Nursing care for women undergoing Uterine Fibroid · PDF fileNursing care for women undergoing...
Transcript of Nursing care for women undergoing Uterine Fibroid · PDF fileNursing care for women undergoing...
Nursing care for women Nursing care for women undergoing Uterine Fibroid undergoing Uterine Fibroid EmbolisationEmbolisation
Jan Jackson BSc (Jan Jackson BSc (HonsHons), DMS, CMS, RN, SEN (UK)), DMS, CMS, RN, SEN (UK)
Head Nurse, Imaging Directorate, Hammersmith Head Nurse, Imaging Directorate, Hammersmith Hospitals NHS Trust, London, UKHospitals NHS Trust, London, UK
Hammersmith HospitalsNHS Trust
UFE UFE -- BackgroundBackground
First used in late 1970s to control postFirst used in late 1970s to control post--partum bleedpartum bleed
RavinaRavina et al (1995) published results on et al (1995) published results on treatment for UF diseasetreatment for UF disease
-- effective in controlling symptoms 80effective in controlling symptoms 80--94%94%
-- fewer complicationsfewer complications
-- over 7,000 women treatedover 7,000 women treated
UFE UFE -- ReputationReputation
Reputation of being Reputation of being ‘‘quick and safequick and safe’’
UF UF -- What are they?What are they?
Common growths in female population (20 Common growths in female population (20 --50%)50%)Smooth muscle in originSmooth muscle in originPredominantly benignPredominantly benignMay be associated with reproductive May be associated with reproductive disordersdisordersAsymptomatic fibroid do not require Asymptomatic fibroid do not require treatmenttreatment
UF UF -- Type of FibroidType of Fibroid
Intramural Intramural -- common and common and develops in the wall of develops in the wall of uterusuterus
SubserosalSubserosal -- develops develops under outside covering of under outside covering of uterusuterus
SubmucosalSubmucosal -- develops develops under the inner lining of the under the inner lining of the uterus and is lease uterus and is lease common and problematiccommon and problematic
UF UF -- Population affectedPopulation affected
Increased incidence between the ages of Increased incidence between the ages of 35 35 -- 4949
AfroAfro--Caribbean women higher riskCaribbean women higher risk
Generic and hormonal factorsGeneric and hormonal factors
UF UF -- SymptomsSymptoms
Abnormal vaginal bleeding (Abnormal vaginal bleeding (menorrhagiamenorrhagia))
Pelvic painPelvic pain
Pelvic pressure (large fibroid) on bladder, Pelvic pressure (large fibroid) on bladder, bowel, kidneys causing increases bowel, kidneys causing increases urination, constipationurination, constipation
Infertility, recurrent spontaneous abortion, Infertility, recurrent spontaneous abortion, prepre--term labourterm labour
UF UF -- DiagnosisDiagnosis
Physical exam (bimanualPhysical exam (bimanual--abdomen)abdomen)
UltrasoundUltrasound
MRIMRI
HysterosalpingogramHysterosalpingogram
CTCT
HysteroscopyHysteroscopy
UF UF -- Treatment optionsTreatment options
Symptoms management Symptoms management
Surgery Surgery
-- NSAIDNSAID
-- Hormone TherapyHormone Therapy
-- HysterectomyHysterectomy
-- MyomectomyMyomectomy
UF UF -- Treatment options (cont)Treatment options (cont)
Endometrial ablationEndometrial ablation
Thermal ablation of uterus fibroidThermal ablation of uterus fibroid
-- percutaneous insertion of laser fibrespercutaneous insertion of laser fibres
-- focussed USfocussed US
Uterine Fibroid Embolisation (UFE)Uterine Fibroid Embolisation (UFE)
Uterine Fibroid Uterine Fibroid Embolisation (UFE)Embolisation (UFE)
Less invasiveLess invasive
NonNon--surgicalsurgical
Performed by Interventional RadiologistsPerformed by Interventional Radiologists
Blood flow in the right and left uterine Blood flow in the right and left uterine arteries is occluded and the fibroids are arteries is occluded and the fibroids are deprived of their blood supplydeprived of their blood supply
Occlusion leads to necrosis and death of Occlusion leads to necrosis and death of the fibroidsthe fibroids
UFE UFE -- IndicationsIndications
Referred by gynaecologistReferred by gynaecologist
Symptomatic patients who have failed Symptomatic patients who have failed other therapy or do not wish to have other therapy or do not wish to have surgerysurgery
UFE UFE –– ContraindicationsContraindications
Coagulation disorder or other Coagulation disorder or other contraindication to angiographycontraindication to angiography
InfectionInfection
Other uterine pathology e.g. endometriosis, Other uterine pathology e.g. endometriosis, adenomyosis, canceradenomyosis, cancer
Patients who desire fertility and have Patients who desire fertility and have exhausted other alternativesexhausted other alternatives
UFE UFE –– Before ProcedureBefore Procedure
Pelvic US TA/TV or MRIPelvic US TA/TV or MRI
Excluding malignancyExcluding malignancy
Gynaecological examination Gynaecological examination -- reviewedreviewed
Discuss with interventional radiologistDiscuss with interventional radiologist
Procedure explained Procedure explained
Patient information leafletPatient information leaflet
ConsentConsent
UFE UFE -- Patient preparationPatient preparation
Hammersmith Hospitals NHS Trust
Directorate of Imaging
HAVING AUTERINE FIBROID EMBOLIZATION
Information for patients
l
HAMMERSMITH HOSPITAL
RADIOLOGY DEPARTMENT
VASCULAR ROOM
Extension: 34943
Type: Time:
Yes No
NIDDM ________________ IDDM ____________________
Last BM __________ Time __________ On Metformin Yes No
Urinary catheter in place. IV access in situ.
