SANDRA SHROFF ROFEL COLLEGE OF NURSING

Subject : obstetrics and gynaecological nursing gynaec Case Study

(PRIMARY AMENORRHOEA with HEMATOCOlPoMETRA)

Submitted To PROFESSOR

Submitted By: Ms. BINI P SAMUEL 1ST Year M.Sc. NURSING.

Mrs. SUDHA PETHE

DATE OF SUBMISSION : /04/13

HISTORY TAKING
I. DEMOGRAPHICAL INFORMATION Name Age Sex Address Religion Marital status Education Occupation Family Income Ward Bed no. Date of Admission I.P No O.P.D. No Diagnosis Surgery Date of surgery Care started Care ended : : : : : : : : : : : : : : : : : : : Miss Varsha Mohan Dubda 13Years Female Sanjan, Kibhariya, Maharashtra Hindu Unmarried 8th Std not working Rs.8000 / month Gynec ward (SVBCH) 3 25/04/13 11527 8681 Primary amenorrhoea with cryptomenorrhoea with hematocolpometra Drainage of hematometra colpos 26/4/2013 25/04/13 28/04/13

II. CHIEF COMPLAINTS (ON THE DAY CARE STARTED): She is being referred from private hospital at Umergaon with USG report suggestive of hematocolpometra, hematosalphinx, right hemorrhagic ovarian cyst. She is being referred to the SVBCH. Her mother complaints of not attended menarche. Miss. Varsha Mohan Dubda came with complaints of lower abdominal pain since 2-3 month and 2-3 episodes of vomiting previous night. III. PRESENT ILLNESS / PRESENT HEALTH STATUS: DAY-1(25/04/13) She came with complaints of abdominal pain. Examination findings Patient conscious, oriented. Vitals Temperature 98.6 oF, Pulse 80beats/min, Respiration- 20breaths/min, BP- 110/70 mmHg. P/A- uterus palpable, abdomen soft and tenderness present at uterine side and around umbilicus. Investigation advised - CBC, urine routine, RFT, RBS, ECG, chest X-ray, - Her Hb was 12.5 gm% and blood group was B +ve. Treatment advised- FD and NBM since midnight as she was posted for the surgery: drainage of hematocolpometra. - Inj. Buscopan 20 mg I.V.Stat. - Physician reference for fitness DAY 2(26/04/13) PATIENTS COMPLAINTS - lower abdominal pain, anxious regarding surgery. FINDINGS Patient conscious, oriented.

Vitals Temperature 98.8 oF, Pulse 82beats/min, Respiration- 22breaths/min, BP- 110/70 mm of Hg. P/A- uterus palpable, abdomen soft and tenderness present at uterine side and around umbilicus - TREATMENT (preoperative orders) - NBM after 10 Pm - Inj T.T. 0.5 ml I.M stat - Consent for surgery - Inj. C-tri 1 gm I/V stat - Shave and prepare parts - Inj. Pantop 40 mg I/V stat - Inj. Emset 4 mg I/V stat - I/V RL from morning 5:00 a.m. OPERATIVE NOTE Surgery : Vaginal dilatation with laprotomy done under spinal anesthesia. Vaginal dilatation done but the orifice of cervix not found, so laprotomy taken. Abdomen opened in layers, peritoneal cavity opened. Haemoperitoneum noted about 200 cc blood suctioned out. Uterus was held with uterine holding forceps. Bladder dissected downward. Nick was kept over vault, blood collected and drained out. One finger was inserted from that orifice and one finger from vagina and orifice was made out. Dilator was inserted in cervix which was kept in situ. Vagina was packed with hemlock soaked roller gauze piece. Abdomen was closed in layers and sterile dressing applied. Postoperative notes: Complaints - pain at surgical side - Per vaginal bleeding Temp: 98.6 F Pulse: 88 beats/mt Resp: 22 breaths/mt BP: 110/70 mmHg TREATMENT (post operative orders) NBM , Head low position Inj. Augmentin 1.2 gm iv bd Inj. Metro100mg iv tds Inj. Emeset 4mg iv bd Inj. Dynapar i.m Inj. Trenexa 500 mg iv diluted Monitoring of Abdominal girth 52 cm DAY 3 (27/4/13) (1st postoperative day) PATIENTS COMPLAINTS -pain over surgical site. FINDINGS P/A abdomen soft. - uterus not palpable as before. - no tenderness. P/V - dark red bleeding present - pack in situation

TREATMENT NBM - TPR/ BP chart Inj. Augmentin1.2 gm I/V BD - Inj. Metro 100 cc I/V TDS - Inj. Pantop 40mg I/V BD - Inj. Emset 4 mg I/V sos - Inj. Voveran 30 mg I/M BD - I/V fluids 1pint RL, 1 Pint 5%dextrose.

DAY 4 (28/4/13) (2nd post operative day) PATIENTS COMPLAINTS - pain Liquids orally allowed, but after drinking sips of water she had vomiting, so nothing given by mouth. FINDINGS TREATMENT Inj. Augmentin 1.2 gm I/V BD P/A soft - Inj. Metro 100 mg I/V TDS - mild pain at surgical side - Inj.Pantop 40 mg iv bd P/V - mild bleeding -Inj. Voveran 30 mg im sos. DAY 5 (29/4/13) (3rd postoperative day) PATIENTS COMPLAINTS - mild pain at surgical site. FINDINGS TREATMENT Liquids orally, Inj. Augmentin 1.2 gm I/V BD P/A soft - Inj. Metro 100 mg I/V TDS - mild pain at surgical side - Inj.Pantop 40 mg iv bd

-Inj. Voveran 30 mg im sos. Vaginal pack removed, dilator removed, mould with condom with placenterax kept in vagina for patency. Dressing twice to be done. IV. PAST HISTORY Medical : she had no history of any communicable disease like HT, DM or IHD any other illness. No allergy to any medication and food Surgical : she has no history of any surgery. V. MENSTRUAL HISTORY

Menarche not attained.

