Create a focused SOAP note to support (only include positive and pertinent data) for a 40-year-old female patient with diagnosis of Endometriosis.
Questions for the case
Discuss and described the pathophysiology and symptomology/clinical manifestations of AUB.
Discuss three differential diagnoses for AUB with ICD 10 numbers for each.
Discuss patient education.
Develop the management plan (pharmacological and nonpharmacological).
Chief Complaint: TS came to the clinic with complains of unusual bleeding and discharge, difficulty urinating, pain around vaginal area, pain during intercourse
Genitourinary: Painful urination, painful coitus, pain in the pelvic area, vaginal discharge and abnormal bleeding, no hematuria, urgency and frequency in urination.
Endometriosis: Symptoms include pain, dyspareunia and painful defecation. It is common in young premenopausal women. Physical examination reveals tenderness and nodularity. Pelvic ultrasound can be done to confirm endometrioma
Forms of Treatment
Surveillance: A “Wait and See” Approach
Some cases remain asymptomaticor do not produce symptoms of a severity to warrant the risks of treatment. Subsequently, the patient and provider may decideto forgeinterventions 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 ofpharmaceutical 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 ofteninduces a state of hypomenorrhea (reduction of menstruation)or amenorrhea (arrest of menstruation) tocontrol the growth endometrial implants andsymptoms. 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 analogssuch as leuprolide (Lupron), goserelin (Zoladex), triptorelin (Trelstar Depot), and nafarelin (Synarel)
· Danazol (Danocrine), anandrogen derivative
· Aromatase enzyme inhibitor (unlabeled use): letrozole (Femara)
· Progestogens: medroxyprogesterone acetate (Provera)
· Antiprogestogens, such asgestrinone
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 forcingendometriosis 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 anandrogen derivative that causes atrophy of ectopic tissue. It blocks the action of tropic hormones send out by the pituitaryglandto 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 characteristicssuch ashirsutism (facial hair growth and other effects). Other risks include weight gain, acne, and emotionaldisturbances.
Procedures Used to Treat Endometriosis
· Cystectomy for endometrioma: coagulation and ablation of the cystwall with laser or electrosurgery or laser; blunt or sharp dissection removal
· Surgical excision of cysts
· Resectionof 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 ablationin 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 cystwall with laser or electrosurgery. It also is used for blunt or sharp dissection of endometriotic tissue.
A bilateraloophorectomy compromises ovarian reserve and results in infertility. If fertility isa 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 preservefertility by preserving thefunction 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 removedalong with thecervix. 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.
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 ofthe stoma.
Nursing Care Plan: Postoperative
Potential Nursing Diagnoses
· Risk for infection
· Ineffective tissue perfusion related to hemorrhage
· Fluid imbalance (dehydration orfluid 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 conCEP
Discussand describe the pathophysiology and symptomology/clinical manifestations of Endometriosis.
The most widely accepted hypothesis for the pathophysiology of endometriosis is that endometrial cells are transported from the uterine cavity during menstruation and subsequently become implanted at ectopic sites. Retrograde flow of menstrual tissue through the fallopian tubes is common and could transport endometrial cells intra-abdominally; the lymphatic or circulatory system could transport endometrial cells to distant sites (eg, the pleural cavity).
Another hypothesis is coelomic metaplasia: Coelomic epithelium is transformed into endometrium-like glands.
Microscopically, endometriotic implants consist of glands and stroma identical to intrauterine endometrium. These tissues contain estrogen and progesterone receptors and thus usually grow, differentiate, and bleed in response to changes in hormone levels during the menstrual cycle; also, these tissues can produce estrogen and prostaglandins. Implants may become self-sustaining or regress, as may occur during pregnancy (probably because progesterone levels are high). Ultimately, the implants cause inflammation and increase the number of activated macrophages and the production of proinflammatory cytokines.
The increased incidence in 1st-degree relatives of women with endometriosis and in large twin studies (1) suggests that heredity is a factor.
In patients with severe endometriosis and distorted pelvic anatomy, the infertility rate is high, possibly because the distorted anatomy and inflammation interfere with mechanisms of ovum pickup, oocyte fertilization, and tubal transport.
