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202458482 final-case-presentation-abnormal-uterine-bleeding

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202458482 final-case-presentation-abnormal-uterine-bleeding

  1. 1. Get Homework/Assignment Done Homeworkping.com Homework Help https://www.homeworkping.com/ Research Paper help https://www.homeworkping.com/ Online Tutoring https://www.homeworkping.com/ click here for freelancing tutoring sites Introduction Abnormal uterine bleeding is a condition in which a woman bleeds from her uterus at an unexpected time or in a way that is unusual for her. For example, bleeding between periods, a period that is heavier longer-lasting than normal, bleeding after sexual intercourse, clots or spots in the menstrual blood and any bleeding after menopause may all be considered abnormal uterine bleeding. The most common reason for irregular uterine bleeding is pregnancy. Spotting or very light bleeding may occur with no real significance, but you should always check with your doctor if you’re bleeding while pregnant. Another common reason for abnormal menstrual bleeding is having too much or too little of certain hormones. This often occurs during adolescence, when hormone levels fluctuate. Intrauterine device (IUD) can cause abnormal bleeding by irritating the uterine lining. The bleeding is usually accompanied by cramping. Also called Stein-Leventhal syndrome, Polycystic Ovarian Syndrome occurs when you don’t ovulate regularly. If your period comes with pain or foul-smelling greenish discharge you may have an infection of a pelvic organ, such as your uterus, cervix or ovaries. Bleeding would commonly follow sex or douching. These 1
  2. 2. infections are often caused by sexually transmitted diseases. Fibroid tumors are non-cancerous tumors that grow in the uterine muscle. They usually affect women in their 30s or 40s. most common among black women, they are also fairly common among white women, but extremely rare in Asian women. Other possible reasons for abnormal menstrual bleeding include polyps, small growths that develop in the cervix or uterus. Their causes are unclear, but are related to an excess of estrogen, which may be result of an infection, hormone treatment or some types of ovarian tumors. The most probable etiology of abnormal uterine bleeding relates to the patient’s reproductive age, as does the likelihood of serious endometrial pathology. The specific diagnostic approach depends on whether the patient is premenopausal, perimenopausal or postmenopausal. In premopausal women with normal findings on physical examination, the most likely diagnosis is dysfunctional uterine bleeding (DUB) secondary to anovulation, and the diagnostic investigation is targeted at identifying the etiology of anovulation. Abnormal uterine bleeding (AUB) in nonpregnant women is a common problem. In fact, AUB accounted for almost 4 million outpatient visits (mostly to physicians’ offices) in the United States in 1996. Indeed, this problem may prompt more than 20% of all visits to OB/GYNs, and may account for more than one fourth of all hysterectomies. AUB is rare in prepubertal females. Newborn girls occasionally have a slight bloody vaginal discharge secondary to withdrawal of placental estrogens. AUB is common in adolescents because of the 1- to 5- year delay in development of regular ovulatory menstrual cycles after menarche. AUB also tens to be more common during the fifth decade of life (the perimenopausal years). In the worst case, AUB may be a sign of atypical endometrial hyperplasia, which, if undiagnosed and untreated, can progress to uterine cancer-the most common female genital cancer. In 1998, estimated 36,100 women were diagnosed with uterine cancer, which led to approximately 6,300 deaths. One popular form of treatment for abnormal uterine bleeding is birth control pills, which contain hormones that can prevent the uterus lining from 2
  3. 3. thickening. If birth control pills are’nt stopping the bleeding, a doctor may prescribe an intrauterine (IUD) device. An IUD is a plastic device that is inserted into a woman’s uterus to prevent pregnancy. In rare cases, surgery may be needed to stop abnormal bleeding. Two surgical procedures are recommended: hysterectomy and endometrial ablation. OBJECTIVES General Objectives This study attempts to examine the case of the client with abnormal uterine bleeding, specifically it attempts: 1. To obtain clients data 2. To perform thorough physical assessment to the client 3. To discuss the anatomy and physiology of the reproductive system 4. To trace the pathophysiology of abnormal uterine bleeding 5. To present laboratory results and its interpretation 6. To formulate appropriate nursing diagnosis who has abnormal uterine bleeding 3
