IMPERFORATED HYMEN

OBJECTIVE:As the researcher develops further into this investigation, the following objectives are directed.

General Objectives:1. To investigate the case.2. To identify the nursing problems and the factors contributing to the clients disease

process.3. To address the identified problems and aid in the recovery and wellness of client.

Specific Objectives:1. To know the nursing history, personal data, health history and physical and functional assessment.

2. To present the laboratory examinations carried out duty for the client, including its findings

3. To expound the normal physiology and pathophysiology imperforated hymen.4. To discuss the pharmacological management of the

disease.5. To lay at hand the nursing care plan and the bounds to which the end are accomplished.

OVERVIEW OF IMPERFORATED

HYMEN

Imperforate hymen is at the extreme of a spectrum of variations in hymenal configuration. Variations in the embryologic development of the hymen are common and result in fenestrations,

septa, bands, microperforations, anterior displacement, and differences in rigidity and/or elasticity of the hymenal tissue. Inspection of the

Inspection of the external genitalia and anus are important components of the physical examination of the female neonate and child. While this

examination can and should be accomplished by the pediatrician, the observant delivering obstetrician can learn much about the normal

variations in genital configuration by examining the female neonate in the delivery room, keeping in mind the influence and structural changes

induced by maternal estrogens. Under this influence, the labia majora are plump, the hymen is elastic and often fimbriated, and the mucosal surfaces

(ie, introitus, fossa navicularis, vaginal vestibule) are pale pink.

ProblemImperforate hymen has been diagnosed with prenatal ultrasound documentation of bladder outlet obstruction due to

hydrocolpos or mucocolpos. However, in spite of the recommendations for inspection of the external genitalia

during the neonatal and early childhood period, variations in hymenal anatomy commonly escape diagnosis until the time of menarche.

Different normal variants in hymenal configuration are described, varying from the common annular, to crescentic, to navicular ("boatlike" with an

anteriorly displaced hymenal orifice). Hymenal variations are rarely clinically significant before menarche. In the caseof a navicular

configuration, urinary complaints (eg, dribbling, retention, urinary tract infections) may result. Sometimes, a cribriform (fenestrated), septate

or navicular configuration to the hymen can be associated with retention of vaginal secretions and prolongation of the common condition of a mixed bacterial vulvovaginitis.

Occasionally a hymenal tag will protrude from the vaginal vestibule, leading to concerns about a tumor or other significant pathology. These hymenal tags are

of no clinical significance, and they do not require therapy if vaginal origin can be excluded based on findings from a careful examination.

SIGNS AND SYMPTOMS OF IMPERFORATED HYMEN

• Abdominal Pain• Abdominal pain crampy• Chroic abdominal pain• Hypogastric pain• Lower abdominal pain• RAP syndrome/children• recurrent abdominal pain• amenorrhea primary• bulging dark hymen/exam• painful coitus or dyspareunia• suprapubic pain

Treatment of Imperforate Hymen Women suffering from such problem should contact a gynecologist as early as possible. Only a gynecologist or specialist plastic surgeon will be able to cure the problem after perforating the hymen surgically.

Surgical therapy which includes hymenotomy is recommended for treatment of Imperforate Hymen. Needletrip electrocautery helps in hemostasis of hymenal edge. Yankauer suction tip is also used for treatment of imperforate hymen. They are usually inserted through the

vagina or through the cervix for proper excretion. Evacuator of high speed is sometimes required for proper treatment. Care must be taken to prevent infection in the post operational phase

PERSONAL DATA OF THE CLIENT

NAME: Ms. EAGE: 14 years oldSEX: FemaleCIVIL STATUS: ChildADDRESS: Nagsinamoc Lucban, Quezon Province

NATIONALITY: FilipinoRELIGION: CatholicPLACE OF BIRTH: Lucban, QuezonDATE OF BIRTH: Lucban, Quezon

DEPARTMENT: Gynecology, Room number 455ATTENDING PHYSICIAN: Ma. Teresita Lajara

CHIEF COMPLAINT: Difficulty urination with hypogastric pain for 1 weekDIAGNOSIS: Enlarged midpositioned uterus with hematometra bilateral ovaries polycystic pattern.