Some patients with minimal endometriosis and normal pelvic anatomy are also infertile; reasons for impaired fertility are unclear but may include the following:
Potential risk factors for endometriosis are
Potential protective factors seem to be
Regular exercise (especially if begun before age 15, if done for > 4 hours/week, or both)
Long-term use of low-dose oral contraceptives (continuous or cyclic)
Exposure to diethylstilbestrol in utero
Müllerian duct defects
Shortened menstrual cycles (< 27 days) with menses that are heavy and prolonged (> 8 days)
Delayed childbearing or nulliparity
Family history of 1st-degree relatives with endometriosis
Nonreceptive endometrium (because of luteal phase dysfunction or other abnormalities)
Increased peritoneal prostaglandin production or peritoneal macrophage activity that may affect fertilization, sperm, and oocyte function
Increased incidence of luteinized unruptured ovarian follicle syndrome (trapped oocyte)
Discuss three differential diagnoses for AUB with ICD 10 numbers for each.
· Adenomyosis. N800
The ICD code N800 is used to code AdenomyosiS
· Endometrial polyps.
· N80 – Endometriosis
· N80.0 – Endometriosis of uterus
· N80.1 – Endometriosis of ovary
· N80.2 – Endometriosis of fallopian tube
· N80.3 – Endometriosis of pelvic peritoneum
· N80.4 – Endometriosis of rectovaginal septum and vagina
· N80.5 – Endometriosis of intestine
· N80.6 – Endometriosis in cutaneous scar
· N80.8 – Other endometriosis
· N80.9 – Endometriosis, unspecified
· Submucous leiomyomata (fibroids).ICD-10-CM Code for Submucous leiomyoma of uterusD25.0
· Surface lesions of the genital tract.N00-N99 Diseases of the genitourinary system
1. N80-N98 Noninflammatory disorders of female genital tract
2. N90- Other noninflammatory disorders of vulva and perineum
· Uterine sarcoma.C00-D49 Neoplasms
· C51-C58 Malignant neoplasms of female genital organs
Discuss patient education Develop the management plan (pharmacological and nonpharmacological).
How is it Treated?
Once the doctor and you are able to discover the cause of your abnormal bleeding, treatments can be discussed. Typically, medications are the first course of action in treating AUB. Often, the medications that are prescribed include:
· Birth control pills— Birth control pills are often used to treat uterine bleeding due to hormonal changes or hormonal irregularities. Birth control pills may be used in women who do not ovulate regularly to establish regular bleeding cycles and prevent excessive growth of the endometrium. In women who do ovulate, they may be used to treat excessive menstrual bleeding. Abnormal bleeding from some abnormal uterine conditions can also be treated with birth control pills.
· Nonsteroidal anti-inflammatory drugs (NSAIDS) -These drugs (e.g. ibuprofen, naproxen sodium) may also be helpful in reducing blood loss and cramping in these women. During the menopausal transition, birth control pills or other hormonal therapy may be used to regulate the menstrual cycle and prevent excessive growth of the endometrium.
· Tranexamic acid- This medication taken during your menses reduces heavy menstrual bleeding.
· Gonadotropin-releasing hormone (GnRH) agonists- These drugs can stop the menstrual cycle and reduce the size of fibroids by inducing a temporary menopause.
· Progesterone—Progesterone is a hormone made naturally by the ovary that is effective in preventing or treating excessive bleeding in women who do not ovulate regularly. A synthetic form of progesterone, called progestin, may be recommended.
· Intrauterine device—An intrauterine contraceptive device (IUD) that secretes progestin (Mirena or Skyleena) may be recommended for women who have abnormal uterine bleeding. Progestin-releasing IUDs decrease menstrual blood loss by more than 50 percent and decrease pain associated with periods. Some women completely stop having menstrual bleeding as a result of the IUD, which is reversible when the IUD is removed.
Medical therapy may not be effective in all patients, or patients may desire a procedure that has long-term efficacy or is a definitive therapy (hysterectomy, removing the uterus surgically). In addition, women may desire surgery to avoid continued frequent dosing or adverse effects associated with medication.
Heavy menstrual bleeding due to structural lesions (leiomyomas, uterine polyps or adenomyosis) is typically the main indication for surgery. The choice of surgical therapy depends upon the patient’s characteristics and therapeutic goals. In patients over the age of 35, biopsy of the uterine lining or hysteroscopy and D&C to rule out cancerous or precancerous uterine conditions is often needed.
Uterine polyps are easily treated with minor surgery to the uterus. Hysteroscopy is a procedure where a small telescope was inserted through the cervix to the uterus and the polyps are removed and tested. This is also usually done with a dilation and curettage or D&C which allows for accurate sampling of the endometrium (uterine lining) to ensure that no precancerous or cancerous conditions are present.