  4. 4. 7. To develop nursing care plan for client based to identifies nursing problems. 8. To present drug studies as medications given to client as a part of treatment regimen. 9. To provide health teaching to patient and significant others about prevention of recurrence of AUB. PERSONAL DATA Name: Cristy Joy Lactason Address: Brgy. Naje, Arakan, Cotabato Date of Birth: August 7, 1990 Birthplace: Brgy. Naje, Arakan, Cotabato Age: 19 years old Sex: Female Civil Status: Single Religion: Roman Catholic Educational Status: Second year high school Nationality: Filipino MEDICAL DATA Hospital: Kidapawan Medical Specialists Center Inc. Ward: NS 2 Room & Bed No. Room 218-A 4
  5. 5. Chief Complaints: Profuse menstruation/Menometrorrhagia Date & Time Admitted: July 25, 2010, 4:30 pm Physicial: Dr. Phillen Drama Ureta Admitting Diagnosis: T/C abnormal uterine bleeding Final Diagnosis: Abnormal Uterine Bleeding FAMILY BACKGROUND I. History of Present Illness The condition started about 1 month prior to admission as onset of prolonged vaginal bleeding lasting for 15 days soaking 4-6 pads per day associated with dysmenorrhea. No consultation done and no medications taken. Two days prior to admission patient’s vaginal bleeding spontaneously regressed. One day prior to admission patient’s vaginal bleeding recurred and completely soaked several pads associated with pallor and dizziness prompting to consult an OB-Gynecologist (Dr. Phillen Drama Ureta) and subsequent admission. II. History of Past Illness Patient was hospitalized last March 2010 at Antipas Hospital due to profuse vaginal bleeding and was treated with Diane pills taken with poor compliance. She is non-asthmatic, non-diabetic, non-hypertensive with no known food and drug allergies. 5
  6. 6. III. Medical History of Family No heredofamilial diseases such as hypertension, diabetes, asthma and cancer were reported in the family. X, IV. Personal and Social History Patient is a second year high school student at Arakan National High School. She is the second child among 3 siblings. Her father is a farmer and her mother is a plain housewife. She is a non-smoker, an occasional alcohol beverage drinker and denies any use of prohibited drug. She has a boyfriend but denies coitus at her age. She spends most of her time watching television. V. Menstrual History She started her menarche at the age of 13 years old, with an interval of 28-30 days and duration of 4-6 days. Amount of blood is heavy soaking 3-4 pads per day accompanied with dysmenorrhea. 6
  7. 7. DEVELOPMENTAL DATA Age/Stage Description according to Theories Analysis • 19 y/o Havighurst -Adolescence Erikson -Adolescence (12-20) Kohlberg -Adolescence and Adulthood Havighurst Erikson Kohlberg On Havighurst theory, the patient has met the indicators of an adolescent except achieving assurance of economic independence. On Erikson’s theory, client indicates positive resolution, she has a sense of self and plans to actualize her abilities. On Kohlberg’s theory, the client is concerned in maintaining expectations and rules of the family group. Adolescence 1. Achieving new and more mature relations with age-mates of both sexes 2. Achieving masculine or feminine social role 3. Accepting one’s physique and using the body effectively 4. Achieving emotional independence from parents and other adults. 5. Achieving assurance of economic independence. 6. Selecting and preparing for an occupation 7. Preparing for marriage and family life. 8. Developing intellectual skills and concept necessary for civic competence 9. Desiring and achieving socially responsible behavior 10. Acquiring a set of values and ethical system as a guide to behavior. Central task -Identity vs. Role Confusion Indicators of Positive Resolution -Coherent sense of self; Plans to actualize one’s abilities Indicator of Negative Resolution -feelings of confusion. Indecisiveness and possible anti-social behavior Conventional Level -Person is concerned in maintaining expectations and rules of the family group, nation or society. A sense of guilt has developed and affects behavior. The person values conformity, loyalty and active maintenance of social order and control. Conformity means good behavior or what pleases or helps another and is approved. Law and Order Orientation -The person wants established rules from authorities, and the reason for decision and behavior is that social and sexual rules and traditions demand the response. 7