To be administered 1/2 hr prior to procedure
Voltarol suppositoire 100mg
Only for female patients of child bearing age.
Date of last LMP _____ / _____ / _____
If LMP more than 10 days: Pregnancy Test Positive Negative
Fasting:
- No solid food for 4 hours prior to procedure. - Clear fluids: offered up to 2 hours prior to procedure, then nil by mouth.* The max. intake of clear fluids between 4 and 2 hours preprocedure is 1 litre only.
PLEASE COMPLETE INVASIVE PROCEDURE CHECKLIST AS WELL AS THE IMAGING ONE
Doc
umen
tatio
n
I.P. Checklist Completed Procedure discussed and documented in medical notes
Signature ___________________ Print __________________ Date __ / __ / __ Time ___:___
Ward
UTERINE FIBROID EMBOLISATION__________________________________________________
120 - 400
" Appointment times are approximate, and are subject to change, but we will keep you informed. Please inform us of any problem with this appointment."
Platelets
Surname
First name(s)
Hospital Number
Date of Birth
Appo
intm
ent
INRAPTT
Bloo
d Te
st
Please inform Imaging Department of any abnormal results.
Level Reference level< 1.2
22.0 - 29.0 secs
Date
Preg
. Sta
tus
Diabetic
Dia
bet.
Sta
tus
60 - 125 umol/l
F
astin
g
Creatinine9.0 - 12.0 secsPT
UFE UFE -- Patient preparationPatient preparation
Imaging nurse visits patient prior to Imaging nurse visits patient prior to procedureprocedure
AssessmentAssessment
Patient preparation instructionPatient preparation instruction
AnalgesiaAnalgesia
AntibioticAntibiotic
Nursing documentationNursing documentation
DIRECTORATE OF IMAGINGRADIOLOGY NURSING PROCEDURE RECORD
Date: ________________________________ Name: ___________________________________
Procedure: ____________________________ Hospital No.: ______________________________
Radiologist: ___________________________ D.O.B.: _____________ Age: _____________
Scrub Nurse: __________________________
Anaesthetist: __________________________ Sex: M / F Ward: ____________
Pre-procedure visit/information Yes / No Pre-procedure Assessment
Nurse__________________ Date __________ Name Band checked by: _________________
Blood results Consent obtained: Yes / No
Hb ________ WBC ______ Platelets ________ Pre-medicated: ________________________
PT_________ APTT ______ TT ___________ Allergies: _____________________________
Fib ________ INR ______ Other ___________ Nil by mouth from: ______________________
Language Spoken: English Other___________ Bilateral groin shaved: Yes / No / NA
Translator: Yes / No Translator Present: Yes / No Pedal Pulses: Rt ______ Lt ______
Relevant Medical History Relevant Drugs_______________________________________ _________________________________________
_______________________________________ _________________________________________
_______________________________________ _________________________________________
_______________________________________ _________________________________________
_______________________________________ Drug Sensitivities:___________________________
IV access _______________________________ Diabetic: Yes / No
_______________________________________ Blood Sugar Level: ________mmol/L
Infusions: _______________________________ Asthmatic: Yes / No
________________________________________ Infectious status: ________________________
TIME
Arrival in Radiology ______________________ Started: _____________ Finished: ______________
Ward Called: ____________________________ Collected ____________ Destination ____________
UFE UFE -- Hammersmith HospitalHammersmith HospitalPre Pre --procedureprocedure
Patient admits to wardPatient admits to ward
Seen by radiologist Seen by radiologist -- consent consent
Prepare for procedure e.g. NBM, shavedPrepare for procedure e.g. NBM, shaved
Collected by IA to ImagingCollected by IA to Imaging
Imaging nurse received patient and hand Imaging nurse received patient and hand over from ward nurseover from ward nurse