VI. PERSONAL HISTORY - She is from middle class family. She is not having any specific likes and dislikes. She is shy in nature and she is introvert. She is not having allergy to any food or medications. She likes to play and watch T.V. VII.SOCIOECONOMIC HISTORY She belongs to low socioeconomic family. Her father is the only earning member of the family. They are having good relation with society, friends and even with the other patients in the ward. They earns approximately Rs.5000/- per month. VIII.ELIMINATION & BOWEL PATTERN: Bowel she has normal bowel pattern.( once a day) Bladder she complained regarding decreased urine output. IX. ENVIRONMENTAL HISTORY She lives with her family in rural area. They are getting water from the boring or street tap. They have electricity supply and closed drainage system in the house. X. PSYCHO SOCIAL HISTORY: Economic history Mother tongue Language known Cultural Group Mood she belongs to middle class family Hindi Gujarati, Hindi Friends Anxious

XI. NUTRITIONAL HISTORY: She is taking all types of vegetarian food. She does not have any specific likes or dislikes. She takes 3 meals per day. At present patient was NBM since 4 day, then patient is started with liquid diet and then taking full diet. XII FAMILY HISTORY: She belongs to nuclear family. No family history of any disease eg. DM, HT. All family members are healthy. S.No Name Age in years 40 yrs Sex Relation with head of family Head of family Education Occupation Health status

1.

Mr. Mohan Dubda

5th std

Company employee

Healthy

2.

Mrs. Leela Mohan Dubda Mr. Harish Mohan Dubda Ms. Varsha Mohan Dubda

38yrs

Wife

Illiterate

House wife

Healthy

3.

20yrs

Son

Degree 8rd std

Healthy

4.

13 yrs

daughter

Primary amenorrhea with cryptomenorrhoea

Family Tree 40 yrs 13 yrs 38 yrs - male - female 20 yrs - patient

No familial history of delayed menarche.

PHYSICAL EXAMINATION (12/03/13) 1) HEIGHT 2) WEIGHT 3) GENERAL OBSERVATION: a) Constitution b) Stature c) State of Nutrition d) Personal appearance e) Posture f) Emotional stage g) Skin h) Cooperativeness 4) VITAL SIGNS: Temperature Pulse Respiration Blood pressure HEAD a) Scalp b) Hair c) Movements of the head EYES a) Eye lids/Eye lashes : No lesion or infection : : : clear, no injury scar. Dandruff present. Black , hair equally distributed. Full range of movement : : : : 98.6oF 80 beats/min 22 breaths/min 110/70 mm of Hg : : : : : : : : thin body built Normal Poor Clean Good Anxious Pink Cooperative : : 135 CMS 36 KGS

5) HEAD TO TOE ASSESSMENT:

b) Conjunctiva c) Pupils e) sclera f) abnormal discharge g) vision EARS a) congenital anomalies b) Discharge c) Hearing d) Lesion NOSE a) Appearance b) Discharge c) Polyps MOUTH AND THROAT: a) Lips b) Tongue c) Teeth d) Gums e) Tonsil NECK: a) Range of movement b) Carotid pulse c) Lymph node d) Thyroid gland e) Cyst and tumor

: : : : :

pink PERRLA white not present normal

: : : :

Not present absent Normal Absent

: : :

No Septal deviation No Not evident

: : : : :

Dry No glossitis or coated tongue Dental carries present. No Gingivitis No swelling of redness.

: : : : :

Normal felt No enlargement Feel smooth and firm Absence

CHEST AND RESPIRATORY SYSTEM: a) Inspection : Size and shape normal, chest expansion equal in both side and respirations are normal. Small breast nodules d) Auscultation BREAST Inspection Size Shape Areola Skin of breast Nipple : : : : : small symmetrical primary areola present no any other changes flat : Breath sounds are normal, normal resonance sound on both side. Respiratory rate 20 bpm, S1 and S2 heart normal, HR- 80 bpm.

Palpation : ABDOMEN:

soft, no any abnormal mass.

Abdominal girth

: 38 cm

a) Inspection :

No any previous surgical scar is visible. Muscle tone intact. Contour normal. Visible

mild swelling at lower abdomen over uterus side. b) Palpation : palpable swelling and tenderness at uterine side. Tenderness around the umbilicus. GENITALIA:, No any bleeding or discharge present. No complaints of itching. UPPER EXTREMITIES: Normal movement, No deformities, No lymph node enlargement LOWER EXTREMITIES Normal movement. No edema. Patients value

INVESTIGATIONS:
Sl. No. 1)

Investigations Blood Hemoglobin

Total W.B.C Differential count Neutrophills Lymphocytes Eosinophils Monocytes Basophils Platelets count

Normal value

Remarks

12.5 gm/dl
12,600 cells / cumm 73% 24% 02% 01% 00% 5.30 lacs / cumm 101 mg/dl

11 13 gm/dl
5,000 13,000 cells/ cumm 30-70% 20-40% 1-6 1-08 2% 150000-400000 /cumm 80-120 mg/dl

Normal
Normal

Normal Normal Normal Normal Normal

Normal Normal

RBS 2) RFT Blood urea Serum creatinine Serum uric acid HbsAg HIV Blood group

17 mg/dl 0.9 mg/dl 2.4 mg/dl Negative Negative B +ve

10-50 mg/dl 0.6-1.2 mg/dl 2.60-6.00 mg/dl

Normal Normal Normal

Urine routine examination 3) pH Specific Gravity Quantity Color 4) Appearance ChemicalExamination Protein Glucose Ketones Blood Bile Salt Bile Pigment Urobilinogen

Acidic 1.020 15ml Pale Yellow Clear Nil Nil Nil Nil negative negative Nil Nil

1.016-1.025

Microscopic examination RBC WBC/Pus cells Epithelial cells Casts Crystals Amorphous materials Bacteria

Nil 2-3/hpf 1-2/hpf Absent Absent Absent Trace

ECG: within normal limit. Chest x-ray : normal Ultrasonography (abdomen):

IMPRESSION hematocolpometra, hematosalphinx, right hemorrhagic ovarian cyst.