  8. 8. PHYSICAL ASSESSMENT Date of Assessment: I. General Apperance Date: July 26, 2010 Time: 9:45AM Received client conscious and coherent on bed with PNSS 1L @ 20 gtts/min at the level of 200 cc infusing well @ right metacarpal vein. Patient appeared ungroomed with uncombed hair and wrinkled clothes with black nail polish. When nail polish was removed, client’s nail bed showed pallor. Client was generally pale. II. Vital Signs and Clinical Measurements Weight: 43 kg Height: 5’1” Vital Signs upon Assessment: BP: 110/90 mmHg PR: 70 bpm RR: 18 cpm Temp: 36.2℃ III. Hair Hair is black, straight and well distributed. No presence of lice and dandruff noted. IV. Head Normocephalic. No deformities noted. V. Eyes Eyes are symmetrically aligned and equal in movement, eyelashes are evenly distributed and curled. Pupils are equally reactive to light and accommodation on 8
  9. 9. examination (using a penlight). She has good visual acuity based on snellen’s test. Conjunctivas are pale and eyeballs are in good position and alignment. VI. Ears Hearing is normal upon assessment using Weber’s test, no gross deformities noted. She is able to locate the direction of the sound of her ringing celphone. VII. Nose No asymmetry, no nasal discharges noted and can identify odors. VIII. Neck/Throat No neck vein engorgement, no lymphadenopathy, tonsils are in normal size, no difficulty on swallowing. The neck can move from left to right and can be flexed, extended and hyper extended. IX. Chest and Lungs Equal chest expansion, no retractions noted, clear breath sounds and with bilateral chest movements. RR: 18 cpm X. Heart and Circulation Distinct heart sounds, regular rhythm, BP: 110/90mmHg PR: 70 bpm. XI. Breasts Breast size and symmetry are relatively equal with slight variation. Shape is round and firm. Color is flesh and skin surface is smooth. Nipples are pink in color 9
  10. 10. with no discharges noted. She uses brassieres, no lumps or masses noted upon palpation. XII. Abdomen No scars noted, soft, normoactive bowel sounds noted. No tenderness. XIII. Genito-urinary Normal external genitalia, abundant pubic hair with moderate bleeding. No alteration in urinary and bowel habits. She experiences 15 days of menstruation and soaks 4-6 sanitary napkins a day. She also urinates every 20 minutes during this period. XIV. Extremities A. Upper Extremities No skin lesion is noted. No growth deformities. She can move her upper extremities freely and are both symmetrical in size and length. With PNSS 1L @ 20 gtts/min at the level of 200 cc infusing well @ right metacarpal vein. B. Lower Extremities No skin lesion is noted. No growth deformities. Her lower extremities are both symmetrical in size and length with limitation of movement because movement and straining or any forceful activity can aggravate profuse vaginal bleeding. XV. Food Preference Patient verbalizes fondness of eating meat, fish and vegetables. XVI. Identified Needs The patient needs to maintain fluid and electrolyte balance, needs to keep body clean and well groomed and protect the integument and needs performance of activities of daily living. 10
  11. 11. XVII. Nursing Diagnoses • Risk for Fluid Volume Deficit R/T Uterine Bleeding • Risk for Activity Intolerance related to decreased hemoglobin • Self-care deficit: bathing/ hygiene related to decreased motivation • Easy fatigability related to decreased hemoglobin TERMINOLOGIES Abnormal Uterine Bleeding – excessive and prolonged menstruation. Endometriosis – ectopic growth and function of endometrial tissue. Fibroids – a fibroma or myoma particularly of the uterus Fibroma – a benign neoplasm consisting largely of fibrous or fully developed connective tissue. Menometrorrhagia - excessive menstrual and uterine bleeding other than that caused by the menstruation. Menorrhagia - abnormally heavy or long menstrual periods. Menorrhagia occurs occasionally during the reproductive years of most women’s lives. Metrorrhagia – uterine bleeding other than that caused by menstruation. It may be caused by uterine lesions and may be a sign of uro-genital malignancy. Myoma – a common benign fibroid tumor of uterine muscle. 11
  12. 12. Polyps – small, tumor like growth that projects from a mucous membrane surface. Proliferation – the reproduction or multiplication of similar forms. Retroverted uterus- titled or tipped backwards. Snellen’s Chart - an eye chart used by eye care professionals and others to measure visual acuity. It is printed with eleven lines of block letters. The first line consists of one very large letter, which may be one of several letters, for example E,H or N. subsequent rows have increasing numbers of letters that decrease in size. Snellen’s Test – a test wherein a person covers one eye and reads aloud the letters of each row beginning at the top. The smallest row that can be read accurately indicates the visual acuity in that eye. Withdrawal bleeding – the passage of blood from the uterus, associated with the shedding of endometrium that has been stimulated and maintained by hormones. Weber’s Test – a test for differentiating conductive hearing impairment from sensorineural hearing impairment. A vibrating tuning for is applied to one of several points in the middling of the forehead; if the sound is heard better in the impaired ear, the middle-ear apparatus is at fault; if the sound is heard better in the normal ear, the hearing impairment is caused by diseased sensorineural apparatus. 12
