the rectum in place </li></ul><ul><li>anal sphincter is weak </li></ul><ul><li>advanced age </li></ul><ul><li>Long term constipation </li></ul><ul><li>Long term diarrhea </li></ul><ul><li>Long term straining during defecation </li></ul><ul><li>Pregnancy and stressess of childbirth </li></ul><ul><li>Previous surgery </li></ul><ul><li>Sphincter paralysis </li></ul><ul><li>Having had surgery on the anus as an infant. </li></ul><ul><li>Malnutrition. </li></ul><ul><li>Deformities or physical development problems. </li></ul><ul><li>Straining during bowel movements. </li></ul><ul><li>Infections. </li></ul>
  69. 69. symptoms <ul><li>Symptoms of rectal prolapse include a vague sense of fullness in the lower abdomen or rectal area. There may be a mucus or watery rectal discharge that sometimes is tinged with blood from the rectum. A firm mass of tissue can be felt at the anus after a bowel movement. People suffering from rectal prolapse frequently complain about having painful bowel movements. </li></ul><ul><li>· Blood in stool </li></ul><ul><li>· Mucus in stool </li></ul>
  70. 70. NURSING CARE <ul><li>PRE-OP </li></ul><ul><li>Before surgery, an intravenous (IV) line is placed so that fluid and/or medications may be easily administered to the patient. </li></ul><ul><li>A Foley catheter will be placed to drain urine. </li></ul><ul><li>Antibiotics are usually given to help prevent infection. The patient will be given a bowel prep to cleanse the colon and prepare it for surgery. </li></ul>
  71. 71. POST OP <ul><li>Foley catheter may remain for one to two days after surgery. </li></ul><ul><li>liquid diet until normal bowel function returns. </li></ul><ul><li>The patient will be instructed to avoid activities for several weeks that will cause strain on the surgical site; these include </li></ul><ul><li>L ifting </li></ul><ul><li>Coughing </li></ul><ul><li>long periods of standing </li></ul><ul><li>sneezing </li></ul><ul><li>straining with bowel movements and sexual intercourse. </li></ul>
  72. 72. Nursing care <ul><li>High-fiber foods should be gradually added to the diet to avoid constipation and straining that could lead to prolapse recurrence. </li></ul><ul><li>Avoid performing activities that causes strain. </li></ul>
  73. 73. COMPLICATIONS <ul><li>Fecal incontinence may become worse, and permanent damage can occur to the circular muscle that controls the anus ( anal sphincter ). </li></ul><ul><li>The rectum can become damaged from the tissues rubbing together, which can result in a sore (ulcer) that may bleed. </li></ul><ul><li>Normal blood flow to tissue in the rectum may be cut off, causing the tissue to die (gangrene). </li></ul><ul><li>If a prolapsed rectum swells, it may prevent the passage of stools. </li></ul>
  74. 74. MEDICAL INTERVENTION <ul><li>Treatments for rectal prolapse in adults focus on changes in diet, medicine (such as stool softeners), and surgery. Treatment choice depends on the type of prolapse, whether you have other physical problems and your age. </li></ul><ul><li>Adding fiber to your diet increases the amount of water in your stools and helps them move through the large intestine quickly. You may also use a prescription medicine, such as lactulose, that softens stools and allows them to move through the intestines and pass easily. </li></ul>
  75. 75. Nursing diagnosis <ul><li>Acute pain related to bleeding of the rectal lining </li></ul><ul><li>Disturbed body image related to exposed rectum </li></ul><ul><li>Deficient knowledge related to the disease </li></ul><ul><li>Self-esteem disturbance related to abnormal of the rectum </li></ul><ul><li>Risk for infection related to expose rectum </li></ul>
  76. 76. SURGICAL INTERVENTION Two types of surgery are used to treat a complete prolapse. A surgeon may operate through the belly to secure part of the large intestine or rectum to the inside of the abdominal cavity (rectopexy). Sometimes the surgeon removes the affected part of intestine. This type of surgery is most often used for younger, physically fit people. RECTOPEXY-Surgical fixation of a prolapsed rectum Surgery also can be done through the area between the genitals and the anus ( perineum ) to strengthen the anal sphincter . This type of surgery is best for people who are elderly or are not physically fit.
  77. 77. IMPERFORATED HYMEN The hymen originates from the embryonic vagina buds from the urogenital sinus. As a consequence, the hymen is a composite of vaginal epithelium and epithelium of the urogenital sinus interposed by mesoderm. Once the hymen becomes perforated or forms a central canal, it establishes a communication between the upper vaginal tract and the vestibule of the vagina (Mishell, 1997) . The cause may be related to failure of apoptosis due to a genetically transmitted signal, or it may be related to an inappropriate hormonal milieu.