DAYWISE TREATMENT - FD Inj. Buscopan I.V.Stat. Physician reference for surgery fitness (26/04/13) (preoperative orders) - NBM after 10 Pm - Consent for surgery - Shave and prepare parts - Inj T.T. 0.5 ml I.M stat - Inj. C-tri 1 gm I/V stat - Inj. Pantop 40 mg I/V stat - Inj. Emset 4 mg I/V stat - I/V RL from morning 5:00 a.m. (25/04/13)

postoperative order NBM Inj. Augmentin 1.2gm I/V BD - Inj. Metro 100 cc I/V TDS - Inj. Pantop 40mg I/V BD - Inj. Trenexa 500mg iv diluted - Inj. Voveran 30 mg I/M BD - I/V fluids 1pint RL, 1 Pint 5% dextrose. nd (27/4/13 & 28/4/13) (2 & 3rd post operative day) TREATMENT Inj. Augmentin 1.2 gm I/V BD - Inj. Metro 100 cc I/V TDS - Tab. Rantac 150mg P/O BD - Tab. Diclofenac 500mg sos.

MEDICATION:
Sl. No Name of Route Medication Dose Freq BD Class Action Indication - Lower respiratory tract infections - urinary tract infection - skin & skin structure infections - uncomplicated cervical/urethral and rectal onorrhea. - PID - Bacterial septicemia - serious infection by anaerobic bacteria - peritonitis - skin and skin structure infections. - endometritis - bacterial septicemia - bone and joint infections - meningitis and brain abscess - amebiasis - Prophylaxis in postoperative period - diarrhea - crohns disease contraindication -hypersensitivity to cephalosporins or related antibiotics, Side effects -Hypersensitivity -rash - eosinophilia - diarrhea - pain, induration, tenderness, warmth at injection site. Nurses responsibility - ask for hypersensitivity of icephalosporin group. - Watch for side effects - Should be given slowly with adequate dilution - monitor CBC, platelets, PT, BS renal and LFTs. -monitor I/O chart.

1.

Inj. Augmentin

I.V

1.2g m

Cephalospo It interefer with the final step in the rin, third generation formation of the
bacterial cell wall, resulting in unstable cell membranes that undergo lysis. Also cell devision and growth are inhibited. Most affective against rapidly dividing & young organisms and are considered bactericidal.

2.

Inj. Metrogyl (metronidazo le)

I.V

100 mg

TDS

- Trichomon acide - Amebicide

Inhibit bacteria and protozoa. Specifically inhibit growth of trichomonae and amoebae by binding to DNA, resulting in loss of helical structure, strand breakage, inhibition of nucleic acid synthesis, and cell death.

- blood dyscrasias - active organic disease of CNS - trichomoniasis in first trimester of pregnancy or lactation - hypersensitivity to drug

Vomiting, stomach upset, diarrhea -loss of appetite -dry mouth or sharp, unpleasant metallic taste -dark or reddishbrown urine, furry tongue or mouth or tongue irritationnumbness or tingling of the hands or feet

Assess the vital signs. Special precautions, if you have or have ever had blood, kidney, or liver disease or Crohn's disease. -remember you should not drink alcoholic beverages while taking metronidazole. Alcohol may cause an upset stomach, vomiting,abdominalc ramps, headache, sweating, and flushing.

3.

Inj Pantop (Pentaprazol e sodium)

IV

40 mg

BD

Proton pump inhibitor

It suppresses the final step in gastric acid production by forming a covalent bond to two sites of the H+/K+ATPase enzyme system at the secretory surface of gastric parietal cells. Results in inhibition of both basal and stimulated gastric acid secretion.

-erosive gastritis associated with GERD. - long term treatment of pathological hypersecretory conditions. - treat duodenal ulcer.

- Hypersensitivity to any components of the formulation. - Lactation.

Gastro-intestinal complaints such as upper abdominal pain, diarrhoea, constipation or flatulence, headache

Assess the vital signs. Monitor liver function regularly (if enzymes increase, discontinue) because it may lead to liver damage.

4.

Inj. Rantac (Ranitidine hydrochloride)

I.V.

50 mg

TDS

Histamine Competitively inhibit - duodenal ulcer H2 receptor gastric acid secretion - active benign antagonist by blocking the effect gastric ulcer of histamine H2 -GERD receptor. erosive esophagitis - peptic ulcer -relief of heartburn due to indigestion or sour stomach

- cirrhosis of liver - impaired renal and hepatic function - use with caution in lactation and in elderly

- Headache, - abdominal pain - insomnia - diarrhoea - flatulence - constipation -nausea and vomiting -

-Do not confuse with rimantadine -May take with or without food. - To report severe diarrhoea, drug may have a discontinued. - instruct patient to take with or immediately following meals. - avoid alcohol, aspirin containing products and baverages that contain caffeine. -report any evidence of yellow discolouration

5.

Inj Emset (ondansetron hydrochloride)

I.V.

4 mg

TDS

Antiemetic

Ondansetron blocks the 5-ht3 antagonists, blocks the effect of serotonin

- Prevent nausea & vomiting associated with chemotherapy & radiotherapy - postoperatively to avoid nausea & vomiting

Use with caution curing lactation

6.

Inj. Voveran (diclofenac sodium injection)

I.M.