  13. 13. ANATOMY AND PHYSIOLOGY Vagina: The vagina is a fibro muscular tubular tract leading from the uterus to the exterior of the body in female mammals. The vagina is the place where semen from the male is deposited into the female's body at the climax of sexual intercourse, commonly known as ejaculation. 13
  14. 14. Cervix: The cervix is the lower, narrow portion of the uterus where it joins with the top end of the vagina. It is cylindrical or conical in shape and protrudes through the upper anterior vaginal wall. Approximately half its length is visible, the remainder lies above the vagina beyond view. The vagina has a thick layer outside and it is the opening where baby comes out during delivery. The cervix is also called the neck of the uterus. Endometrium Is the inner membrane of the mammalian uterus. The endometrium functions as a lining for the uterus, preventing adhesions between the opposed walls of the myometrium, thereby maintaining the patency of the uterine cavity. During the menstrual cycle or estrous cycle, the endometrium grows to a thick, blood vessel-rich, glandular tissue layer. This represents an optimal environment for the implantation of a blastocyst upon its arrival in the uterus. The endometrium is central, echogenic (detectable using ultrasound scanners), and has an average thickness of 6.7mm.During pregnancy, the glands and blood vessels in the endometrium further increase in size and number. Vascular spaces fuse and become interconnected, forming the placenta, which supplies oxygen and nutrition to the embryo and fetus. Ovary Is an ovum-producing reproductive organ, often found in pairs as part of the vertebrate female reproductive system. Ovaries in females are homologous to testes in males, in that they are both gonads and endocrine glands. Ovaries are oval shaped and, in the human, measure approximately 3 cm x 1.5 cm x 1.5 cm (about the size of a Greek olive). The ovary (for a given side) is located in the lateral wall of the pelvis in a region called the ovarian fossa. The fossa usually lies beneath the external iliac artery and in front of the ureter and the internal iliac artery. 14
  15. 15. Uterus or Womb Is a major female hormone-responsive reproductive sex organ of most mammals including humans. It is a flattened, pear-shaped, hollow organ in the pelvis of the human female. The uterus consists of a body, a base or fundus, a neck or cervix, and a mouth. Suspended in the pelvis, it lies with the base directed upward and forward and the cervix directed slightly backward. It is connected to the vagina by the cervix. On either side of the uterus lies an ovary. Eggs produced by the ovaries reach the uterus through the fallopian tubes. ETIOLOGY PREDISPOSING FACTOR ACTUAL RATIONALE 1. Age  - Abnormal uterine bleeding is one of the most common reasons women see their doctors. It can occur at any age and has many causes. (http://www.acog.org/publications/patient_ed ucation/bp095.cfm) Age: 19 years old. 2. Gender  - The uterus or womb is a major female hormone-responsive reproductive sex organ of most mammals including humans. (http://en.wikipedia.org/wiki/Uterus) Female PRECIPITATING FACTOR ACTUAL RATIONALE 1. Poor compliance to treatment Noncompliance and poor compliance may lead to relapse, aggravation of the disease state, hospitalization, 15
  16. 16.  escalating health care costs, and even death. (http://www.pharmacytimes.com/issu e/pharmacy/2003/2003-07/2003-07- 7310) Complying only for 1 month and stopping thereafter. SYMPTOMATOLOGY SYMPTOMS ACTUAL RATIONALE 1. More than 4 to 6 days of menstruation.  Causes may be due to disruption of normal hormonal regulation of periods or disorders of the endometrial lining of the uterus. (http://en.wikipedia.org/wiki/Menorrhagia) She experiences 15 days of menstruation. 2.Blood loss of greater than 80 ml.  Without subsequent progesterone secretion, estrogen secretion continues and causes extreme proliferation in the endometrium. (Maternal and Child health Nursing, Volume 2, 4th edition , Pillitteri) Easily soaks 4 to 6 sanitary napkins a day. ( 1 sanitary napkin is equal to 25 ml) 3.Anemia > Dizziness > Pallor Bleeding causes loss of blood. This causes an abnormally low number of red blood cells which causes anemia. Red blood cells, also called erythrocytes, contain hemoglobin, a red, iron-rich protein that carries oxygen in the blood to the body’s tissues. These symptoms include pale skin, shortness of breath, rapid heartbeat, low 16
  17. 17.  vitality, dizziness, and, if left untreated, stroke or heart failure. (Microsoft ® Encarta ® 2008. © 1993-2007 Microsoft Corporation.) Client has pale conjunctiva and nail beds. She experiences dizziness 17
