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Bladder Endometriosis: A Nursing Case Study by reylangarcia Problems of Altered Sexual and Reproductive Function Endometriosis Case Presentation by: Maria Reylan M. Garcia, R.N. Name: J.S Date of Interview: August 11, 2012 Age: 24 years old Informant: patient Sex: Female Relationship to Patient: patient herself Address: Pavia, Iloilo Civil Status: Married Date and Time Admitted: August 8, 2012 Chief Complaint: sacral and left lower quadrant pain Ward: Female Surgical Ward (Western Visayas Medical Center) Bed No.: 3 Allergies: none to food, pollen, medications and other environmental agents Religious Affiliation: Roman Catholic Physician’s Initials: Dr.M/Dr. L.Q. Impression/Diagnosis: Bladder Endometriosis; G1P1(1001) as of May 2012 Pre-op Diagnosis: Bladder Endometriosis Post-op Diagnosis: N/A Surgical Operation Performed: for segmental bladder resection Days Post-op: N/A II. CLINICAL ASSESSMENT II.A. NURSING HISTORY 1. History of Present Illness a. Usual Health Status J.S. has no accompanying morbidities. She experiences occasional fever and flu which can be relieved with over-the-counter medications(e.g. Biogesic, Decolsin). She had her menarche at age 10 (Grade 4). During her menses, for approximately five years before she got pregnant she would experience lower abdominal pain and cramps which can be relieved with Mefenamic Acid 500 mg/tab PRN for pain. She was also prescribed with an oral contraceptive pill (Althea)to regulate her cycles. She usually has a 3-5 day menstrual flow and can consume two fullysoaked vaginal pads per day. She also reports to have had experience dyspareunia during menses. She had a healthy pregnancy giving birth to a cephalic 7 lbs. baby boy. b. Chronologic Story 2 months prior to admission (June 2012), J.S. experienced excruciating back pain, particularly in the sacral area and on some occasions, in the lower left quadrant. The pain would worsen in intensity one and a half weeks prior to her menstruation. She verbalized little relief offered by self-care measures of heat application and over the counter medication (Mefenamic acid 500 mg/tab). She continues on taking her oral contraceptive pills as prescribed five years ago. She reported dyspareunia. 1 month prior to admission (July 2012), J.S. observed that aside from the back and left lower quadrant pain, she had a heavier and longer menstrual flow. She was able to consume at least four fully-soaked vaginal pads and her menses lasted for more than a week. She also noticed an increasing frequency of voiding and dribbling episodes. J.S. also reported several boats of nausea. She continued her self-care measures. A week prior to admission (August 1,2012), J.S. felt the pain even worsened, rating it as 8 out of 10 in a scale of 0-10. She also had her menses a week early and had the same heavy and long flow. She continued to experience the abovementioned signs and symptoms. She got concerned and opted for out-patient consultation to the clinic of Dr. M on August 8, 2012 (day of admission). She was asked to do a Pelvic ultrasound which revealed, a mildly enlarged, irregular uterus with a 4 to 5-cm anterior mass, suspected to represent a fibroid, but no adnexal masses. The ultrasound further revealed an irregular 3.5-cm mass anterior to and separate from the uterus, invaginating the urinary bladder. J.S. was then scheduled for a segmental bladder resection and thus, duly admitted. c. Relevant Family History (-) Endometriosis (+)Uterine Myoma – maternal aunt d. Disability Assessment The pain J.S. felt interfered with her ability to perform household chores and to take care of her 8-month old baby. 2. Past Health Problems/Status 3. Childhood Illness: (+) chicken pox – 8 years old (+) measles – 1 year old (+) mumps – 2 years old b. Immunization (+) Tetanus Toxoid – throughout pregnancy (+) Flu vaccine – annual c. Allergies (-) food (-) drugs (-) pollen (-) animals (-) environmental agents d. Accidents and Injuries No recorded accident or injury e. Hospitalization for serious illnesses None f. Medications Althea (Cyproterone acetate, ethinyl estradiol) 1 tablet daily Mefenamic Acid 500 mg/tab 1 tab PRN for pains 3. Family History of Illness (-) Endometriosis (+) Uterine Myoma – maternal aunt (+) Hypertension – maternal and paternal grandparents (-) Diabetes Mellitus (+) Bronchial Asthma – mother (+) Metaplastic disease (Cancer) – maternal aunt, maternal cousin 4. Patient’s Expectations a. What does he/she expect to occur during this hospitalization? Akon gina ekspektar nga maoperahan ako sang mayo para maguntat na akon nga dinugo kag sakit sa tiyan, as verbalized by J.S. 1. What does he/she expect regarding nursing care? Nga makabulig man kamo sa mga doctor magasikaso sa akon, as verbalized by J.S. 5. Patterns of Functioning a. Breathing Patterns Respiratory Problems: none as claimed Usual Remedy: N/A Manner of Breathing: spontaneous, regular in rate and rhytym b. Circulation Usual Blood Pressure: 90/70-100/80 mmHg Any history of chest pain, palpitations, coldness of extremities: none as claimed c. Sleeping Patterns Usual bedtime: 10:00pm -11:00 pm Number of pillows: 2 Bedtime Rituals: general hygiene Problems regarding sleep: none as claimed Usual Remedy: N/A d. Drinking Patterns: Kinds of Fluid in 24 hours
Amount in cc
Water
1,500-1750 cc
Coffee
250-500
Softdrinks
360
Total
2110-2610
e. Eating Patterns Usual Food Taken
Time
Breakfast
1 cup steamed rice, 1 matchbox size dried fish
6:30-7:00am
Lunch
1 cup steamed rice, 1 small-sized bowl of laswa
12:00-12:30pm
Dinner
1 cup steamed rice, 1 medium-sized fish (pinamalhan)
7:00-7:30 pm
Snacks
N/A
Food likes: vegetables Food dislikes: sweets f. Elimination Patterns 1. Bowel Movement Frequency: once a day Problems or Difficulties: occasional constipation Usual Remedy: increase oral fluid intake; papaya 2. Urination Frequency: 7-8 times a day Problems: increased frequency in voiding “busisaw” Usual Remedy: none g. Exercise: J.S. does not engage in planned exercise. h. Personal Hygiene 1. Bath Type: full-body Frequency: once a day Time of Day: 9:00 am 2. Oral Care Frequency: 2-3 times a day Care of Dentures: N/A 3. Shaving Frequency: N/A 4. Use of Cosmetics: Not assessed i. Recreation: J.S. takes care of a vegetable garden at home for leisure. j. Health Supervision: J.S. doesn’t have annual check-ups. However, she has a religious prenatal consultation throughout her pregnancy in 2011. II.B. PHYSICAL ASSESSMENT II.B1.Vital Signs Date and Time taken: August 11, 2012 T: 35.3°C PR: 102 bpm BP: 90/70 mmHg RR: 22 cpm II.B.2. Height: 5’3” II.B.3. Weight: 120 lbs General Appearance: Awake, conscious and coherent; pale skin; slightly disheveled. With running IVF of D5LR 1 L X 8 hours attached to left cephalic vein. 1. Integumentary System Pale skin, slightly cold to touch on distal extremities, good skin turgor 1. Neuro-sensory System Oriented to person, place and time, reports of pain in the sacral and left lower quadrant rated as 6 out of 10 in a 0-10 scale. 1. Respiratory System RR=22 cycles per minute, regular in rhythm, symmetrical chest expansion, with normal breath sounds. 1. Cardiovascular System PR (apical) = 102 beats per minute, regular in rhythm, pale conjunctivae, capillary refill