The choice of whether to proceed with surgery and the type of procedure depends upon plans for fertility. For women who desire future childbearing, surgical options include removal of uterine polyps or fibroids. Fibroids can be removed by performing a myomectomy and often with minimally invasive robotic surgery.
For women who do not desire to preserve fertility, other minimally invasive options may be appropriate. Procedures include endometrial ablation or uterine artery embolization. Endometrial ablation is an outpatient procedure which cauterizes the endometrium and will reduce or eliminate bleeding. Uterine artery embolization is performed by an interventional radiologist and can decrease the size of uterine fibroids. Hysterectomy is appropriate for women who have failed other medical or surgical treatments or who desire definitive treatment. Most hysterectomies can now be done with minimally invasive robotic laparoscopic techniques which have less complications and more rapid return to full activities than older open techniques.
Discuss the 3 topics listed below for your case:
· An effective health assessment incorporates not only physiological parameters; please suggest other parameters that should be considered and included on health assessments to reach maximal health potential on individuals.
The Top Seven Healthcare Outcome Measures Explained
There are hundreds of outcome measures, ranging from changes in blood pressure in patients with hypertension topatient-reported outcome measures (PROMs). The seven groupings of outcome measures CMS uses to calculate hospital quality are some of the most common in healthcare:
Mortality is an essential population health outcome measure. For example, Piedmont Healthcare’s evidence-based care standardization for pneumonia patients, resulted in a 56.5 percent relative reduction in the pneumonia mortality rate.
#2: Safety of Care
Safety of care outcome measures pertain to medical mistakes. Skin breakdown and hospital-acquired infections (HAIs) are common safety of care outcome measures:
· Skin breakdown—happens when pressure decreases blood flow to the skin. A skin assessment tool can be used to reduce skin breakdown. Patients with skin breakdown are at a higher risk of infection. Patients’ risk scores go up if they’re diabetic, for example, because their circulation is poor.
· HAIs—caused by viral, bacterial, and fungal pathogens. For example,Texas Children’s Hospital identified evidence-based bundles to reduce HAIs in children through their partnership with the Solutions for Patient Safety National Children’s Network. Using an enterprise data warehouse (EDW) and analytics applications to identify vulnerable patients and monitor clinicians’ compliance with best practice bundles, Texas Children’s Hospital decreased HAIs by 35 percent.
Readmissionfollowing hospitalization is a common outcome measure. Readmission is costly (and often preventable). In fact, researchers estimate that in one year, $25 to $45 billion is spent on avoidable complications and unnecessary hospital readmissions. After increasing efforts to reduce their hospital readmission rate, the University of Texas Medical Branch (UTMB) saw a 14.5 percent relative reduction in their 30-day all-cause readmission rate, resulting in $1.9 million in cost avoidance. UTMB reduced their hospital readmission rate by implementing several care coordination programs and leveraging their analytics platform and advanced analytics applications to improve the accuracy and timeliness of data for informing decision making and monitoring performance.
#4: Patient Experience
Patient-reported outcome measures (PROMs) fall within the patient experience outcome measure category. According to theAgency for Clinical Innovation(ACI), PROMs “assess the patient’s experience and perception of their healthcare. This information can provide a more realistic gauge of patient satisfaction as well as real-time information for local service improvement and to enable a more rapid response to identified issues.” For example, a patient might be asked to complete a satisfaction survey (on a scale of 1-5) about the care they received.
Patient experience may also be used as a balance metric for improvement work. For example, a care delivery process may decrease the LOS, which can be a positive outcome, but result in a decreased patient satisfaction score if patients instead feel they are being pushed out.
#5: Effectiveness of Care
Effectiveness of care outcome measures evaluate two things:
1. Compliance with best practice care guidelines.
2. Achieved outcomes (e.g., lower readmission rates for heart failure patients).
Given the rapid changes that occur within healthcare, making sure best practice care guidelines are current is critical for achieving the best care outcomes. It’s important to track clinician compliance with care guidelines; It’s equally important to monitor treatment outcomes and alert clinicians when care guidelines need to be reviewed.
Failing to adhere to evidence-based care guidelines can have negative consequences for patients. For example, according toThe Dartmouth Atlas of Healthcare, “even though it is well established that beta-blockers can reduce the risk of heart attack in patients who have already had one heart attack, many heart attack patients are never prescribed beta-blockers.”