  18. 18. Pathophysiology 18 Predisposing Factors  Gender – Female  Age - Adolescent Precipitating Factors  Poor medical Compliance OVULATORY Irregular Sloughing of Endometrial Basalis Layer No Corpus Luteum is formed Estrogen levels remain the same No production of progesterone Hyperplasia of Endometrium As follicles degenerate, estrogen levels decreases
  19. 19. NURSING CARE PLANS 19 Heavy Prolonged Bleeding (Duration of 15 days Menstruation and soaking 4-6 Pads per day). AnemiaDecreased Serum Hemoglobin (Hgb Lab. Result 102) Abnormal Uterine Bleeding Decreased O2 Carrying Capacity of Blood (Dizziness) Dizziness and Pallor If not treated Complications Death If treated:  Back to normal Homeostasis Meds.  ALTHEA 1 Tab. O.D X3 months  FeSO4 Tab. 200 mg BID Prognosis Good
  20. 20. Date: July 26, 2010 Assessment Needs Diagnosis Goal Intervention Rationale Expected/Outcome Subjective Cues: > “Gagawas pirmi akoang dugo. Gamens ko ug 15 days” as verbalized. Objective Cues: > Pallor of conjunctiva and nail beds. >Consumes 4-6 sanitary napkin per day > Menstruation lasting for 15 days PHYSIOLOGIC NEEDS To facilitate in the maintenance of fluid and electrolyte imbalance. According to: Abraham Maslow’s Hierarchy of Needs >Risk for Fluid Volume Deficit R/T Uterine Bleeding Scientific Basis: Blood is composed of blood cells suspended in a liquid called blood plasma. Plasma, which constitutes 55% of blood fluid, is mostly water (90% by volume) (http://www.wikipedia. org) After 8 hours of nursing care, patient will be able to maintain fluid volume within functional level as evidenced: a. cessation of bleeding b. V/S within normal range c. Good skin turgor and moist mucous membrane. Independent 1. Monitored Vital Signs for changes 2. Counted number of pads consumed to monitor actual fluid loss. 3. Encouraged increase oral fluid intake 4. Promoted high water content fruits. Dependent 1. IVF PNSS 1L @ 80cc/hr 2. Tranexamic Acid 500mg QID as ordered by physician >Indirect indicators of fluid status. >Serves as baseline data > To provide volume to volume replacement > To replacefluid lost. > Fluid replacement. >It stops bleeding. >Goal met. After 8 hours of nursing care, patient was able to: Show good fluid volume status as evidenced by a) Minimal bleeding b) Vital Signs within normal range c) Lips and mucous membranes are moist with good skin turgor. Date: July 26, 2010 20
  21. 21. Assessment Needs Diagnosis Goal Intervention Rationale ExpectedOutcome Subjective Cues: >No subjective cues Objective Cues: > Pale conjunctiva > Pale nail beds > Hgb = 102 (normal value: 120-140) > Weakness > Dizziness PHYSIOLOGIC NEEDS - need for activity (Maslow’s Hierarchy of Needs) >Risk for Activity Intolerance related to decreased hemoglobin Scientific Basis: Hemoglobin in the blood is what transports oxygen from the lungs or gills to the rest of the body (i.e. the tissues) where it releases the oxygen for cell use. >After 8 hours of nursing care, patient will be able to identify alternative ways to maintain desired activity level and endure performance of Activities of Daily Living(ADL) Independent 1. Discussed with client the relationship of illness to inability to perform desired activities. 2. Assisted client in doing basic activities 3. Encouraged patient to take foods rich in iron. Dependent 1. FeSO4 1tab BID as ordered by physician. >Understanding these relationships can help with acceptance of limitations or reveal opportunity for changes of practical value. >to conserve energy and promote safety. >to replace iron lost > Provides elemental iron an essential component in the formation of hemoglobin. >Goal met. Client was able to endure & sustain basic activity such as moving to and from the bathroom without assistance. Date: July 26, 2010 21
  22. 22. Assessment Needs Diagnosis Goal Intervention Rationale Expected Outcome Subjective Cues: > “Wala pa koy ligo” client verbalized Objective Cues: > dirty nail noted > unfixed hair noted. PHYSIOLOGIC NEEDS - need to keep body clean and well groomed and protect the integument (Maslow’s Hierarchy of Needs) >Self-care deficit: bathing/ hygiene related to decreased motivation. Scientific Basis: Motivation is the psychologic al feature that arouses an organism to action toward a desired goal. (http://www. thefreedicti onary.com/ motivation) .After 8 hours of nursing care, patient will be able to: Perform proper hygiene Independent 1. Monitored vital signs. 2. Performed cleansing bed bath to patient. 3.Encouraged patient to take a bath explain the possible risks for infection. 4. Encouraged patient to do oral care. 5. Trimmed patients nails. > Serves as baseline data. > To promote comfort and reduce risk for infection. > To denote importance of proper hygiene. > To promote taste and decrease bacteria. > To prevent microorganis m from staying under nails. >Goal met. After 8 hours of nursing care, patient was able to perform proper hygiene and good grooming. Date: July 27, 2010 22