30 mg

TDS

NSAID

Anti-inflammatory effect is likely due to inhibition of the enzyme cyclooxygenas That result in decrease prostaglandin synthesis. Analgesicn due to relief of inflammation

Rheumatic inflammatory disease Non rheumatic inflammatory conditions mild to moderate pain e.g.sprain, strain, dental pain Primary dismenorhoea - pregnancy - given earlier in routine childhood immunization - after any injury -

- children under 14 years -lactation - acute asthama -urticaria -bronchospasm -hepatic porphyria

Diarrhea, malaise headache, fatigue dizziness, constipation, bradycardia, drowsiness, sedation, hypoxia, anxiety, pruritus, pyrexia, shivers. headache, dizziness, abdominal pain, cramps, nausea, diarrhea, constipation, dyspepsia.

It should be given exactly at prescribed time. Assess for any side effects Report rash if persist. Do not confuse with Zoloft an antidepressant Advise to take with meal, or full glass of water if G.I. upset occur. Do not crush or chew tablet. Maintain fluid intake,

7.

Inj. T.T. I.M. (tetanus toxoid injection)

0.5 ml

stat

vaccine

This medication is given to provide (immunity) against tetanus (lockjaw) in adults and children 7 years or older. Vaccines work by causing the body to produce its own protection (antibodies

- hypersensitivity - bleeding disorder - gullian berre syndrome - neurological disease - less than 7 years of age

fever, redness, swelling around the injections, and soreness or tenderness around the injection site.

- administer deep intramuscularly - use five R of giving medication - use aseptic technique for giving injection. - if possible mote than 1 inch needle.

8.

Inj. Trenexa

iv

500 mg

tds

Antifibrinol ytic

9.

Inj. I.V Buscopan (Hyoscine butylbromide injection)

20m g

stat

Antispasmodic. Anticholinergic Cervical relaxants

Hyoscine has selective spasmodic effect in the parasympathetic innervations of the cervical os. - one of the belladonna alkaloids; acts by blocking the action of acetylcholine at the postaglandinic nerve endings of the parasympathetic nervous system.

- Hypermotility in spastic, colitis, spastic bladder, cystitis, - pylorospasm, and associated abdominal cramps. -irritable bowel sundrome. - parkonsinism - preoperative medication to reduce saliva, tracheobronchial and pharyngeal secretions. - reduce motility before diagnostic procedure.

allergic to hyoscine or any ingredients of this medication are allergic to other atropinics (e.g., atropine, scopolamine) have myasthenia gravis, megacolon (enlarged colon), glaucoma, orobstructive prostatic hypertrophy (enla rged or blocked prostate) are receiving this medication as an intramuscular injection and are taking a blood thinner medication (e.g., warfarin, heparin) have narrowing of the gastrointestinal tract, a fast heartbeat, angina, or heart failure

- dry mouth - drowsiness - flushing of face - headache -blurred vision -photosensitivity -constipation - decreased perspiration - thirst

- give as prescribed - do not give antacid within 1 hour of giving drug -report any loss of symptom control so dose can be adjusted -advise patient to avoid excessive temperament and activity - males with enlarged prostate may experience urinary retention -stop drug and report if any mental confusion, impaired gait, disorientation, or hallucination.

ANATOMY AND PHYSIOLOGY AMENORRHOEA

Definition : Amenorrhoea is the absence of a menstrual period in a woman of reproductive age. Physiological states of amenorrhoea are seen during pregnancy and lactation (breastfeeding), the latter also forming the basis of a form of contraception known as the lactational amenorrhoea method. Outside of the reproductive years there is absence of menses during childhood and after menopause. Amenorrhoea is a symptom with many potential causes. Primary amenorrhoea (menstruation cycles never starting) may be caused by developmental problems such as the congenital absence of the uterus, failure of the ovary to receive or maintain egg cells, and genetic diseases such as 5alpha-reductase deficiency which causes one to be intersex. Also, delay in pubertal development will lead to primary amenorrhoea. It is defined as an absence of secondary sexual characteristics by age 14 with no menarche or normal secondary sexual characteristics but no menarche by 16 years of age. Secondary amenorrhoea (menstruation cycles ceasing) is often caused by hormonal disturbances from the hypothalamus and the pituitary gland, from premature menopause or intrauterine scar formation. It is defined as the absence of menses for three months in a woman with previously normal menstruation or nine months for women with a history of oligomenorrhoea. CLASSIFICATION There are two primary ways to classify amenorrhoea. Types of amenorrhoea are classified as primary or secondary, or based on functional "compartments" (Speroff). The latter classification relates to the hormonal state of the patient that could be hypo-, eu-, or hypergonadotropic (meaning FSH levels are either low, normal or high). By primary vs. secondary: Primary amenorrhoea is the absence of menstruation in a woman by the age of 16. As pubertal changes precede the first period, or menarche, women by the age of 14 who still have not reached menarche, plus having no sign of secondary sexual characteristics, such as thelarche or pubarchethus are without evidence of initiation of puberty are also considered as having primary amenorrhoea.

Secondary amenorrhoea is where an established menstruation has ceasedfor three months in a woman with a history of regular cyclic bleeding, or nine months in a woman with a history of irregular periods. This usually happens to women aged 4055. Amenorrhoea may cause serious pain in the back near the pelvis and spine. This pain has no cure, but can be relieved by a short course of progesterone to trigger menstrual bleeding.

By compartment: The reproductive axis can be viewed as having four compartments: 1. outflow tract (uterus, cervix, vagina), 2. ovaries, 3. pituitary gland, and 4. hypothalamus. Pituitary and hypothalamic causes are often grouped together.

