Endometriosis

Endometriosis 4 Nursing Care Plans Diagnosis and Interventions

Endometriosis NCLEX Review Care Plans

Nursing Study Guide on Endometriosis

Endometriosis is a painful disorder in which tissues that are similar to tissues that normally line the inside of the uterus (endometrium) grows outside the uterus. Areas where endometrial-like tissues are found in ectopic locations are called endometrial implants.

Body parts that are commonly affected by endometriosis are the ovaries, fallopian tubes, and the tissues lining the pelvis. Endometriosis is less commonly found to involve the vagina, cervix, and bladder.

Nursing Stat Facts 1

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Nursing Stat Facts 1

Although endometrial implants are problematic, they are usually benign.

In endometriosis, the endometrial-like tissues act like an endometrial tissue would. These endometrial-like tissues thicken, break down, and bleeds with each menstrual cycle but this blood has nowhere to go.

The surrounding tissue may become irritated, eventually developing adhesions and scar tissues. Endometriosis is estimated to affect 10% among women of reproductive age.

It commonly affects the ovaries and blood can become embedded in the normal ovarian tissue forming a “blood blister” that is surrounded by a fibrous cyst, called an endometrioma.

Types of Endometriosis

There are three primary types of endometriosis, based on where it is located:

  1. Superficial peritoneal lesion. These are the most common type of endometriosis, lesions are present in the peritoneum (a thin film that lines the pelvic cavity).
  2. Endometrioma (ovarian lesion). These lesions are dark, fluid-filled cysts that form deep in the ovaries. These do not respond well to treatment and can also damage healthy tissue.
  3. Deeply infiltrating endometriosis. This type of endometriosis develops under the peritoneum and may also involve other organs near the uterus such as the bowels or bladder.

Stages of Endometriosis

  1. Stage 1 – Minimal. There are isolated implants but no significant adhesions.
  2. Stage 2 – Mild. There are superficial implants on the ovaries and peritoneum but there are still no significant adhesions
  3. Stage 3 – Moderate. There are multiple implants that are both deeply invasive and superficial and adhesions may be present in the ovaries and surrounding areas
  4. Stage 4 – Severe. There are multiple deep and superficial implants with large ovarian endometriomas. There is also the presence of dense and filmy adhesions.

Signs and Symptoms of Endometriosis

The following are the most common signs and symptoms for endometriosis, but symptoms may be experienced differently by women. Some women may not exhibit any symptoms at all.

  • Pain – the most common symptom of endometriosis but the severity of pain does not indicate the stage or degree of endometriosis. Women may have a mild form of the disease but experience agonizing pain. It is also possible to have be in the severe stage but with very little discomfort.
  • Pelvic pain is the primary symptom of endometriosis. This is often associated with menstrual periods (dysmenorrhea). Pelvic cramping and pain may start before and extend for several days during a menstrual period.
    • Lower back and abdominal pain
    • Pain during or after sexual intercourse
    • Pain with urination or bowel movements during the menstrual period
  • Occasional heavy menstrual periods or bleeding between periods (intermenstrual bleeding)
  • Periods that last for more than 7 days
  • Fatigue
  • Diarrhea
  • Constipation
  • Blood in the stool or urine
  • Bloating or nausea
  • Infertility

Pain often disappears after menopause and pregnancy may provide temporary relief of symptoms. It is important to have regular gynaecological exams to monitor any changes.

This is of utmost importance if there is the presence of two or more symptoms.

Causes of Endometriosis

There is still no certainty regarding the exact cause of endometriosis but there are possible explanations which include:

  • Retrograde Menstruation – in retrograde menstruation, menstrual blood that contains endometrial cells flow back through the fallopian tubes then into the pelvic cavity instead of being expelled out of the body. These endometrial cells adhere to the pelvic walls and the surfaces of the pelvic organs, where they develop and continue to thicken and bleed over the course of every menstrual cycle.
  • Transformation of peritoneal cells – Hormones or immune factors promote the transformation of peritoneal cells into endometrial-like cells.
  • Embryonic cell transformation – The hormone estrogen may transform embryonic cells into endometrial-like cell implants during puberty.
  • Surgical scar implantation – After a surgery such as a caesarean section or a hysterectomy, the endometrial cells may attach to a surgical incision.
  • Endometrial cell transport – the tissue fluid (lymphatic) system or blood vessels may transport endometrial cells to other parts of the body.
  • Immune system disorder – disorders of the immune system may leave the body unable to recognize and destroy endometrial-like tissues that are developing outside the uterus.