  23. 23. Assessment Needs Diagnosis Goal Intervention Rationale Expected/Outcom e Subjective Cues: >” Ginakapoy gud ko” client verbalized. Objective Cues: > Pale conjunctiva > Pale nail beds > Always lying on bed. >Feeling of weakness. > Hgb = 102 > 15 days of menstruation > 4 to 6 sanitary pads a day. PHYSIOLOGIC NEEDS - need for activity (Maslow’s Hierarchy of Needs) >Easy Fatigability R/T decreased hemoglobi n. Scientific Basis: Hemoglobi n in the blood is what transports oxygen from the lungs or gills to the rest of the body (i.e. the tissues) where it releases the oxygen for cell use In the 8 hours of nursing care, patient will be able to: >Participate willingly in necessary desired activities such as going to the bathroom, eating, standing and walking without ambulatory. Independent 1. Noted client reports of weakness and/or fatigue. 2. Adjusted activities according to client’s condition. 3. Assisted client with activities. Dependent 1. FeSO4 1tab BID. > Symptoms may be result of/or to contribute to Intolerance to activity. > To prevent Overexertion > To prevent client from injury. >Provides elemental iron an essential component in the formation of hemoglobin. >Goal met. After 8 hours of nursing care, patient was able to: > Perform the desired activities such as going to the bathroom with assistance. 23
  24. 24. LABORATORY RESULTS Diagnostic Test Purpose Result Interpretation Nursing Implication Complete Blood Count Date: July 25, 2010 Complete Blood Count: General survey of bone marrow functions and evaluates all three cell lines (WBCs, RBCs, platelets) White Blood Cells (WBC): total WBC count Hemoglobin: (Hgb): delivers O2 through circulation to body tissues and returns CO2 from tissues to lungs Hematocrit (Hct): indicates relative proportions of plasma and RBCs ( volume of RBCs/L whole blood) Platelet: total number of platelets in circulation Lymphocytes: integral component of immune system Segmenters: Monocytes: Test Result Normal Values The Hemoglobin levels are below the normal range. The Hematocrit levels are below than the normal levels. Below than normal levels of Hemoglobin are found in iron- deficiency anemia (Fischbach, 1988). Below than the normal of hematocrit are found in Acute, massive blood loss. (Fischbach, 1988). WBC Hgb Hct Plt.ct Lympho Segs Mono 9.4 (10 e g/L) 102 0.35 302 0.30 0.66 0.04 5 – 10 120-140 0.37-0.43 150-350 x10 g/L 0.25-0.35 0.55-0.65 0.03-0.06 24
  25. 25. Diagnostic Test Purpose Result Interpretation Nursing Implication Bleeding Time and Clotting Time Date: July 25, 2010 Bleeding time: measures the primary phase of hemostasis: the interaction of the platelet with the blood vessel wall and the formation of the hemostatic plug. This is one of the four primary screening test for coagulation disorders. (Fischbach, 1988). Clotting time: the time required for blood to form a clot, tested by collecting 4 mL of blood in a glass tube and examining it for clot formation. The first appearance of a clot is noted and timed. The normal coagulation time in glass tubes is 5 to 15 minutes. This simple test has been used to diagnose hemophilia, but it does not detect mild coagulation disorders. (http://medical- dictionary.thefreedictionary.com/clotting+time ) Test Result Normal Values The Bleeding time higher is than normal. A single prolonged bleeding time does not prove the existence of hemorrhagic disease because a larger vessel may have been punctured. (Fischbach, 1988). Bleeding time: Clotting time: 4 mins 7 mins 1-3 mins 2-8 mins 25
  26. 26. Diagnostic Test Purpose Result Interpretation Nursing Implication Urinalysis Date: July 25, 2010 Urinalysis: The urinalysis is used as a screening and/or diagnostic tool because it can help detect substances or cellular material in the urine associated with different metabolic and kidney disorders. It is used to detect urinary tract infections (UTI) and other disorders of the urinary tract. (http://www.labtestsonline.org/understandin g/analytes/urinalysis/test.html) Physical Examination Color: Yellow Transparency: Cloudy Yellow is the normal color of urine. Glucose is normally not present in urine. Normal Urine can be clear or cloudy. The protein test pad measures the amount of albumin in the urine. Normally, there will not be detectable quantities. The ph reaction of the urine is alkaline. Specific gravity is normal. Pus cells are within normal range. HCG is not found in urine. "Normal" urine can be clear or cloudy. Albumin is smaller than most other proteins and is typically the first protein that is seen in the urine when kidney dysfunction begins to develop. A vegetarian diet, a low- carbohydrate diet, or the ingestion of citrus fruits will tend to make the urine more alkaline. (http://www.labtestsonlin e.org/understanding/anal ytes/urinalysis/ui_exams. html) Normal urine ranges from 1.010 to 1.025.