PAST AND PRESENT HEALTH HISTORY

11 Gordon’s Health Pattern

PAST PRESENTHealth perception

  

Does not comply to annual check upDoes not have regular exercisePerceive self as a healthy person

does not perceive self as a healthy person

Nutritional metabolic

Has good appetiteWith good skin turgorWithout artificial dentition

Has poor appetiteWith poor skin turgor

Elimination Has pain when voidingUrine; moderate in amount; yellowish in colorCan pass out normal stoolStool soft in characteristics; brown in color

With difficulty in urination; moderate in amount; yellowish in color

Activity-Exercise

Does not go to schoolStays @ homeLoves watching T.V

Patient has limited activities due to the hospitalization

Cognitive-Perceptual

Has good visionHas good sense hearing touch and perceptionHas good decision-makingCan use language effectively

With good visionPain perception high; tolerable

Sleep-Rest

Self-concept

Can sleep @ 8 hours every night 10pm-6amUndisturbed self-conceptHas poor postureCan maintain eye contactSoft voice tone

Can sleep @ 8 hours from 9pm-5am

Has disturbed self-conceptHas poor postureCannot maintain eye contactSoft voice tone; usually not audible

Role Relationship

With good relationship with the family and siblings Usually shy and home budStopped going to school; elementary graduate

Shy and feels isolatedQuiet most of the time

Sexually reproductive

Coping/ Stress Tolerance

Not applicable

Utilize support systemSuch as family and friends to share own problem 

Not applicable

Usually quietStill dependent to parents

Value-Belief

Roman CatholicBelieves in “quack” doctors or “albularyo” and goes to them when sick

No specific beliefs related to current condition

PHYSICAL ASSESSMENT

Date of Assessment: August 29, 2009 / 5:00 am

General Appearance:-weak in appearance- Pale in appearance

Skin–Skin–With uniform brown skin color–Skin warm to touch–No lesions noted–With good skin turgor–No edema

Head-Rounded and symmetrical

-No infection or infestation

-With thick hair which is black in color

-Hair evenly distributed

Eyes and Vision

-Pupils are constricted at 2-3 mm in diameter

-Both pupils are equally round and reactive to light accommodation

-No discharges noted

-With pale conjunctiva

-Eyebrows symmetrically aligned

Ears and Hearing-Color same as facial skin

-Symmetrical

-Firm and not tender

-No lesion

-No discharges noted

-Normal voice tones audible

Nose-Symmetrical and straight

-With uniform color

-Air moves freely on both nares

-No discharge

-No lesions noted

-No tenderness

Mouth and Tongue-With pinkish gums

-With good set of teeth, yellowish in color

-With pale and dry lips

-With non protruding tongue

-

-Tongue whitish in color

-Without halitosis

Neck -Straight and symmetrical

-Muscles equal in size

-With coordinated, smooth movements with no discomfort

-No swelling on lymph nodes

Chest

-with symmetrical chest expansion upon respiration

-right and left shoulders are at same height

-with bronchovesicular sound heard on both lung fields upon auscultation

-skin is intact with uniform temperature

-no tenderness

-no retraction

Breast

• Symmetrical• With uniform skin color• No tenderness, masses or nodules

• No discharge

Abdomen

-unblemished skin

-with uniform color

-with localized protrusions and tolerable pain upon palpation on the right lower quadrant

Back-With straight alignment of spine

-With clear breath sound on both lung fields upon auscultation

-No deformities

-No lesions noted

Genito-urinary

-No lesions noted

-With tolerable pain upon urination

Upper extremities

-With IVF inserted on right metacarpal vein

-No edema

-No lesion

-No joint deformities

Nails

• Thick and smooth

• With good capillary refilling time of 2-3 secs.

• With pinkish nail beds

Lower extremities

-No edema

-no lesion noted

-no joint deformities

ANATOMY AND PHYSIOLOGY OF IMPERFORATED

HYMEN

Types of Hymens:A Guide for TeensHymen: a thin membrane that surrounds the opening to a young woman's vagina. Hymens can come in different shapes. . The most common hymen is shaped like a half moon. This shape allows menstrual blood to flow out of a girl's vagina.