  78. 78. Pathophysiology Any obstruction of the vaginal tract during the prenatal, perinatal, or adolescent periods results in the entrapment of vaginal and uterine secretions. In patients with imperforate hymen, this obstruction is at the level of the introitus and becomes evident when the distensible membrane bulges between the labia. Various terms, such as mucocolpos, hematocolpos, and pyocolpos, are used to describe this condition depending on the nature of the retained contents. In fetal development and in the immediate perinatal period, mucoid secretions from the uterovaginal tract result in mucocolpos under the influence of maternal estrogens. When the diagnosis is made in adolescence, the retained secretions consist of menstrual products, and the resulting mass effect in the vagina and uterus are referred to as hematocolpos and hematometrocolpos, respectively. Reflux of the endometrial tissue through the fallopian tubes (ie, hematosalpinx) may result in secondary endometriosis. An accumulation of infected material within the vaginal cavity (ie, pyocolpos) may occur because of an infection that is ascending through microperforations in the membrane.
  79. 79. Signs and symptoms <ul><li>No menstrual bleeding </li></ul><ul><li>Normal other symptoms of menstruation </li></ul><ul><li>Enlarged uterus </li></ul>
  80. 80. Etiology Imperforate hymen and related genital tract anomalies result from abnormal or incomplete embryologic development. <ul><li>Diagnostics </li></ul><ul><li>Ultrasonography is an essential first step in diagnosis, precluding unwise and unplanned surgical intervention with resultant injury to the urethra or other pelvic structures, and excluding other more complicated anomalies. Imaging studies: </li></ul><ul><li>Pelvic and abdominal ultrasound </li></ul><ul><li>Pelvic and abdominal MRI </li></ul><ul><li>There are no diagnostics procedures are indicated for a classic presentation and findings of imperforate hymen </li></ul>
  81. 81. COMPLICATIONS <ul><li>Incomplete drainage and failure of marsupialization may result in recurrent obstruction and, potentially, an ascending pelvic infection. </li></ul><ul><li>Postoperative fever or abdominal pain must be evaluated and treated promptly. Potential complications include endometritis, salpingitis, or tuboovarian abscess—any of which can affect subsequent fertility. </li></ul><ul><li>Concern for secondary endometriosis resulting from retrograde menstruation is sufficient for some authors to advocate irrigation of the peritoneal cavity by using a laparoscopic technique. Compared with primary endometriosis, secondary endometriosis generally does not become a chronic condition that impairs fertility. Endometriosis is not a uniformly chronic consequence of hematometrocolpos secondary to imperforate hymen. </li></ul><ul><li>Retrograde menstruation can occur with secondary endometriosis as a result of vaginal outflow obstruction. However, this condition is believed to be self-limited after the primary condition is corrected. </li></ul>
  82. 82. NURSING DIAGNOSIS <ul><li>Anxiety related to infertility </li></ul><ul><li>Deficient knowledge related to self care practices and treatment </li></ul><ul><li>self-esteem disturbance related to sexual dysfunction </li></ul><ul><li>Risk for infection related to surgical procedure (post-op) </li></ul><ul><li>Medical therapy has no role in the management of imperforate hymen because the retained secretions are typically sterile. </li></ul>MEDICAL INTERVENTION
  83. 83. SURGICAL INTERVENTION Surgical intervention for imperforate hymen should require only 1 definitive procedure to evacuate the retained secretions and to ensure the maintenance of patency. Simple drainage of the material confined beyond the hymen is contraindicated because it does not allow for adequate drainage of the thick fluid, it is not definitive, and it increases the risk of infection (pyometras). Two techniques are most commonly advocated: simple incision and small excision of the membrane. Simple incision of the hymen may be associated with postoperative stenosis with strictures, and it is not the method generally preferred at many centers. Use of an X -shaped incision ought to be the method of choice. An elliptical excision of the membrane is performed close to the hymenal ring, followed by evacuation of the obstructed material. This technique is considered to be most effective in definitive treatment. Avoid compressing the uterus and fallopian tubes to speed evacuation of the trapped contents after the hymen is incised.
  84. 84. NURSING CARE <ul><li>PRE-OP/INTRA/POST </li></ul><ul><li>NPO 8-10 hrs. prior to the procedure </li></ul><ul><li>Local anesthetic can be injected into the edges of the hymen to achieve postoperative analgesia. As an alternative, lidocaine jelly can be applied topically. </li></ul><ul><li>For postoperative analgesia, acetaminophen or nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, are usually sufficient. </li></ul><ul><li>IV fluids </li></ul><ul><li>Uterine and/or vaginal cramping should also be anticipated and treated with NSAIDs. </li></ul>
  85. 85. TOXIC SHOCK SYNDROME Toxic shock syndrome (TSS) is a serious but uncommon bacterial infection. TSS was originally linked to the use of tampons, but is now also known to be associated with the contraceptive sponge and diaphragm birth control methods. TSS has also resulted from wounds secondary to minor trauma or surgery incisions where bacteria have been able to enter the body and cause the infection. The symptoms of TSS include sudden high fever, a faint feeling, watery diarrhea, headache, and muscle aches. If your child has these symptoms, call your doctor right away.