(Kozier & Erb’s, 2007) Normal value for pus cells in urine is 0- 5/hpf(http://www.medhelp .org/posts/Urology/Urinal ysis- interpretation/show/7313 97) The girl is not pregnant. The human chorionic gonadotropin (hCG) test is done to check for the hormone hCG in blood or urine. Some hCG tests measure the exact amount and some just check to see if the hormone is present. HCG is made by the placenta during pregnancy. The hCG test can be used to see if a woman is pregnant or as part of a Chemical Examination Albumin: Trace pH reaction: 5.0 Sugar: Negative Specific Gravity: 1.020 Microscopic findings Pus cells: 1-3/hpf Red Blood Cells: Packed Serology Urine HCG - Negative 26
  27. 27. Pelvic Ultrasound Date: July 26, 2010 Ultrasonography is an ultrasound-based diagnostic imaging technique used to visualize subcutaneous body structures including tendons, muscles, joints, vessels and internal organs for possible pathology or lesions. Obstetric sonography is commonly used during pregnancy and is widely recognized by the public. (http://en.wikipedia.org/wiki/Medical_ultraso nography) The uterus is retroverted. It measures 4.2x3.6x3.9 cm and is normal in size for nullipara. No myoma or adenomyosis is noted. Endometrial stripe hyperechoic measuring 0.6 cm. adnexae are free. Minimal pelvic fluid is seen. Impression: Normal studies save for minimal pelvic fluid. Retroversion of the uterus is not normal screening test for birth defects. (http://www.nlm.nih.gov/ medlineplus/ency/article/ 003619.htm) A retroverted uterus is usually diagnosed during a routine pelvic examination. Lower back pains It usually does not pose any medical problems, though it can be associated with dyspareunia (pain during sexual intercourse) and dysmenorrhea (pain during menstruation). (http://en.wikipedia.org/wi ki/Retroverted_uterus) 27
  28. 28. DRUG STUDIES Name Dosage and Indication Mechanism of Action Adverse Effects Contraindication Nursing Responsibilities Generic Name: Ferrous Sulfate Brand Name: Magniferron Classification: Hematologic Drugs: Hematinics Iron Deficiency  200 mg P.O BID Provides elemental iron an essential component in the formation of hemoglobin. GI: Nausea, epigastric pain, vomiting, constipation, black stools, diarrhea, anorexia. Other: temporarily stained teeth in liquid forms Contraindicated in patients with Hemosiderosis, primary hemochromatosis, hemolytic anemia (unless patient also has iron deficiency anemia), Peptic ulceration, ulcerative colitis or regional enteritis and in those receiving repeated blood transfusions. Use cautiously on long term basis. 1. Identify the client correctly using the appropriate means of identification, such as checking the identification bracelet or asking the clients name. 2. If the client is unfamiliar with the medication, the nurse should explain the intended action as well as any side effects or adverse effects that may occur. 3. Administer drug in the prescribed dosage by the route intended and the correct time. 4. Record the medication given, dosage, time, any complaints or assessments and your signature. 5. Explain to the client that she may have black stool as effect of the drug. 6. Administer the drug with juice for faster absorption. 28
  29. 29. Name Dosage and Indication Mechanism of Action Adverse Effects Contraindication Nursing Responsibilities Generic Name: Tranexamic Acid Brand Name: Hemostan Classification: Hematologic Drugs: Hematinics amino acid antifibrinolytic s. Indicated for short term use for hemorrhage or risk of hemorrhage in those with increased fibrinolysis or fibrinogenolysis . Local fibrinolysis as occurs in menorrhagia. 1tab 500mg QID Tranexamic acid competitively inhibits activation of plasminogen (via binding to the kringle domain), thereby reducing conversion of plasminogen to plasmin (fibrinolysin), an enzyme that degrades fibrin clots, fibrinogen, and other plasma proteins, including the procoagulant factors V and VIII. GI: nausea, vomiting, diarrhea may occur but disappear when the dosage is reduced. In patients with acquired defective color vision, since this prohibits measuring one endpoint that should be followed as a measure of toxicity. In patients with active intravascular clotting. 1. Identify the client correctly using the appropriate means of identification, such as checking the identification bracelet or asking the clients name. 2. If the client is unfamiliar with the medication, the nurse should explain the intended action as well as any side effects or adverse effects that may occur. 3. Administer drug in the prescribed dosage by the route intended and the correct time. 4. Record the medication given, dosage, time, any complaints or assessments and your signature. 5. Check for presence of spontaneous bleeding. 29