Imperforate hymen: An imperforate hymen can be diagnosed at birth but sometimes the diagnosis isn't made until the teen years. An imperforate hymen is a thin membrane that completely covers the opening to a young girl's or young woman's vagina.

Menstrual blood cannot flow out of the vagina. This usually causes the blood to back up into the vagina and the abdomen (belly) resulting in abdominal and/or back pain. Some teens may also have pain with bowel movements and difficulty passing urine.

The treatment for an imperforate hymen is minor surgery to remove the extra hymenal tissue and create a normal sized vaginal opening so that menstrual blood can flow out of the vagina.

Microperforate hymen: A microperforate hymen is a thin membrane that almost completely covers the opening to a young women's vagina. Some menstrual blood may be able to flow out of the vagina but the opening is very small.

A teen with a microperforate hymen usually will not be able to get a tampon into her vagina and may not realize that she has a very tiny opening. If she is able to put a tampon into her vagina she may not be able to remove it when it becomes filled with blood.

The treatment is minor surgery to remove the extra hymenal tissue making a normal sized opening for menstrual blood to flow out.

Septate hymen: A septate hymen is when the thin hymenal membrane has a band of extra tissue in the middle that causes two small vaginal openings instead of one. Teens with a septate hymen may have trouble getting a tampon in or trouble getting a tampon out.

The treatment for a septate hymen is minor surgery to remove the extra band of tissue and create a normal sized vaginal opening.

Illustrations of Hymen Types

PATHOPHYSIOLOGY OF IMPERFORATED

HYMEN

PATHOPHYSIOLOGY OF IMPERFORATED HYMEN

ETIOLOGY

Teratogenic Effect

Genetics Abnormal/incomplete

Embryologic Development

Urinary Retention

Hydronephrosis

Difficulty of Urination

Retention of Vaginal Secretion

Hematometra

Hematocolpos

Hematosalphinges

Vaginal Cysts

No menstrual Bleeding

Hypogastric Pain

Back Pain

Abdominal Pain

Pelvic Pain

Reproductive Organ

Infection

Enlarged uterus

Mass

Constipation

Bleeding

COURSE IN THE WARD

DOCTOR’S ORDER RATIONALE

8-27-09Please admit to Gyne Ward

Secure consent

V/S q 4

NPO

the patient has an existing problem in her reproductive organto know if the patient agrees with the procedures

for monitoring

for laboratory examination

Lab. Req. CBC Blood typing

CT BT platelet count

Urinalysis For transrectal ultrasound

IVF D5LR 1L x 12

to know if there is an abnormal value that can contribute to the patient’s present condition.to visualize if there are other organs affected

to maintain the normal electrolyte balance with in the body

Refer to pedia

BY: Dr. LajaraProceed with transrectal ultrasound done

for co-management purposesTo remove the extra hymenal tissue and create a normal sized vaginal opening so that menstrual blood can flow out of the vagina

For BUN, creatinine

8-28-09For hymenectomy after pedia clearance Follow up BUN, creatinine resultsNoted by OR, AODReferred to Dr. Imperial

To know the result and if there is an abnormal findings

For removal of imperforated hymenTo visualize the other complications

5:00 pm For CXR

8:00pm > NPO

8-29-09May proceed with hymenectomyThank you for the following referral, will follow up patient

To know if there is deviation in the lungsFor preparation of patient’s operation

6:35pmPatient is for hymenotomy not hymenectomy

POST OP ORDERTo PACU

Vital signs every 15 mins

The procedure is not for removal but for making an opening in the hymen

For care of post-op and post anesthesia patientFor BP monitoring

IVF t follow D5 LR 1L x 20 gtts/mins

Flat on bed for 6 hrs.NPO for 6 hrs.