P/S

Outflow tract anomalies/obstruction

Gonadal/end-organ disorders The ovary or gonad does not respond to pituitary stimulation. Gonadal dysgenesis or premature menopause are possible causes. Chromosome testing is usually indicated in younger individuals with hypergonadotropic amenorrhoea. Low oestrogen levels are seen in these patients and the hypooestrogenism may require treatment. Gonadal, usually ovarian, abnormalities tend to be linked to elevated FSH levels or hypergonadotropic amenorrhoea. FSH levels are typically in the menopausal range.

Pituitary and hypothalamic/central regulatory disorders Generally, inadequate levels of FSH lead to inadequately stimulated ovaries which then fail to produce enough oestrogen to stimulate theendometrium (uterine lining), hence amenorrhoea. In general, women with hypogonadotropic amenorrhoea are potentially fertile. Both hypothalamic and pituitary disorders are linked to low FSH levels leading to hypogonadotropic amenorrhoea.

Overview

The hypothalamic-pituitary-ovarian axis is functional.

FSH

Outflow tract abnormalities tend to be normogonadotropic and FSH levels are in the normal range.

Uterine: Mullerian agenesis (Second most common cause, 15% of

Primary

primary amenorrhoea)[5] Vaginal: Vaginal atresia,cryptomenorrhoea,imperforat e hymen.

Gonadal dysgenesis, including Turner syndrome, is the most common cause. Androgen insensitivity syndrome (Testicular feminization syndrome) Receptor abnormalities for hormones FSH and LH Specific forms of congenital adrenal hyperplasia Swyer syndrome Galactosaemia Aromatase deficiency Prader-Willi syndrome Male pseudo-hermaphroditism (about 1 in every 150,000 births) Other intersexed conditions

Hypothalamic: Kallmann syndrome

Secondary

Intrauterine adhesions (Asherman's syndrome)

Pregnancy (most common cause) Anovulation Menopause Premature menopause Polycystic ovary syndrome (PCO-S) Drug-induced

Hypothalamic: Exercise amenorrhoea, related to physical exercise, stress amenorrhoea, eating disorders and weight loss (obesity, anorexia nervosa, or bulimia) Pituitary: Sheehan syndrome, hyperprolactinaemia,haemochromatosis Other central regulatory: hypothyroidism, hyperthyroidism,arrhe noblastoma

CRYPTOMENORRHOEA
DEFINITION Cryptomenorrhea or cryptomenorrhoea, also known as hematocolpos, is a condition where menstruation occurs but is not visible due to an obstruction of the outflow tract. Specifically the endometrium is shed, but a congenital obstruction such as a vaginal septum or on part of the hymen retains the menstrual flow. A patient with cryptomenorrhea will appear to have amenorrhea but will experience cyclic menstrual pain. The condition is surgically correctable. The patient usually presents at the age of puberty when the commencement of menstruation blood gets collected in the vagina and gives rise to symptoms. ETIOLOGY Book picture CONGENITAL - Imperforated hymen due to failure of disintegration of the central cells of the mullerian eminence that projects into the urogenital sinus - Transverse vaginal septum due to failure of canalization of the fused mullerian ducts and the urogenital sinus. - Atresia of upper- third of vagina and cervix ACQUIRED - Stenosis of the cervix following amputation, deep cauterization and conisation. - Secondary to vaginal atresia following neglected and difficult vaginal delivery. PATHOPHYSIOLOGY periodic shedding of the endometrium and bleeding obstruction in the passage may be congenital or acquired menstrual blood fails to come out from the genital tract accumulation of blood in the vaginal cavity behind hymen & it distend the vagina ( haematocolpos) extension of accumulation upto uterus and uterine cavity dilate (haematometra) if neglected blood may enter in the tubes and distend the tube block the fimbrial ends distention of tubes by blood Haematosalpinx Patient picture

CLINICAL MANIFESTATION Book picture At the age of 13-15 chief complaints are - Periodic continuous lower abdominal pain - Primary amenorrhoea - Urinary symptoms like frequency, dysuria, and even retention of urine. Per abdominal examination - Suprapubic swelling Vulval inspection - Tense bulging membrane of bluish colouration Rectal examination - Buldged vagina Amenorrhoea dated back from the events Pelvic examination reveal the offending lesion in the vagina or cervix Patient picture

DIAGNOSTIC EVALUATION ( laboratory investigation)

S.No 1. Book picture Abdominal USG - CBC - RFT - URINE ROUTINE - RBS - HIV & HBs Ag - ECG - Chest X-ray Patient picture

MANAGEMENT
S.No Book picture 1. Surgical management- cruciate incision is made in the hymen. The quadrant of the hymen are partially excised not too close to the vaginal mucosa. Spontaneous escape of the dark tarry coloured blood is allowed. Antibiotic treatment Dilatation of the cervix in stenosis Transverse vaginal septum can be treated with Z-plasty Blind vagina will require a partial or complete vaginoplasty Hematosalpinx may require laprotomy or laparoscopy for removal and reconstruction of affected tube Patient picture

2. 3. 4. 5. 6.