Check patientCheck patient
Medication Medication -- DiclofenacDiclofenac suppository 100 suppository 100 mgmg
UFE UFE -- Hammersmith HospitalHammersmith HospitalProcedure TechniqueProcedure Technique
Conscious sedationConscious sedationLocal anaesthesiaLocal anaesthesiaFemoral punctureFemoral puncturePelvic arteriogram performed Pelvic arteriogram performed Use of Use of microcathetersmicrocatheters and and guidewiresguidewires to to select uterine arteriesselect uterine arteriesPVAPVAFinal uterine arteriogramFinal uterine arteriogram
UFE UFE -- conscious sedation conscious sedation
AdultAdultSedation policySedation policyTo allow gastric emptying:To allow gastric emptying:
-- Solid food up to 4 hours prior to procedure.Solid food up to 4 hours prior to procedure.-- Clear fluids up to 2 hours prior to Clear fluids up to 2 hours prior to
procedure.procedure.-- Nil by mouth.Nil by mouth.
American Society of Anaesthesiologists Task Force on Sedation anAmerican Society of Anaesthesiologists Task Force on Sedation and Analgesia by nond Analgesia by non--anaesthesiologists (1996) Practice anaesthesiologists (1996) Practice guidelines for sedation and analgesia by nonguidelines for sedation and analgesia by non--anaesthesiologistsanaesthesiologists
UFE UFE -- PeriPeri--procedureprocedure
Conscious sedationConscious sedation
Pain managementPain management
-- pain assessmentpain assessment
Monitor vital signsMonitor vital signs
Comfort and reassuring patientComfort and reassuring patient
DocumentationDocumentation
UFE UFE -- Nursing documentation.Nursing documentation.PERI-OPERATIVE PROCEDURAL OBSERVATIONS
ECG, Blood Pressure, Pulse, Respiration, O2 Saturation, O2, Temperature and Medication Recordings
Date
Time
B 220L 210O 200O 190D 180
170P 160R 150E 140S 130S 120U 110R 100E 90
8070
P 60U 50L 40S 30E 20
100
RespirationO2 Sat %O2 L / MinECG Rhythm
DRUGSLidocaine % mlBuscopan mg
Glucagon mg
Fentanyl mcg
Hypnovel mg
Heparin units
ContrastBatch no
NURSING INTERVENTIONS
Intra Procedure Post Procedure Evaluation
Respiratory Self Ventilating O2 __________ L / minVia Mask Nasal cannula GA Intubated Ventilated
Self ventilating O2 __________ L / min for ______ hr
Chest X-Ray Checked
Cardiovascular Refer to observation chart Infusion: _______________________
---------------------------------------------------
Neurological Conscious levelAwake Drowsy Rousable Specify __________
Conscious levelFully awake Drowsy Orientated Other ________________________
Pain Analgesia Sedation Local Anaesthesia Refer to observation chart
Pain free Comfortable Pain scale 0 – 5: _________(1 = no pain, 2= mild, 3 = moderate, 4 =severe, 5 = unbearable)
Hygiene/Dressing Puncture site:
Femoral artery: Right Left
Jugular vein: Right Left
Puncture site ____________________
Pedal pulses Right Left
Drainage _______________________
Specimens taken_________________
Ultrasound guidance Fluoroscopy
Nursing Documentation_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
Notes and property returned with patient Yes / No
Signature _________________________________ Print Name ____________________________
Date _____________________________________ Time _________________________________
Ward Nurse Signature _______________________ Print Name ____________________________
UFE UFE –– Pain Management During Pain Management During ProcedureProcedure
Pain assessmentPain assessment
MedicationsMedications
-- HypnovelHypnovel IV (IV (MidazolamMidazolam))
-- DiamorphineDiamorphine IVIV
-- ZofranZofran IV (IV (OndansetronOndansetron))
-- ParacetamolParacetamol infusioninfusion
UFE UFE -- Post procedurePost procedure
RecoveryRecovery
Pain managementPain management
AntiAnti--nausea medicationnausea medication
Activities Activities -- bed restbed rest
Education Education -- patients, ward nurse patients, ward nurse
UFE UFE -- Post procedure painPost procedure pain