Start oral meds after 6 hrs

-cefalexine 500 mg TID

to maintain the normal electrolyte balance with in the bodyFor fast recoveryCannot tolerate foods

Antibiotic; post-op; risk for infection

-MFA 500mg TID

-ferrous sulfate OD by: Dr. Baldovino

8-30-09Continue medsReffer

by: Dr. Baldovino

To relief and manage painTo have sufficient iron in the body

For continuous treatment regimen

8-31-09Full diet

Continue all meds

9-1-09MGH

By: Dr. Lajara

9-2-09MGH still

By: Dr. Baldovino

G.I. tract is now in good condition

For continuous home management and recovery

LABORATORY RESULT

08/28/09 9:45amTEST

NAME RESULT NORMAL

VALUES

BUN Kinetic UV

6.5mg/dl 7.0 to 18.0

Creatinine 0.6mg/dl 0.3 to 1.3

INTERPRETATIONDecrease in BUN is rare, and occur during liver failure, when protein metabolism is inhibited, and in negative nitrogen balance when protein breakdown exceeds protein intake. Negative nitrogen balance may occur during anorexia, malnutrition or intravenous patient’s therapy in patient receiving oral nutrition.

COMPLETE BLOOD COUNT RESULT

CBC RESULTS REFERENCE VALUE

HEMOGLOBIN 11.7 MALE 14-18gm/dl

FEMALE 12-15 gm/dl

HEMATOCRIT 35.2% MALE 40-50%FEMALE 30-40%

WBC count 9500 5000-10000/ cu mm

Differential Count

NEUTROPHILS 66 40-60

LYMPHOCYTE 34 35-40

PLATELET COUNT

450000/ cu mm 150000-450000/ cu mm

Clotting Time 2.00

Bleeding Time 1.20

 INTERPRETATION-When the hemoglobin level decrease, anemia is present.-An increase in neutrophils indicates the presence of bacterial infectious process.-Decrease in lymphocytes are associated with Hogkin’s disease, lupus erythematosus, burns trauma, and the administration of corticosteroids.

URINALYSIS COLOR: yellowTRANSPARENCY: SPECIFIC GRAVITY: 5.0CHEMICAL TEST            SUGAR: +            ALBUMIN: +

PREGNANCY TEST: -MICROSCOPIC:            RBC: loaded            WBC: 1-2 EPITHELIAL: +CRYSTAL :A.    URATES:+

ULTRASOUND REPORT GYNECOLOGY08/27/09 PERTINENT DATA: Transrectal I. UTERUS 10.6 x 8.4 x 8.2 cm midpositioned The uterus is dilated by homogenous medium level echoes probably a hematometra amounting to 287cc ( 10.0 x 6.9 x 7.3 cm)

II. ENDOMETRIUMIII. ADNEXAE  Rt. Ovary 4 x 3.7 x 2 cmLocated: Lateral/ Posterolateral/ Posterior to uterusLeft Ovary: 3.0 x 1.8 x 1.4 cmBoth ovaries have polycystic patternIV. CERVIX:  ____x____x____ Nabothian cyst:  Present/ None

V. OTHERS (-) free fluid in cul de sac DIAGNOSIS:      Enlarge midpositioned uterus with hematometra.      Bilateral ovaries with polycystic pattern.

EXAMINATION KUB and PELVIC Result:  The KIDNEYS are normal in size with intact CMB.            The right measures (97.12) x (36.70) x 35.57mm    CMB= (9.22)mm            The left measures (95.71) x (34.38) x (38.28)mm.         CMB= (9.80)mm

  However, both are heterogenous with increased echogenecity and prominent pyramids. No evidences of stones of hydronephrosis noted. The ureters are not dilated.                   The URINARY BLADDER is well-filled with no wall thickening or irregularities noted. No intraluminal echoes seen.

  The UTERUS is anteverted and midline in orientation. It is enlarged measuring (112.3)mm. In length (67.30) in thickness and 81.65mm in width. The endometrial cavity is fluid distended sand a fluid volume of 323.2cc.   The ADNEXAE are unremarkable.

CLINICAL IMPRESSION RENAL PARENCHYMAL DISEASE BILATERAL.NORMAL URINASRY BLADDER WITH IONICALLY HYDROCALPOS MOST PROBABLY SECONDARY TO IMPERFORATED HYMEN.

