Endometriosis: Clinical Nursing Care — Transcript

Endometriosis gets its name from the endometrium, which lines the inside of the uterine cavity. With endometriosis, there is ectopic endometrial tissue, which means endometrium can be present in other parts of the body like the ovaries or fallopian tubes or even as far as the lungs. Also, with endometriosis, the ectopic tissue behaves just like regular endometrium would, and it undergoes cyclic changes in response to the menstrual cycle.

Now let's look at the overall anatomy and physiology of the uterus. Remember that the uterine wall is comprised of three layers: the endometrium, which is the innermost mucosal layer and is itself made up of a basal layer and a functional layer; the myometrium, which is the strong smooth muscle that gives the uterine wall its thickness; and the perimetrium, which is the outermost layer and is basically a continuation of the peritoneal lining.

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Now, during each menstrual cycle, an egg is released from the ovaries at ovulation, and estrogen and progesterone levels increase. Estrogen thickens the functional layer of the endometrium to prepare it for implantation. If there is no fertilization, hormone levels drop, and the functional layer sloughs off and is eliminated along with a small amount of blood during menstruation. And after menstruation, the cycle repeats itself all over again.

Okay. Now, the exact cause behind endometriosis is still unknown, but there are a few theories that try to explain this phenomenon. One such theory is retrograde menstruation, which suggests that during menstruation, some blood and endometrial cells could flow backwards into a fallopian tube and implant into the nearby pelvic tissues. Next, there is the benign metastasis theory, which suggests that endometrial cells can travel to distant organs like the heart or lungs through lymph and blood.

While some theories blame it on genetics, immunity, and abnormal hormonal patterns. In addition to these proposed causes, there are some risk factors for developing endometriosis.

These include a family history of endometriosis, never having been pregnant, early menarche, and late menopause.

Now, let's discuss the pathophysiology of endometriosis. Once the migrated endometrial cells have implanted elsewhere, they begin to release pro-inflammatory factors.

Inflammation promotes the growth of new blood vessels that deliver blood and oxygen to the ectopic endometrial tissue. As it grows, the implant starts behaving exactly like the endometrium of the uterus. So, in response to estrogen, it thickens, and when hormone levels drop, it sloughs off and bleeds a little, only to regenerate with the next menstrual cycle. In some clients, chronic inflammation and adhesions can damage the reproductive structures, thus inhibiting the release of the egg or its movement through the fallopian tube. As a result, infertility may occur. Finally, a particular scenario is when there is ectopic endometrial tissue on an ovary. This can cause the formation of an endometrioma, also called a chocolate cyst because it contains old, dark blood as well as shed tissue. When these get too large, they can rupture and spill their contents, causing inflammation and pain. Alternatively, a large endometrioma can cause ovarian torsion, which is when the ovary twists around its vascular support, blocking blood flow.

The clinical manifestations of endometriosis vary depending on the location of ectopic endometrial tissue, but the most common symptom is pain, which can sometimes be quite debilitating.

Endometriosis on the reproductive organs causes pelvic pain, excessive menstrual bleeding, and painful menstruation, as well as painful sexual intercourse, which is called dyspareunia. Other manifestations include painful urination and defecation, as well as abdominal pain. In the rare case of lung endometriosis, clients may cough up blood during their monthly menstrual cycle. All of these manifestations often vary with the hormone changes throughout the menstrual cycle, and they tend to get worse during menstruation.

Finally, endometriomas can be associated with unilateral pelvic pain, which can be acute and severe in case of ovarian torsion.

So the diagnosis of endometriosis starts with the client's history and physical assessment. Abnormal pelvic examination findings include tenderness on palpation as well as focal pain or a palpable mass that could suggest an endometrioma.

Other investigations can include an ultrasound or MRI. Finally, laparoscopy can be performed, and the diagnosis can be confirmed with a biopsy of the implanted tissue.

Finally, treatment for mild forms of endometriosis can rely on monitoring the client's condition. Otherwise, treatment is focused mainly on pain management, trying to limit the progression of the implants and preserve fertility. For pain, NSAIDs are used. Common hormonal medications that are used to limit the growth of ectopic tissue include combined estrogen-progesterone oral contraceptive pills, progesterone analogues like medroxyprogesterone and levonorgestrel, androgen agonists like Danazol, and gonadotropin-releasing hormone modulators.