COMPLICATIONS:
S.No Book picture 1. 2. 3. 4.
hematometra (collection of blood in the uterine cavity) hematosalpinx (collection of blood in fallopian tubes) endometriosis in long-standing cases in severe, untreated forms, infertility and urinary retention

Patient picture

DIET PLAN
CALORIE REQUIREMENT CALCULATION Height: 135 cm Weight: 36 kg Age: 12 yrs

BMR=66.47+13.75(w)+5.0(H)+6.76(A) = 66.47+13.7536+5.0135+6.7612 = 66.47+ 495+675+81.12 = 1317.59 Kcal

Time 8:00 am Menu Tea Bread slice Amount 1 cup (100ml) 1 Calories 36 60 Protein (gram) 1.4 10 Fat (gram) 1.6 1.8 Iron (mg) 0.65 Calcium (mg) 0.06 0.003

12:30pm

Rice Dal roti mixed veg. curry Tea Salted biscuit roti mutter curry Tea puri Total

1 vati 1 cup 2 1 vati 1 cup (100 ml) 2 2 1 vati 1 cup (100ml) 1

200 118 160 210 36 40 160 200 36 63 1319 kcal

6.0 6.0 5.0 15.8 1.4 4.4 5.0 12 1.4 3.6 72

10.9 10.9 5.5 19.94 1.6 1.6 5.5 112 1.6 6.8 59.34

3.8 3.8 5.3 15.7 5.3 0.4 1.0 35.95

0.004 0.14 0.04 27

5:00 pm

0.06 0.02 0.05 0.06 0.014 27.451

8:00pm

8:00 am

APPLICATION OF THEORY ( FAYGLENN ABDELLAHS NEED ORIENTED THEORY)

MAJOR ASSUMPTION

1. PERSON Miss. Varsha Mohan Dubda is at age of 13 years. She is diagnosed as primary amenorrhoea with cryptomenorrhoea with hematometracolpos. Patient is having physical, Emotional and sociological needs. 2. ENVIRONMENT Persons surrounding environment is Hospital, Nursing Staff, Family member other patients. 3. HEALTH Patient is having primary amenorrhoea with crypyomenorrhoea with hematometracolpos. Patient is having small vaginal pouch. 4. NURSE - Preoperative diagnosis Pain related to distention of vagina and uterus as evidence by pain scale 7/10 and verbalization Anxiety related to surgical procedure as evidenced by verbalization and anxious look. Imbalance nutrition less than body requirement related to poor economy as evidence by verbalization - Postoperative diagnosis Pain related to surgical incision as evidence by pain scale 8/10 and verbalization. Self care deficit related to pain and surgery as evidence by verbalization Knowledge deficit related to lack of exposure as evidence by verbalization. Risk for infection related to lack of information and presence of surgical incision & I.V. intraceth. SUMMARY Patient is having congenital cryptomenorrhoea with hematometrocolpos. She is having acute pain. Patient is in preoperative phase and she is planned for surgery that is drainage of hematocolpos under general anesthesia. - Reduce the patient and parents fear and anxiety related to surgery and outcome of disease condition. - explained about future requirement for reference.

THEORY APPLICATION
PERSON Name Miss. Varsha Mohan, Age- 13 yrs Diagnosis- Primary amenorrhoea with cryptomenorrhoea with Colpohematometra ENVIRONMENT Ward ,Father, nurses, doctors, other patients Comfort, Hygiene and Safety 1. Hygiene and Physical comfort Health Patient is not able to sleep because of pain at surgical site. - Bleeding from vagina Nurse Advice the patient to take rest and gave analgesic drugs. Activity and rest Health Patient do not able to perform activity because of pain. Nurse help patient in her daily activity. Kept required things near to her. 3. Safety Health Patient at risk of infection because of surgery, presence of intracath and low nutritional status. Nurse- Advice the patient to keep perineal area clean. Wear clean pads and change it frequently. Administer antibiotic Physiological changes 1. Nutrition Health- Patient has poor nutritional status. Nurse advice the patient to take High protein, Iron containing nutritious diet. 2. Elimination Health - Patient has risk of urinary tract infection. Nurse- given perineal care changed pad and advice to Maintain good perineal hygiene. 3.Fluid and electrolyte Health Patients fluid and electrolyte balance is maintained. Psychological and social factor 1. Response to Disease Health Patient is anxious and tense as she is alone in hospital and she is unknown about the condition Nurse Advice the patient to take help of staff member whenever needed. Advice her mother to be with her. Explain about menstruation and its hygiene. 2. Regulatory mechanism Health normal outflow of menstrual can be achieved as vaginal canal is formed. - Pain can be reduced with analgesic. Nurse check the amount of blood. 3. Feeling and Reaction Health Patient is having fear and anxiety related to disease condition. Nurse Reduce the fear and anxiety of the patient by explaining positive effect of treatment. Sociological and community factor 1. Emotions and illness Health Patient is not talking much. Patient is alone in ward. worried about the disease condition. Nurse Informed her about disease condition in her language and gave information about menstrual cycle. 2. Therapeutic Environment Health Patient is taking treatment from the hospital. Nurse Nurse, Doctor and her Father is providing care to the patient. E N V I R O N M E N T

E N V I R O N M E N T

ENVIRONMENT (ward, Family member, hospital, nurses, doctors )

HEALTH EDUCATION PLAN: S.No 1 Topic Hygiene Education Bathing- advised her to take daily bath with adequate perineal wash. Advice her to use pad, or clean clothes during menstruation and maintain cleanliness of perineal area. 2. Dietary management To take iron rich diet as she is in adolescent period. Good sources of iron are beef, whole meal bread and cereals, eggs, spinach and dried fruit. Supplementing the diet with iron, vitamins and especially folic acid. A combined iron and folic acid supplements is very useful. To absorb the maximum amount of iron from the diet and for healing, it will help to eat a diet rich in vitamin C. Raw vegetables, potatoes, lemon, lime and oranges are all good sources of vitamin C. Advice her mother to give protein rich diet for her adequate growth. Advised her parents to bring her for follow up on given date. Advised her parents to take physician and obstetrician opinion for her further management.

3. Follow -up
1. 3

4.

General advice 2.

advice her mother to be with her as first time she is having this type of experience. - be careful with her renal function as she is having absence of right kidney and enlarged left kidney. - gave information about need of future surgery and consultation.