RADIOLOGY RESULT08/29/09 CHEST X-RAYThe lungs fields are clear with normal lung roots.The heart mediastinum, diaphragm and costaphrenic sinuses appear physiologic normal soft tissues and asseous structures in the chest wall.

IMPRESSION:  ESSENTIALY NORMAL CHEST FINDING.

 

DRUG STUDY

Name of Drug

Action Indication Adverse Reaction

Dosage Nursing Consideration

Cefalexine

Inhibit cell wall synthesis increasing bacterial growth

Chronic infection due to susceptible micro organism

Nausea, vomiting, abdominal discomfort skin rash

500mg TID

-if large

doses are given or if therapy is prolonged, monitor patient for super infection especially if patient is high risk.

-ask patient about past reaction to cephalosporin or penicillin therapy before giving first

dose.

Name of Drug

Action Indication Adverse Reaction

Dosage Nursing Consideration

Mefenamic Acid

Anti-inflammatory, analgesic activities related to inhibitation of prostaglandin synthesis

Mild to moderately severe pain associated with past-op and post-partum pain, menorrhagia and dysmenorrhea

Headache, dizziness, nervousness, GJ disturbances and GI bleeding

500mg TID

-take drug with food

-take only a prescribed dosage

-do not take drug longer than 1 week

Name of Drug

Action Indication Adverse Reaction

Dosage Nursing Consideration

Ferrous Fumarate

Elevates the senim iron concentration, which then helps to form hgh or trapped in the eticuloendothelial cells for storage and eventual conversion to usable form of iron.

-dietary supplement of iron

-prevention and treatment of iron deficiency anemias

Nausea,vomiting, constipation, diarrhea, dark stools

give drug with meals (avoiding milk, eggs, coffee and tea) if GI discomfort is severe; slowly build up tolerance

-warm patient that stool may be dark or green

NURSING CARE PLAN

ASSESSMENT

NURSING DIAGNOSIS

NURSING GOAL

INTERVENTION

RATIONALE

EVALUATION

S- “kinakabahan ako sa aking operasyon,” as verbalized by the patient.

Anxiety r/t upcoming surgical operation

At the end of nursing intervention the pt. will demonstrate understanding through use of effective coping behavior.

•Assessed degree of anxiety and reality of threat perceived by the pt.

•To assess the level of anxiety

•Goal partially met.•Seen pt comfortable in bed

ASSESSMENT

NURSING DIAGNOSIS

NURSING GOAL

INTERVENTION

RATIONALE

EVALUATION

•Conscious and •Coherent•Increased alertness•Increased tension

•Encourage client to acknowledge and to express feelings

•Monitor verbal and non verbal responses.

•To assist client to identify feelings and begin to deal with problem

“kapag medyo nahihirapan akong , itinataas ko lang yung ulo ko gamit ang unan” as verbalized by the pt. humiga

ASSESSMENT

NURSING DIAGNOSIS

NURSING GOAL

INTERVENTION

RATIONALE

EVALUATION

•Pacing back and forth inside the room

•With blank expression

•Provide accurate information and situation.

•Helps client to identify what is reality based.

ASSESSMENT

NURSING DIAGNOSIS

NURSING GOAL

INTERVENTION

RATIONALE

EVALUATION

S- ”nanglalambot pa rin ako,” as verbalized by the pt.

ASSESSMENT

NURSING DIAGNOSIS

NURSING GOAL

INTERVENTION

RATIONALE

EVALUATION

S- ”nanglalambot pa rin ako,” as verbalized by the pt.

Activity intolerance r/t decrease body strength secondary to previous surgery.

At the end of the nursing intervention the pt. will demonstrate techniques to increase

activity.

•Assess energy level

•Encourage in active and passive ROM

exercise

•To assess limitation of activity •To enhance blood circulation

•Goal met•Seen pt walking through the use of IV stand and SO

ASSESSMENT

NURSING DIAGNOSIS

NURSING GOAL

INTERVENTION

RATIONALE

EVALUATION

O> •With complaint of body weakness

•With limited activity

•With complaint of pain

•Always lying on

bed

•Encourage in adequate rest and sleep period•emphasize adequate fluid intake

•To reduce fatigue]

•Fluid intake can increased maintained energy level.