  86. 86. pathophysiology
  87. 87. ASSESSMENT <ul><li>high fever (greater than 102° Fahrenheit [38.8° Celsius]) </li></ul><ul><li>rapid drop in blood pressure (with lightheadedness or fainting) </li></ul><ul><li>sunburn-like rash on the entire body </li></ul><ul><li>vomiting and diarrhea </li></ul><ul><li>severe muscle aches or weakness </li></ul><ul><li>bright red coloring of the eyes, throat, and vagina </li></ul><ul><li>headache, confusion, disorientation, or seizures </li></ul><ul><li>kidney and other organ failure </li></ul><ul><li>Diagnostics: </li></ul><ul><li>Doctors typically diagnose TSS and STSS by doing a physical exam and conducting blood tests that assess a child's liver and kidney function. In toxic shock syndrome, doctors may want to rule out conditions like measles or Rocky Mountain spotted fever , which can produce similar symptoms. A doctor may also take samples of fluid from an abscess, boil, or infected wound to look for a possible source of staphylococcus or streptococcus infection. </li></ul>
  88. 88. Complications <ul><li>Dangerous complications of toxic shock syndrome include: </li></ul><ul><li>Shock , causing decreased blood and oxygen circulation to the vital organs. </li></ul><ul><li>Acute respiratory distress syndrome (ARDS) . Lung function decreases, breathing becomes difficult, and blood oxygen levels drop. </li></ul><ul><li>Disseminated intravascular coagulation (DIC) . This condition causes the clotting factors in the blood to become too active. Many blood clots may form throughout the body, which uses up the clotting factors. This can cause excessive bleeding. </li></ul><ul><li>Kidney failure , also called end-stage renal disease. Failure happens when kidney damage is so severe that treatment with dialysis or a kidney transplant is needed to prevent death. </li></ul>
  89. 89. Nursing diagnosis <ul><li>Impaired skin integrity related to sunburn like rashes </li></ul><ul><li>Fluid volume deficit related to frequent defecation of watery stool and vomiting </li></ul><ul><li>Acute pain related to headache </li></ul><ul><li>Deficient knowledge related to lack of exposure to the disease </li></ul><ul><li>Risk for infection related to broken skin </li></ul>
  90. 90. MEDICAL INTERVENTION <ul><li>start intravenous (IV) fluids and antibiotics as soon as possible. </li></ul><ul><li>Medical staff will remove tampons, contraceptive devices, or wound packing; clean any wounds; and, if there is a pocket of infection (called an abscess), </li></ul><ul><li>drain pus from the infected area. </li></ul><ul><li>Antibiotics </li></ul><ul><li>hypotension, you'll need medication to stabilize it and fluids to treat dehydration. </li></ul><ul><li>If your kidneys fail, you may need dialysis. </li></ul>
  91. 91. NURSING CARE <ul><li>Hand washing is extremely important. </li></ul><ul><li>Toxic shock syndrome (TSS) </li></ul><ul><li>Follow the directions on package inserts when using tampons, diaphragms, or contraceptive sponges. </li></ul><ul><li>Keep all skin wounds clean to prevent infection and promote healing. This includes cuts, punctures, scrapes, burns, sores from shingles, insect or animal bites, and surgical wounds. </li></ul><ul><li>Keep children from scratching chickenpox sores. </li></ul><ul><li>If you have had menstrual TSS, do not use tampons, barrier contraceptives (such as a diaphragm, cervical caps, or sponges), or an intrauterine device (IUD). </li></ul>
  92. 92. SURGICAL INTERVENTION <ul><li>TSS has developed after a surgical procedure, and the surgical wound needs to be drained and cleaned to remove the source of the infection. </li></ul><ul><li>Strep bacteria are causing necrotizing fasciitis, a bacterial infection that destroys skin, and the dead tissue and toxins produced by the bacteria must be removed. </li></ul><ul><li>Strep TSS with necrotizing fasciitis progresses rapidly and is life-threatening, so emergency surgery may be needed to remove the source of infection. For more information, </li></ul><ul><li>Surgery is rarely needed to treat toxic shock syndrome(TSS) caused by staph bacteria, but it is an important part of treatment for TSS caused by strep. </li></ul>
  93. 93. THANK YOU. . So do not fear, for I am with you; do not be dismayed, for I am your God. I will strengthen you and help you; I will uphold you with my righteous right hand. Isaiah IV : X God bless.. by: CMG