Endometriosis is a hormonal and immune system disease characterized by a benign growth of endometrial tissue that occurs atypically outside of the uterine cavity. Although endometriosis can grow anywhere in the body, it is found most commonly around the ovaries, pouch of Douglas (cul-de-sac), cervix, uterosacral ligaments, rectovaginal septum, sigmoid colon, round ligaments, and pelvic peritoneum. During the reproductive years, the atypical endometrial tissue responds the same to hormonal stimulation as does the tissue within the uterus. Thus, the tissue grows during the proliferative and secretory phase of the woman’s menstrual cycle and bleeds during or immediately after it. This bleeding drains into the peritoneal cavity and causes an inflammatory process with subsequent fibrosis and adhesions. Such scarring may lead to blockage or distortion of any of the surrounding organs. The primary complication of endometriosis is infertility, which results from adhesions and scarring that are caused by bleeding from the atypical endometrial tissue. These adhesions may occur around the uterus and fix it into a retroverted position. They may also block the fallopian tubes or the fimbriated ends, thereby preventing the ovum from being carried into the uterus. Endometriosis can also lead to spontaneous abortion and anemia.
The cause of endometriosis is not known. The most predominant theory is the retrograde menstruation theory, which suggests that endometriosis results from a backflow of endometrial tissue from the uterus into the pelvic cavity during menstruation. This flow starts through the fallopian tubes and passes into the peritoneal cavity, where it implants to form atypical (ectopic)
sites of endometrial tissue. Other theories of endometrial etiology include: the transformation of cells lining the peritoneum undergo metaplastic transformation and give rise to the endometrial lesions; spread of tissue via the vascular and lymphatic systems; and also the idea that dormant, immature cells spread during the embryonic period and metaplasia is now occurring in adulthood. There also may be a genetic predisposition for endometriosis. Women who have had mothers and sisters with this disease process have been found to be at higher risk of developing endometriosis.
Nursing care plan assessment and physical examination
Elicit a complete history of the woman’s menstrual, obstetric, sexual, and contraceptive practices. Endometriosis is difficult to diagnose because some of its symptoms are also manifestations of other pelvic conditions, such as pelvic inflammation, ovarian cysts, and ovarian cancers. A thorough description of the patient’s symptoms becomes important, therefore, in the early diagnosis of the condition. Symptoms of endometriosis vary with the location of the ectopic tissue. Some women may even be asymptomatic during the entire course of the disease. The classic triad of symptoms of endometriosis are dysmenorrhea, dyspareunia, and infertility. The symptoms may also change over time. The major symptom is dysmenorrhea (pain associated with menses) that is different from the normal uterine cramping during the woman’s menstrual cycle. This cramping has been referred to as a deep-seated aching, pressing, or grinding in the lower abdomen, vagina, posterior pelvis, and/or back. It usually occurs 1 to 2 days before the onset of the menstrual cycle and lasts 2 to 3 days. Other possible symptoms are pain during a bowel movement around the time of menstruation, a heaviness noted in the pelvic region, menorrhagia, nausea, diarrhea, and pain during sexual intercourse (dyspareunia) or exercise. Some women may have no symptoms at all, and endometriosis is diagnosed during infertility testing.
During a pelvic examination, the cervix may be laterally displaced to the left or right of the midline. Palpation of the abdomen may uncover nodules in the uterosacral ligament, with tenderness in the posterior fornix and restricted movement of the uterus. Palpation may also identify ovarian enlargement that was caused by the presence of ovarian cysts. Speculum examination may reveal bluish nodules on the cervix or posterior wall of the vagina.
During acute flare-ups of the disease, an internal pelvic examination may cause the patient excruciating suprapubic and abdominal pain. The acute disease may be difficult to distinguish from appendicitis or other conditions that lead to an “acute abdomen.” The patient may have a rigid abdomen, abdominal guarding, and a low-grade fever.
Endometriosis is a chronic, long-term condition, with symptoms that occur every month for 2 to 3 days until menopause. Severe discomfort, interferences with activities of daily living or leisure activities, impaired sexual function, and the disappointments of infertility can contribute to depression in women with this chronic disease. Inquire about the level of partner support.
Nursing care plan primary nursing diagnosis: Pain, chronic, related to cramping, internal bleeding, swelling, and inflammation during the menstrual cycle.
Nursing care plan intervention and treatment
Women who are nearing menopause are usually treated prophylactically until they enter menopause. If the woman is in no distress and is approaching menopause, no treatment will be necessary except observing the progression of the disease. By contrast, a younger woman who wishes to become pregnant may be treated more aggressively. Some women may be instructed to get pregnant as quickly as possible if they wish to have children. Pregnancy and lactation suppress menstruation and result in shrinkage of the endometrial tissue implants. Relief from symptoms has been noted to persist years after the pregnancy.
Surgery is performed conservatively, by laparoscopy or laparotomy using laser via the laparoscope. The goal is to remove as much of the ectopic endometrial tissue as possible and retain the woman’s reproductive ability. In older women with severe symptoms who have completed childbearing, or as a last resort in childbearing-aged women, a hysterectomy may be the surgery of choice with or without a bilateral salpingo-oophorectomy.
Unless a total hysterectomy is done, the patient needs to understand that all other treatments offer relief and not cure. The nurse needs excellent communication skills to teach, inform, and support the patient. Care focuses on strategies to relieve pain and discomfort, to support the patient during a stressful time, and to provide patient education. The pain of endometriosis can be mild or severe. Unless the patient has other underlying diseases, she will generally be managed on an outpatient basis until surgical intervention is needed. To relieve pain, instruct the woman that over-the-counter analgesics such as acetaminophen are preferable to nonsteroidal anti-inflammatory drugs (NSAIDs) and aspirin because of the latter’s tendency to increase bleeding. Some patients obtain relief from cramping by lying on the side with the legs bent, taking warm baths, or using a heating device on the lower abdomen. Make sure that the patient uses heating devices on a low setting to prevent burns. Caution the patient with acute abdominal pain from unknown causes not to use a heating pad because of the risk of a perforated appendix.
Assess the woman’s cultural and ethnic influences, which will play a part in her understanding and subsequent coping with endometriosis. Be emotionally supportive. Provide interested couples with information on the Endometriosis Association, Resolve (a support, education, research group for infertile couples), and newer techniques for infertility management. Encourage the couple to talk openly about the disease and its effects on their sexual compatibility, and urge the woman to tell her partner about any discomfort during sexual intercourse to minimize misunderstandings. Encourage the couple to try different positions during sexual intercourse to find those most comfortable for the woman.
Nursing care plan discharge and home health care guidelines
Ensure that the patient understands the dosage, route, action, and side effects
before going home. Encourage the patient to be alert to her emotions, behavior, physical symptoms, diet, and rest and exercise. Encourage the patient to maintain open communication with her significant other and her family to discuss concerns she may have about the disease process.