Uterine Fibroid Control & Management-Free-Samples for Students

Question: Discuss about the Case Study of Janet Jackson. Answer: Etiology Pathophysiology of Uterine Fibroids/Leiomyoma Leiomyomas are monoclonal tumors that develop from just a single uterine mutated smooth muscle cell which divides and eventually creates rubbery mass that is distinctively firm within the uterine muscles (Agnihotri, 2016). Some chromosomal rearrangements including translocations trigger the growth proliferation of these leiomyomas.Collectively, genetic changes, hormones and growth factors contribute to growth of leiomyomas (Lipman, et al, 2015). Estrogen and progesterone hormones whose role includes stimulating the uterine lining development during menstrual cycles in readiness for pregnancy promote leiomyoma development. The leiomyomas have more estrogen and/or progesterone receptors as compared to normal cells in the uterine muscles (Lerner et al, 2016). Their patterns of growth however, vary and can be rapid, slow or just remain constant in size. They shrink at menopause due to the decrease in estrogen and progesterone production(Mackenzie Johnson, 2010). Growth factors like the transforming growth factor- (subscript) 3, the basic fibroblast growth factor, insulin growth factor and the epidermal growth factor which are all mitogenic also contribute to fibroid growth as they are likely effectors in promoting estrogen and progesterone hormonal activities. Leiomyomas can either remain in the uterine muscular layer or even protrude outwardly becoming subserosal in location. Those which protrude inwardly towards the endometrial cavity become submucous fibroids(Agnihotri, 2016). Both the subserosal and submucous fibroids can become elongated forming a stalk of tissue. The abnormal vaginal bleeding which normally accompanies uterine fibroid presence results from distortion of ones endometrial lining (Engh Hauso, 2012). Cavity distortion causes second trimester loss in patients while leiomyomas which obstruct ones menstrual flow normally results to dysmenorrhea (Dain Abramov, 2011). Large leiomyomas contributes to extensive effects on the contiguous organs like the bladder and the bowel. This effect brings about symptoms like urinary urgency, frequency, incontinence, and constipation among affected women. The fibroids can even outstrip their own blood supply and lead to acute and/or chronic pain while they degenerate (Bhalerao et al, 2011 ). On the other hand, submucous uterine fibroids that have been pedunculated often dilate ones uterine cervix, prolapse into their vagina and get infected. It is believed that the bleeding which results from fibroid is caused by dilatation of venules in the myometrium and the endometrium thus interfering with fibrin and platelet plug hemostatic action. Heavy menses among individuals with uterine fibroids is caused by the ulcerations on the submucosal uterine fibroid surfaces. Other causes of heavy menses in these individuals include the fibroid-related anovulation, endometrial-surface-area increase and the normal uterine contractility interference (Agnihotri, 2016). Therefore, the interaction of the growth factors, hormones, and the genetic changes in the myometrium bring about the development and proliferation of leiomyomas. Pathophysiology of the Patients Post-operative Deterioration From the observation, it is clear that the patients vital signs are deteriorating and therefore Janet requires immediate stabilization. The patient is undergoing hypovolemic shock which occurs particularly when the circulatory system does not have sufficient amounts of blood to meet the bodys requirements (Fletcher, et al, 2010). The low blood pressure as observed in the patient occurs due to the insufficient amounts of blood for the heart to pump. The condition is followed by high pulse rate and decreased urinary output. Normally, the blood pressure for an individual at rest should be 120/80mm Hg. Lower blood pressure beyond 90/60mm Hg as seen in Janet (90/50 mm Hg) indicates potential post operation hemorrhage (Dain Abramov, 2011). General anesthesia including the mechanical ventilation used during the surgery, usually impair the pulmonary function thus decreasing oxygenation in the period after anesthesia. This also contributed to loss of breath and low blood pressure as observed in the patient. General anesthesia drugs also reduce the functional residual capacity to about half of the bodys pre-anesthesia value (Fletcher, et al, 2010). The loss of breath is also a result of pulmonary atelectasis which is the collapsing of a section of the lungs, a condition that is contributed to by anesthetic drugs (Shetty et al, 2014). Pulmonary atelectasis occurs in about 85- 90% of any given healthy adults. The combination of atelectasis, ventilation perfusion mismatch and the alveolar hypoventilation contributes to postoperative hypoxemia among patients. The patient is experiencing hypoxemia as seen by her high respiration rate of 30 breaths per minute as compared to the maximum normal of 20 breaths per minute. Her cigarette smoking effect reduces the lung function while increasing mucous production (Mackenzie Johnson, 2010). Being a smoker, Jane has a hindered circulation caused by plaque deposits in blood vessels and narrowed vessels. These factors interact with the low amounts of blood to bring about hypoxemia, high respiration rate, and a faster heart beat as homeostatic responses of the body to recover. Nursing Management From the deteriorating vital signs, it is apparent that Janet is undergoing a suspected postoperative hemorrhage. Studies indicate that postoperative hemorrhage particularly after vaginal hysterectomy presents first as bleeding through the vagina some hours after surgery. In this case, the patient could be bleeding particularly from the cuff within the vagina (Shiota et al, 2011). Secondly, the patient can have little vaginal bleeding but present with deteriorating vital signs including a low blood pressure, rapid pulse, high respiration rate, flank and/or abdominal pain. This is mainly associated with retroperitoneal hemorrhage (Agnihotri, 2016). Since