#6: Timeliness of Care
Timeliness of care outcome measures assess patient access to care. Overcrowding in the emergency department has been associated with increased inpatient mortality, increased length of stay, and increased costs for admitted patients.
A community hospital system implemented an improvement process to address overcrowding in its ED after determining that approximately 4,000 patients were leaving its ED each year without being seen. They leveraged their analytics platform to develop an ED analytics application that provided actionable, timely ED performance data to focus improvement efforts on four areas: staffing patterns, registration, triage assessment by the registered nurse, and early access to a qualified medical provider. They achieved significant performance improvements, including an 89 percent relative reduction in the rate of patients that left without being seen, with current performance at 0.4 percent.
#7: Efficient Use of Medical Imaging
The efficient use of medical imaging is an increasingly important outcome measure. According to theEuropean Science Foundation, “Medical imaging plays a central role in the global healthcare system as it contributes to improved patient outcome and more cost-efficient healthcare in all major disease entities.”
For example, duringTexas Children’s Hospital’s efforts to improve asthma careit discovered a high volume of chest X-rays being administered to asthma patients. Using its EDW to examine real-time X-ray data, it realized clinicians were ordering chest X-rays for 65 percent of their asthma patients—evidence-based practice calls for X-rays in only five percent of cases. Texas Children’s Hospital’s IT team traced the problem to a faulty order set within the hospital’s EHR, and rewrote the order set to reflect the evidence-based best practice.
· Name the different family developmental stages and give examples of each one.
Early Stages – Forming and Nesting
Family Stage marker: The family begins at the establishment of a common household by two people; this may or may not include marriage.
Family Task: Individual independence to couple/dyadic interdependence.
II. Becoming Three – and more
Family Stage marker: The second phase in family life is initiated by the arrival and subsequent inclusion/incorporation of the first child/dependent member.
Family Task: Interdependence to incorporation of dependence.
Middle Stages – Family Separating Process
Family stage marker: The third phase in signaled by the exit of the first child/dependent member from the intrafamily world to the larger world. This occurs at the point of entrance into school or other extrafamilial environment.
Family task: Dependence to facilitation of beginning separations – partial independence.
Family Stage Marker: This phase is marked by the entrance of the last child/dependent member of the family into the community.
Family task: Support of facilitation of continuing separations – independence.
Family Stage Marker: This phase starts with the first complete exit of a dependent member from the family. This is achieved by the establishment of an independent household which may include marriage or another form of independent household which may include marriage or another form of independent household entity.
Family Task: Partial separations to first complete independence.
Late Stages: Finishing
VI. Becoming smaller/extended
Family Stage marker: Ultimately the moment comes for the exit of the last child/dependent member from the family.
Family Task: Continuing expansion of independence.
Family Stage markers: The final years start with the death of one spouse/partner and continue up to the death of the other partner.
Family Task: Facilitation of family mourning. Working through final separations.
· Describe family structure and function and the relationship with healthcare.
It appears, the family environment does indeed have a huge impact on a person’s health status. The challenge for researchers and clinicians is that the way this effect takes place is not clear. The author discusses three general pathways that the family and social relationships can influence an individual’s health.
The first way is by a direct biological pathway. This includes the shared physical environment. People living in close proximity are at increased risk of transmitting airborne and blood-borne diseases. They share the same toxic environments including smoking and asbestos. Of course, there are also genetic influences.
Another pathway that influences health is health behavioral pathways. Our families strongly influence our health behaviors including smoking, exercise, diet, nutrition, and substance abuse. Parents have a strong influence on what kind of health behaviors their children or adolescents will adopt.
And the third general way that families can influence health is psychophysiological pathways. “Family relationships can influence physical health by changes in cognition and emotion that results in physiological responses, which in turn can influence health outcomes.” (Campbell, 2003) This includes the effect of stress on the immune system and psychosomatic illness. A very interesting study was done that showed a clear and directly-related increase in diabetic ketoacidosis in children with diabetes to the amount of stress and conflict in the home. (Minuchin et al. 1975, 1978).
By understanding these pathways, medical and mental-health professionals can choose appropriate and effective family interventions to improve a patient’s health status. The paper identified the different types of possible family interventions which include family education and support, family psychoeducation, and family therapy. This discussion included the strengths and shortcomings of the different types of interventions on health behaviors.
To analyze the effectiveness of family interventions, the author reviewed several studies in four areas: family caregiving of elders, childhood chronic illness, spouse involvement in chronic adult illnesses, and health promotion/disease prevention.
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