Risk Factors of Endometriosis

  • Women who have never given birth
  • Early menarche (≤ 11 years old)
  • Late menopause (≥ 55 years old)
  • Short menstrual cycles (< 27 days)
  • Heavy menstrual periods that last longer than 7 days
  • Having higher estrogen levels in the body
  • Low BMI (< 18.5)
  • One or more relatives who have endometriosis
  • Any medical condition that prevents the expulsion of blood from the body during menstrual periods
  • Those with reproductive tract disorders

Complications of Endometriosis

Diagnosis of Endometriosis

Endometriosis can be suspected based on symptoms of pain in the pelvis and findings during physical examinations.

The patient may also undergo:

  • Ultrasound
  • CT scan
  • MRI
  • Biopsy
  • Laparoscopy (confirms diagnosis)

Treatment for Endometriosis

There is currently no cure for endometriosis. The goals of endometriosis treatment include symptom relief and/or enhancing fertility.

  1. Medications
    • Non-steroidal Anti-inflammatory Drugs (NSAIDs) – these sre commonly prescribed to relieve pelvic pain and cramping due to menstruation. NSAIDs have no effect on endometrial implants or the progression of endometriosis.
    • Gonadotropin-releasing hormone analogs (GnRH analogs) – used to relieve pain and reduce the size of endometriosis implants. GnRH analogs suppress estrogen production in the ovaries through the inhibition of the secretion of regulatory hormones from the pituitary gland. Menstrual periods stop as a result, mimicking menopause.
    • Birth Control Pills
    • Progestins – recommended for women who do not obtain pain relief or are unable to take birth control pills.
    • Aromatase inhibitors – interrupts local estrogen formation within the endometriosis implants. These drugs also inhibit estrogen production in the ovaries and adipose tissue.
  2. Surgery

There is a need for surgical intervention if the symptoms of endometriosis are severe or there is inadequate response to medical therapy. Surgery may be conservative (where the uterus and ovarian tissues are preserved) or definitive (involves the removal of the uterus) without or with the removal of the ovaries.

Nursing Care Plans for Endometriosis

Nursing Care Plan 1

Nursing Diagnosis: Acute Pain related to abdominal cramping secondary to endometriosis as evidenced by pain score of 10 out of 10, guarding sign on abdomen, restlessness, and irritability

Desired Outcome: The patient will report a pain score of 0 out of 10.

InterventionsRationales
Assess the patient’s vital signs. Ask the patient to rate the pain from 0 to 10, and describe the pain he/she is experiencing.To create a baseline set of observations for the patient. The 10-point pain scale is a globally recognized pain rating tool that is both accurate and effective.
Administer analgesics/ pain medications as prescribed.To provide pain relief to the patient.
Ask the patient to re-rate his/her acute pain 30 minutes to an hour after administering the analgesic.To assess the effectiveness of treatment.
Provide more analgesics at recommended/prescribed intervals.To promote pain relief and patient comfort without the risk of overdose.
Reposition the patient in his/her comfortable/preferred position. Encourage pursed lip breathing and deep breathing exercises.To promote optimal patient comfort and reduce anxiety/ restlessness.

Nursing Care Plan 2

Nursing Diagnosis: Deficient Knowledge related to acute pain management of endometriosis as evidenced by patient’s verbalization of “I want to know more how to relieve my pain.”

Desired Outcome: At the end of the health teaching session, the patient will be able to demonstrate sufficient knowledge of his/her acute pain and its management.