there is a patient controlled analgesic, the patient has 0/10 pain. The nursing management therefore in this case includes rapid diagnosis, vital-sign stabilization, blood replacement and further, a continuous surveillance of the patient. To control the suspected hemorrhage and hypoxemia the nursing management must ensure that they secure the airway for the patient, arrest bleeding and also replace the lost volume (Shetty et al, 2014). The multidisciplinary team should first carry out patient oxygenation and this involves intubating and using the mechanical ventilator, in order to increase the amount of oxygenated blood reaching vital organs and prevent further shock. Secondly, there is need to restore the body fluid volume and in this case, the nursing team should create two intravenous lines for fluid resuscitation of the patient and administer normal saline (Mackenzie Johnson, 2010). This also should include blood transfusion. The current indwelling urinary catheter should be left in place to ensure that urinary output is monitored. If hypotension persists even after the first bolus of normal saline, the team should administer packed red blood cells. This should also be the case if the patients Hgb goes below 6 gm /dL. This limits the crystalloid dilution effect and also boosts the bloods oxygen-carrying capacity (Shiota et al, 2011). The patients Hgb should be maintained above 7 gm/dL. The patient can also be administered with fresh frozen plasma (FFP) especially if her INR is more than 2. On the other hand, platelets are necessary particularly when the patients thrombocyte count goes below 50,000 mm3 (Shetty et al, 2014). Further, the patient should have a cryoprecipitate if her fibrinogen level is below 80 100 mg/dL. Thirdly, drug therapy to support the patients blood pressure should be started after sufficient fluid resuscitation. Inotropes like dopamine or dobutamine, and vasopressors such as norepinephrine or phenylephrine are ideal (Agnihotri, 2016). Antibiotics can also be given as treatment to prevent sepsis while H2blockers like famotidine (Pepcid) and or cimetidine should be given to prevent ulceration of the gastric mucosa. To remedy hemorrhage cause, which could be a bleeding vaginal cuff, the nursing team should confirm any bright red blood coming out of the vagina despite the administered clotting factors (Ali Iskaros, 2015). This sign shows that the patient should immediately be taken back to the operation room for wound inspection and exploration, to inform immediate appropriate suturing and/or ligation. The patient can be treated with hemostatic agents including the VIIa (NovoSeven), and the Desmopressin (DDAVP) to promote blood clotting (Shetty et al, 2014). Antifibrinolytics like aprotinin (Trasylol) and/or aminocaproic acid should be started to prevent any breaking of clots which could be forming at the vaginal cuff. In vaginal hysterectomy, a vessel can retract from a tie and/or ligature leading to bleeding either retroperitoneally or intraperitoneally (Shiota et al, 2011). Extremely brisk bleeding means there is need for an exploratory laparotomy to enable the examining of the pelvis, identifying and isolating the bleeding vessels, and arresting the bleeding accordingly. Where localization of bleeding to a certain pelvic vessel is difficult, the doctors can ligate the hypogastric artery/arteries (Shetty et al, 2014). Minimal vaginal bleeding along with the indicated deteriorating vital signs, should imply suspected retroperitoneal hemorrhage. They should order immediate hematocrit, after which blood transfusion can be done. Brisk bleeding can also be controlled via selective angiographic embolization (Bhalerao et al, 2011). When there is adequate exposure the pelvis, there is need for the peritoneum above the potentially formed hematoma to be opened to evacuate blood (Shiota et al, 2011). Every bleeding vessel should then be identified for ligation. After hemostasis has been achieved, the patients pelvis should then be drained through the closed system. These approaches can thus help in stabilizing the patients vital signs and prevent mortality. Interdisciplinary Healthcare Team The Social Worker The social worker will provide assistance to the patient and her three children in regard to handling their overwhelming stress (Shaw et al, 2014). According to Dubus (2010), a social worker should help patients to better understand and/or adjust to their condition, expel any fears and rid related anxiety on treatment. They can also provide patients with extensive information on financial counseling, spiritual services, ethical issues considered, and available support groups referrals (Bowen, 2014). The social workers can introduce behavior change to the patient in regard to smoking. Physical and/or Occupational Therapist A physical therapist is important as they provide services to the patient which restore their functioning, improve their mobility, and bring about relieve from pain. This therapist will help assist the patient in preventing and/or limiting potential permanent physical disabilities (Shaw et al, 2014). An occupational therapist on the other hand will carry out a complete assessment of the impact of vaginal hysterectomy on the patients later activities at home, at work, and during recreation. Their combined effort helps to reduce the patients risk of potential disability both physically and psychologically. The Family The family should offer the patient emotional support by visiting and being close (Shaw et al, 2014). Family members can be invited to help in making medical decisions in agreement with the patient and also the patients behalf. The family in partnership the critical care team can offer to share critical relevant crucial information regarding the patient for decision making (Bowen, 2014). This can help inform on the possible financial support, referral groups among other social factors that can promote the patients health post-operation. References Agnihotri, S. (2016). Assessment and treatment of uterine fibroids.Prescriber,27(6), 28-33. Ali, R., Iskaros, J. (2015). 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