Start shortly after 2nd uterine is occludedStart shortly after 2nd uterine is occluded
Worsen for 2 hours then plateau for 6Worsen for 2 hours then plateau for 6--8 8 hourshours
Improvement over next 12 hoursImprovement over next 12 hours
Improve over next several daysImprove over next several days
UFE UFE -- Post procedure Pain Post procedure Pain ManagementManagement
DiclofenacDiclofenac 50mg oral 8 50mg oral 8 hrlyhrly
TramadolTramadol 50mg oral 6 50mg oral 6 hrlyhrly
AntiAnti--emetic. emetic. ZofranZofran or or CyclizineCyclizine
UFE UFE -- Post Procedure SyndromesPost Procedure Syndromes
Pyrexia, nausea and vomitingPyrexia, nausea and vomiting
Pelvic painPelvic pain
Could last up to 24 Could last up to 24 -- 48 hours and up to 48 hours and up to
7 days7 days
Worse with large and multiple fibroidsWorse with large and multiple fibroids
UFE UFE -- ComplicationsComplications
Groin haematomaGroin haematomaPelvic painPelvic painUterine infection leading to hysterectomy Uterine infection leading to hysterectomy 0.5 0.5 -- 2%2%Fibroid impactionFibroid impactionPremature ovarian failure (menopause) 1 Premature ovarian failure (menopause) 1 --5%5%NonNon--target organ target organ ischaemiaischaemia2 reported deaths related to infection2 reported deaths related to infection
UFE UFE -- Discharge instructionsDischarge instructions
Femoral instruction site careFemoral instruction site care
Contact numberContact number
FollowFollow--up appointmentup appointment
Pain controlPain control
AntiAnti--emeticemetic
ShowerShower
Nothing in vagina for 2Nothing in vagina for 2--3 weeks (no sexual 3 weeks (no sexual intercourse, no tampon)intercourse, no tampon)
UFE UFE -- BenefitsBenefits
Treats all fibroid simultaneouslyTreats all fibroid simultaneously
Permanent infarction without Permanent infarction without regrowthregrowth
Minimally invasiveMinimally invasive
Preserve options for other therapiesPreserve options for other therapies
Effective in controlling bleedingEffective in controlling bleeding
Significant uterine volume reductionSignificant uterine volume reduction
Shorter recovery times Shorter recovery times
UFE UFE -- Benefits (cont)Benefits (cont)
Clinical success 80 Clinical success 80 -- 94%94%
Average reduction of fibroid volume 41 Average reduction of fibroid volume 41 --64%64%
Reported pregnancy post UFEReported pregnancy post UFE
UFE UFE -- NICE GuidelinesNICE Guidelines
July 2003July 2003
Remains uncertain over safety and Remains uncertain over safety and effectivenesseffectiveness
Both gynaecologists and radiologists are Both gynaecologists and radiologists are involved in the decision to carry out involved in the decision to carry out procedureprocedure
BSIR RegistryBSIR Registry
Systemic reviewSystemic review
UFE UFE -- ConclusionConclusion
Good short term resultsGood short term results
Require long term followRequire long term follow--upup
Need to carry out RCTNeed to carry out RCT
Effect on pregnancyEffect on pregnancy
ReferencesReferences
Walker, WJ Walker, WJ –– Uterine Artery Uterine Artery EmbolisationEmbolisation for Symptomatic Fibroids: for Symptomatic Fibroids: Clinical Result in 400 Women with Imaging FollowClinical Result in 400 Women with Imaging Follow--up up
Siskin, GP et al (2000) Siskin, GP et al (2000) –– Outpatient Uterine Artery Outpatient Uterine Artery EmblisationEmblisation for for Symptomatic Uterine Fibroids: Experience in 49 patients, JVIR 1Symptomatic Uterine Fibroids: Experience in 49 patients, JVIR 11:3051:305--311311
National Institute of Clinical Excellence (NICE) National Institute of Clinical Excellence (NICE) –– Uterine artery Uterine artery embolisationembolisation for fibroids, 2003for fibroids, 2003
Ryan, JM et al (2002) Ryan, JM et al (2002) –– Simplified PainSimplified Pain--Control Protocol after Uterine Control Protocol after Uterine Artery Artery embolisationembolisation, Radiology 2002;224:610, Radiology 2002;224:610--613613