Surgical options are available for severe cases. If fertility is desired, the surgery involves only excision of endometrial implants, endometriomas, and adhesions. If fertility is not desired, a hysterectomy and oophorectomy with excision of any other endometrial implants is done.

Finally, the ultimate natural treatment of endometriosis is menopause because when ovulation and menstrual cycles stop, hormone levels fall, and the symptoms usually go away.

All right, let's take a look at the nursing care you'll be providing for a client with endometriosis.

Your priority nursing goals are to manage your client's pain and provide emotional support. Begin by asking your client to rate the intensity of pain they experience and describe its characteristics. Then determine how the pain impacts their health-related quality of life, including increased stress, fatigue, absence from work, and intimate relationships. Encourage them to express their feelings about the impact of endometriosis on their life and provide reassurance regarding the available treatments. Report if your client experiences severe disabling pain that is unrelieved by the prescribed analgesics and interferes with daily life, and ensure referrals for fertility counseling and psychosocial support are in place for ongoing support.

Now moving on to client and family teaching. Begin by explaining how the growth of endometrial cells outside the uterus causes their pain. Review the plan of care, including the prescribed pharmacological treatments. Next, provide education on non-pharmacological therapies and coping strategies they can use, such as relaxation techniques, warm baths, massage, or applying a heating pad on the abdomen.

Review the importance of maintaining a healthy lifestyle that includes regular physical activity, resting as needed, and a well-balanced diet. Remind them of the importance of not smoking, as well as limiting alcohol and caffeine.

If they are experiencing pain when having a bowel movement, discuss ways to prevent constipation by staying well hydrated and including fiber in their daily diet.

Finally, instruct them to contact their health care provider if they have new or worsening pain or if they feel anxious, sad, or if they are experiencing symptoms of depression such as feeling hopeless, easily irritated, or frustrated.

All right, as a quick recap, endometriosis is an inflammatory condition in which endometrial tissue growth occurs outside the uterus.

Clinical manifestations of endometriosis are pelvic pain, excessive menstrual bleeding, and painful menstruation, as well as painful sexual intercourse, pain during urination, and with bowel movements. Diagnosis starts with a pelvic examination, imaging studies, and laparoscopy.

Finally, the ultimate natural treatment of endometriosis is menopause because when ovulation and menstrual cycles stop, hormone levels fall and the symptoms usually go away.

All right, let's take a look at the nursing care you'll be providing for a client with endometriosis.

Your priority nursing goals are to manage your client's pain and provide emotional support. Begin by asking your client to rate the intensity of pain they experience and describe its characteristics. Then determine how the pain impacts their health related quality of life,

including increased stress, fatigue, absence from work, and intimate relationships. Encourage them to express their feelings about the impact of endometriosis on their life and provide reassurance regarding the available treatments. Report if your client experiences severe disabling pain that

is unreieved by the prescribed analesics and interferes with daily life and ensure referrals for fertility counseling and psychosocial support are in place for ongoing support.

Now moving on to client and family teaching. Begin by explaining how the growth of endometrial cells outside the uterus causes their pain. Review the plan of care, including the prescribed pharmacological treatments. Next, provide education on non-farmacological therapies and coping strategies they can

use, such as relaxation techniques, warm baths, massage, or applying a heating pad on the abdomen.

Review the importance of maintaining a healthy lifestyle that includes regular physical activity, resting as needed, and a well- balanced diet. Remind them of the importance of not smoking, as well as limiting alcohol and caffeine.

If they are experiencing pain when having a bowel movement, discuss ways to prevent constipation by staying well hydrated and including fiber in their daily diet.

Finally, instruct them to contact their health care provider if they have new or worsening pain or if they feel anxious, sad, or if they are experiencing symptoms of depression such as feeling hopeless, easily irritated, or frustrated.

All right, as a quick recap, endometriosis is an inflammatory condition in which endometrial tissue growth occurs outside the uterus.

Clinical manifestations of endometriosis are pelvic pain, excessive menstrual bleeding, and painful menration, as well as painful sexual intercourse, pain during urination, and with bowel movements. Diagnosis starts with a pelvic examination, imaging studies, and laparoscopic biopsy. Treatment depends on the client's symptoms and desire to

become pregnant and is typically focused on pain management, decreasing abnormal development of endometrial tissue outside the uterus, and surgical removal of the endometrial implants. Goals of nursing care include pain management and providing emotional support. Client and family teaching focuses on learning

about the disorder, pain management options, coping strategies, and when to contact the healthcare provider.

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