List of nursing diagnosis - Preoperative diagnosis Pain related to distention of vagina and uterus as evidence by pain scale 7/10 and verbalization Anxiety related to surgical procedure as evidenced by verbalization and anxious look. Sleep disturbance related to hospitalization and pain as evidenced by verbalization. Imbalance nutrition related to anorexia as evidenced by less body weight secondary to hospitalization. - Postoperative diagnosis Pain related to surgical incision as evidence by pain scale 8/10 and verbalization. Self care deficit related to pain and surgery as evidence by verbalization Knowledge deficit related to lack of information as evidence by verbalization. Risk for infection related to surgical incision and presence of I.V. intracath.

Theory applied
For Miss. Varsha Mohan I am going to provide care by applying. Fayglenn abdellahs theory

Assessment
Sub. data : Patient complaints about pain in lower abdomen. Obj data : Visible swelling at the suprapubic area. - On palpation tenderness is present at suprapubic area and uterus is palpable upto below the umbilicus. Sub. data : Patient is asking about type of surgery, its duration etc. Obj data : Patients looks anxious and verbalize that I am having too much fear about surgery.

Diagnosis
Pain related to distention of vagina and uterus as evidence by pain scale 7/10 and verbalization

Objective
Patient will experience less pain as evidenced by verbalization of decreasing pain levels.

Interventions
- assess the general condition of patient - assess the pain and discomfort. - explain about reason and its management - provide the comfortable position, assist in her work - provide non pharmacological Measures. - Use diversional activities - administer antispasmodic drugs as per doctors order.

Implementations
- Assessed the general conditions of the patient. - Assessed the pain, tenderness & discomfort. Pain scale was 7/10 - Explained the reason at her understanding level and inform about complete recovery from pain after surgery. - Provided the sideline position as patient is feeling some comfort in this position. - Use diversional activities such as watching TV or talking to other patient and family members. - Provided back massage - Administered Inj Buscopan 20 mg I.V.at 10:00 am

Evaluation
Sub evaluation : Patient verbalizes that she is felling little comfortable after providing warm applications -pain is not reduced much. Objective evaluation : Patient is look little comfortable than before but still tenderness is present.ing comfortable.

For Miss. Varsha Mohan I am going to provide care by applying. Fayglenn abdellahs theory

Anxiety related Patients will verbalize of to surgical less anxiety procedure as evidenced by verbalization and anxious look.

- provide clear information about surgery and ascertain for cope up - accompany patient - advice mother to be with her. - give consolation - advice to clear doubts from doctor or staff nurse.

- provide information about surgery and its duration in her language and at her understanding level. - ascertain for patients understanding for outcome of her surgery. - accompany patient upto O.T. and introduce her to O.T. staff of preoperative area. - advice mother to be with her till she will go for surgery. - Gave psychological support and allow her to cope by her own manner - Advised to consult obstetrician or staff nurse if any doubt about surgery is there in their mind.

Subjective evaluation Patient verbalizes for reduced level of anxiety. Objective evaluation Parents and patient still have some anxiety.

Theory applied
For Miss. Varsha Mohan I am going to provide care by applying. Fayglenn abdellahs theory

Assessment
Sub. data : Patient complaints of not getting sleep during night because of pain. Obj. data Patient complaints of improper sleep at night because of pain. patient does not look fresh in morning and feel sleepy during day time.
Subjective data: Patient complaints of weakness and not feeling to eat food Objective data: Patient is not eating adequate food. weight is 36 Kg. only

Diagnosis
Sleep disturbances related to hospitalization and pain as evidenced by patients verbalization

Objective
Patient will not sleep during day time and looks fresh.

Interventions
- observe for underlying cause of disturbed sleep - determine level of pain - provide measure to assist with sleep - keep environment quiet -give sleep protocol

Implementations
- pain is the reason in my patient for sleep disturbance. - provided information about her surgery and reason for pain to reduce anxiety -advice patient to verbalize her anxiety and use diversional therapy. - explained effect of not sleeping on her health. - try to provide quiet environment by reducing noise producing events in ward. - advice patient to take short nap before routine working hours of wards. - advice patient to take luke warm milk if possible.

Evaluation
Subjective evaluation Patient verbalize for getting good sleep during yesterday night. Objective evaluation Patient looks fresh in morning. Patient is not feeling sleepy during daytime.

For Miss. Varsha Mohan I am going to provide care by applying. Fayglenn abdellahs theory

- patient will Imbalance progressively nutrition less gain weight than body requirement related to anorexia as evidenced by less body weight secondary to hospitalization.

- determine healthy body weight for age and height. - Provide companionship at mealtime - weigh client weekly under same condition - monitor food intake. Consult dietician for actual calorie requirement. - monitor state of oral cavity - advice for environment change.

- Patients weight is 36 Kg which is less according to her height. -provided food in attractive manner and advice mother to be with her and if possible feed her. - Patient is taking less food than requirement. So advice mother to give small feed in between. - Took diet plan from dietician and hand over to mother. - oral hygiene is poor. So advice to maintain oral hygiene. - advice mother to take her out for meal with permission of staff..

Objective evaluation Patient eats given food. She shows interest in eating with companion. Oral hygiene improved. Appetite improved.

Post- operative care plan Theory applied

For Miss. Varsha Mohan I am going to provide care by applying. Fayglenn abdellahs theory

Assessment
Sub. data : Patient complaint of pain at surgical site. Objective data Patient is not allowing for any examination.

Diagnosis
Pain related to surgical incision as evidence by pain scale 8/10 and verbalization

Objective
Patient will experience less pain as evidenced by verbalization of decreasing pain levels.

Interventions
- assess the general condition of patient - assess the pain and discomfort. - provide the comfortable position provide extra pillows - , assist in her work - Use diversional activities - give consolation. - administer analgesics drug as per doctors order.