Kinakaya kong tumayo dahil kapag nakahiga ako lalo akong nanghihina, verbalized

by the pt.

ASSESSMENT

NURSING DIAGNOSIS

NURSING GOAL

INTERVENTION

RATIONALE

EVALUATION

•assist an ambulation •instruct to intake vitamin C rich foods like citrus fruits.

•To enhance blood circulation•To increased resistance/ maintain tolerable level.

ASSESSMENT

NURSING DIAGNOSIS

NURSING GOAL

INTERVENTION

RATIONALE

EVALUATION

S> no subjective complaint

O>

With presence of wounds

With poor hygiene

Slightly decrease in lympocyte

Risk for infection r/t traumatized tissue

At the end of nursing intervention the pt. will demonstrate technique, lifestyle changes to promote safe environment.

•Monitor visitor/ caregivers

•Change of dressing as needed/ indicated

•To prevent exposure of client

•To reduce/correct existing risk factors.

Goal met.

The patient was able to demonstrate techniques, lifestyle, changes to promote

ASSESSMENT

NURSING DIAGNOSIS

NURSING GOAL

INTERVENTION

RATIONALE

EVALUATION

•Encourage early ambulation deep breathing, couching, and position change.

•Administer medication regimen

•To prevent pneumonia

•To determine effectiveness of therapy.

Safe environment as evidence by improved her personal hygiene

ASSESSMENT

NURSING DIAGNOSIS

NURSING GOAL

INTERVENTION

RATIONALE

EVALUATION

•Administer prophylactic amitotic and imminicable as indicated.

•To determine effectiveness of therapy.

ASSESSMENT

NURSING DIAGNOSIS

NURSING GOAL

INTERVENTION

RATIONALE

EVALUATION

S> “masakit pa ung pagkaka-opera sa akin, “

Pain r/t tissue trauma from surgical incision

At the end of nursing intervention the pt. scale of 8 out of 10 will be down to 2

out of 10.

•Perform pain assessment each time pain occurs.•Assess for referred pain as appropriate.

To rule out worsing of underlying condition of organ dysfunction requiring treatment.

To help determine possibility of underlying condition of organ dysfunction of requiring treatment.

•Goal partially met.•Pain scale of the pt. is down to 3 out of 10.•Seen comfortably lying on bed

ASSESSMENT

NURSING DIAGNOSIS

NURSING GOAL

INTERVENTION

RATIONALE

EVALUATION

•Encourage divertional activities.•Encourage adequate rest period

•To assist client of explore method.•To prevent fatigue

•No further complaint•Seen at frequent intervals

ASSESSMENT

NURSING DIAGNOSIS

NURSING GOAL

INTERVENTION

RATIONALE

EVALUATION

•Ascertain client knowledge of expectation about the pain management

•To provide comfort

ASSESSMENT

NURSING DIAGNOSIS

NURSING GOAL

INTERVENTION

RATIONALE

EVALUATION

•Provide comfort measurers

•To provide non pharmacologic pain management.

DISCHARGE PLAN - CEFALEXIN 500mg isang beses isang araw. Iinumin tatlong sa oras ng 8 ng umaga, 1 ng hapon, at 6 ng gabi. -FERROUS FUMARATE isang beses isang araw. Iinumin sa oras ng 9 ng umaga.

-MEFENAMIC ACID 500mg tatlong beses isang araw. Iinumin sa oras ng 8 ng umaga, 1 ng hapon, 6 ng gabi

HEALTH TEACHING1.Teach patient the importance of adequate rest and sleep.2. Increase fluid intake.3. Adherence to treatment regimen.4. Eat nutritious foods such as fruits and vegetables.

5. Encourage the client to use breathing techniques especially during times of increased pain.6. Instruct patient to proper positioning in times of difficulty in breathing or when coughing.

THE END

Ma’am, thanks for everything..

We will miss you=)