InterventionsRationales
Assess the patient’s readiness to learn, misconceptions, and blocks to learning (e.g., denial of diagnosis or poor lifestyle habits).To address the patient’s cognition and mental status towards pain management and to help the patient overcome blocks to learning.
Explain what his/her pain management program entails (e.g., medications, relaxation techniques, related physiotherapy or exercises). Avoid using medical jargons and explain in layman’s terms.To provide information on his/her pain management program.
Inform the patient the details about the prescribed medications (e.g., drug class, use, benefits, side effects, and risks) to treat acute pain. Ask the patient to repeat or demonstrate the self-administration details to you.To inform the patient of each prescribed drug and to ensure that the patient fully understands the purpose, possible side effects, adverse events, and self-administration details.
Educate the patient about non-pharmacological methods for acute pain such as imagery, distraction techniques, recommended exercises, and relaxation techniques.To reduce stress and to promote optimal pain relief without too much dependence on pharmacological means.

Nursing Care Plan 3

Nursing Diagnosis: Activity intolerance related to acute pain secondary to endometriosis as evidenced by pain score of 8 to 10 out of 10, fatigue, disinterest in ADLs due to pain, verbalization of tiredness and generalized weakness

Desired Outcome: The patient will demonstration active participation in necessary and desired activities and demonstrate increase in activity levels.

InterventionsRationales
Assess the patient’s activities of daily living, as well as actual and perceived limitations to physical activity. Ask for any form of exercise that he/she used to do or wants to try.To create a baseline of activity levels and mental status related to acute pain, fatigue and activity intolerance.
Encourage progressive activity through self-care and exercise as tolerated. Explain the need to reduce sedentary activities such as watching television and using social media in long periods. Alternate periods of physical activity with 60-90 minutes of undisturbed rest.To gradually increase the patient’s tolerance to physical activity. To prevent triggering of acute pain by allowing the patient to pace activity versus rest.
Administer analgesics as prescribed  prior to exercise/ physical activity. Teach deep breathing exercises and relaxation techniques. Provide adequate ventilation in the room.To provide pain relief before an exercise session. To allow the patient to relax while at rest and to facilitate effective stress management. To allow enough oxygenation in the room.
Refer the patient to physiotherapy / occupational therapy team as required.To provide a more specialized care for the patient in terms of helping him/ her build confidence in increasing daily physical activity.

Nursing Care Plan 4

Nursing Diagnosis: Constipation related to the disease process of constipation as evidenced by type 1-2 stools on Bristol stool chart, inability to open bowels in the last 3 days, irritability

Desired Outcome: The patient will be able to re-establish normal bowel elimination.

InterventionsRationales
1. Commence a stool chart. Use a standardized stool assessment tool such as Bristol stool chart.To monitor the patient’s bowel pattern.
2. Administer laxatives as prescribed.To help evacuate stools, the following laxatives can be used as prescribed:
•Stimulant laxatives •Stool softeners, especially for the elderly patients •Bulk laxatives
Encourage to increase oral fluid intake as tolerated, ideally at least 2L per day. Check if the patient is in any fluid restriction before doing so.To help soften the stool and make it easier to pass.
Encourage physical mobility and exercise as tolerated.To increase bowel peristaltic movement.
Encourage fiber intake of at least 25 grams per day for women and 38 grams per day for men, as recommended by the dietitian.To help the food move through the intestines. Examples of good dietary fiber include artichokes, carrots, and spinach.

Other possible nursing diagnoses:

Nursing References

Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). Nursing diagnoses handbook: An evidence-based guide to planning care. St. Louis, MO: Elsevier.  Buy on Amazon

Gulanick, M., & Myers, J. L. (2017). Nursing care plans: Diagnoses, interventions, & outcomes. St. Louis, MO: Elsevier. Buy on Amazon

Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2018). Medical-surgical nursing: Concepts for interprofessional collaborative care. St. Louis, MO: Elsevier.  Buy on Amazon

Silvestri, L. A. (2020). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier.  Buy on Amazon

Disclaimer:

Please follow your facilities guidelines, policies, and procedures.

The medical information on this site is provided as an information resource only and is not to be used or relied on for any diagnostic or treatment purposes.

This information is intended to be nursing education and should not be used as a substitute for professional diagnosis and treatment.

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