Implementations
- Assessed the pain & discomfort. Pain scale was 8/10 - Provided the semifowler position with additional pillows. patient is feeling comfortable in this position. - Assist he in changing perineal pad. - use diversional activities such as watching TV or talking to other patient and family members. - Provided information that this pain will be for short time and reduce gradually. - Administered Inj Voveran 30 mg I.M. at 1:00 pm

Evaluation
Sub evaluation : Patient verbalizes that pain reduced after 1 hour Objective evaluation : Patient is allowing to assess for amount and type of bleeding. look little comfortable than before but still tenderness is present.ing comfortable. Sub evaluation : Patient verbalize for feeling fresh. Objective evaluation : Patient looks clean and fresh. - Patient assures that she will maintain good hygiene.

For Miss. Varsha Mohan I am going to provide care by applying. Fayglenn abdellahs theory

Sub. data : Patient verbalize that I can not perform my routine work.. Objective data Patient has not change the clothes or perineal pad.

Self care deficit related to pain and surgery as evidence by verbalization

Patient will perform her activity with assistance of caregiver.

- assess the clients ability to perform - help to perform daily activities - explain importance of hygiene

- patient can perform activity within bed with help - help the patient in brushing, bathing, changing clothes combing of hair and other activities. - provided perineal care with all aseptic measures. - explained the importance of cleanliness for good health and for prevention of infection at surgical site.

Theory applied
For Miss. Varsha Mohan I am going to provide care by applying. Fayglenn abdellahs theory

Assessment
Sub. data : Patients mother ask question about her treatment and outcome of surgery Obj. data Patients mother looks tense and worried.

Diagnosis
Knowledge deficit related to lack of information as evidence by verbalization.

Objective
Patients mother verbalize for understanding of information.

Interventions
- determine mothers knowledge. - determine the mothers understanding level - use pictures to explain treatment and outcome - help the family to identify resources for continuing information and support

Implementations
- assess Knowledge available with patients mother. She has incomplete information about her daughters management. - mother can understand with simple explanation. - used picture for her doubt clearing. - advice them to meet obstetrician of ward staff for their doubts or problem and take their help.

Evaluation
Subjective evaluation Patients mother verbalize for decreased tension about her daughter. Objective evaluation Patients mother thanked for providing information. looks less worried.

For Miss. Varsha Mohan I am going to provide care by applying. Fayglenn abdellahs theory

Objective data: Patient has surgical wound and intracath for I.V. injection.

Risk for infection related to surgical incision and presence of I.V. intraceth.

patient will show no signs of infection as evidence by vitals, ESR, and WBC within normal limit and no increase in pain and discomfort.

- assess wound line - monitor vital signs - assess for signs of infections - monitor WBC and ESR count - Administer prescribed antibiotic - maintain aseptic technique for all nursing procedure - advice to maintain personal hygiene

- Assessed the general conditions of the patient and Monitor patients vital signs. - WBC and ESR count compared with previous report. - Administered Inj. C-tri1gm, Inj. Metrogyl 500 mg I.V. at 11:00 am - Advice to take daily bath and maintain perineal hygiene & wear clean clothes

No signs of infection present as patients vitals ESR, WBC are within normal limit. Patient verbalize for reduction in pain.

PROGNOSIS: DAY-1 perform physical examination of patient carry out pre- operative orders and accompany patient up to operation theatre. prepare patient physically and psychologically for operation. DAY-2 Done post operative assessment of patient. Assess for pain & bleeding Monitored vitals & administered Inj C-tri l gm, Inj. Metrogyl 500 mg I.V. and Inj. Voveran 30 mg I.M. Provide perineal care to patient with all aseptic precautions. Teach the patients mother about perineal care. Educated patients mother regarding diet in rich sources of Protein, iron and vitamin-c.

DAY-3 Assess for pain & bleeding Monitored vitals & administered Inj Augmentin 1.2 gm. Inj. Metrogyl 100 m.g I.V. and Inj. Voveran 30 mg I.M. Provide perineal care to patient with all aseptic precautions. Educated patients mother regarding regular follow up to maintain good health. Explain her regarding positive outcome of surgery.

SUMMARY :

My Patient Miss Varsha Mohan came with complaints of lower abdominal pain and menarche not attained. I have attended her on 1st day of her hospitalization. Patient was stable and NBM as she is posted for surgery on that day. Done physical examination of patient and accompany her upto operation theatre. On 1 st postoperative day do assessment and gave perineal care and assist patient for her daily activity. On the last day of my care I have given health education regarding importance of follow up care, diet, rest, and personal hygiene and advice her to be more attentive for her menstruation.
CONCLUSION :

During my clinical posting in SVBC Hospital at Vapi, I got chance to provide care to Miss. Varsha Mohan with diagnosis of primary amenorrhoea with cryptomenorrhoea with colpohematometra. By this study I learn in detail about cryptomenorrhoea with colpohematometra and its surgical management. I thank my client for her cooperation and my clinical coordinator for her valuable guidance.

BIBLIOGRAPHY: 1. Dr Dawn C. S.. Textbook of Gynaecology, contraceptives & reproductive & demography .16th edition. Kolkata: Smt. Arati Dawn, Debabrata Dawn publishers;2004.chapter.10.p.77 2. Dutta D.C., Textbook of Gynaecology, 6th Edition, India: published by new central book agency; 2004. Page no.413-415. 3. Howkins & Bourne, Textbook of Gynaecology, 13th edition, Reed Elsevier Private Limited, Delhi; 2006. Page no. 279-80 4. Jeffcoates, Principles of Gynaecology. 7th edition, Jaypee Brothers medical publication; 2008 . Page.no.579 5. Padubidri V.G. Prep manual for Undergraduates of Gynaecology, Reed Elsevier Private Limited, Delhi; 2005. Page no. 33. Internet sources:
http://kidshealth.org/amenorrhoea/ cryptomenorrhoea.html http://www.nlm.nih.gov/medlineplus/ency/article/000810.htm