  30. 30. Tranexamic acid also directly inhibits plasmin activity, but higher doses are required than are needed to reduce plasmin formation. 30
  31. 31. Name Dosage and Indication Mechanism of Action Adverse Effects Contraindication Nursing Responsibilities Generic Name: Cyproterone acetate Brand Name: Althea Classification: Natural and semisyntheti c estrogens. OC, control of acne & hsirsutism, regulation of menstrual cycle, reduction of premenstrual tension, relief from pain & excess bleeding during menstruation. Take 1 tab starting on the 1st day of menses & throughout the cycle. Oral contraceptive. Althea is a combined low- dose oral contraceptive pill with antiandrogenic properties. Each tablet contains cyproterone acetate, a progesterone with antiandrogenic and progestogenic properties and ethinyl estradiol, an estrogen. Oral Contraceptive: Althea stops ovulation, thins the lining of the uterus and thickens the cervical mucus. In combination, these actions prevent pregnancy. Antiandrogen: Althea contains cyproterone acetate that works as an antiandrogen. It competes at the receptor sites with androgens and reduces their effects. Cyproterone acetate GI: Nausea, vomiting, chloasma (melasma) & other skin or hair changes, headache, water retention, slight wt change, breast tenderness, changes in libido. Menstrual irregularities eg spotting, breakthroug h bleeding & amenorrhea . Impaired liver function or cholestasis, Dubin- Johnson or Rotor syndromes, hepatic adenoma, estrogen- dependent neoplasms eg breast or endometrial cancer, CV disease, disorders of lipid metabolism, undiagnosed vag bleeding, pregnancy, history of pruritus or cholestatic jaundice during pregnancy, chorea, herpes gestationis, pemphigoid gestationis, deteriorating otosclerosis, severe or focal migraine, lactation. 1. Identify the client correctly using the appropriate means of identification, such as checking the identification bracelet or asking the clients name. 2. if the client is unfamiliar with the medication, the nurse should explain the intended action as well as any side effects or adverse effects that may occur. 3. Administer drug in the prescribed dosage by the route intended and the correct time. 4. Record the medication given, dosage, time, any complaints or assessments and your signature. 5. Report any signs of headache. 31
  32. 32. inhibits the influence of the androgens produced in women. Althea reduces the development of acne and seborrhea. It heals existing acne efflorescence after 3-4 months therapy. It also reduces the greasiness of the hair and skin. 32
  33. 33. Name Dosage and Indication Mechanism of Action Adverse Effects Contraindication Nursing Responsibilities Generic name: Ketorolac tromethamine Brand name: Toradol Classification: Central nerovous system drugs; Nonsteroidal anti- inflammatoy drugs Short-term management of moderately severe, acute pain -30mg IV TT Unknown. May inhibit prostaglandin synthesis, to produce anti- inflammatory, analgesic, and antipyretic effects. GI: Nausea, dyspepsia, GI pain, diarrhea, peptic ulceration, vomiting, constipation, flatulence, stomatitis. Contraindicated in patients hypersensitivity to drug and in those with active peptic ulcer disease, recent GI bleeding or perforation, advanced renal impairement, cerebrovascular bleeding, hemorrhagic diathesis, or incomplete hemostasis and those at risk for renal impairment from volume depletion or at risk of bleeding. 1.identify the client correctly using the appropriate means of identification, such as checking the identification bracelet or asking the client’s name 2.If the client is unfamiliar with the medication, the nurse should explain the intended action as well as any side effect or adverse effects that may occur. 3.Check IV patency and observe for complication of Iv therapy such as infiltration and extravasation phlebitis, thrombophlebitis, hematoma, and clotting of the needle. 4.Administer drug in the prescribed dosage by the route intended and the correct time. 33
  34. 34. 5.Administer the medication slowly 6.Record the medication given, dosage, time, any complaints or assessment and your signature. 34
  35. 35. COURSE IN THE WARD Progress notes Doctor’s order July 25, 2010 - admit under the service of Dr. Ureta - DAT - V/S Q4 h - Labs: CBC, PLT Count, HCT, Urinalysis, Pregnancy Test Soaking 1 – 4 napkin/ day for CT, BT For pelvic ultrasound in AM - IVF: PNSS at 100 cc/hr - IVF TF: PNSS in at 80 cc/hr - Meds: Tranexamic acid 500 mg IM – now Tranexamic acid 500 mg 1 cap, QID, to start in AM FeSO4 1 cap BID - AP aware - Refer accordingly July 25, 2010 Continue Meds 8:30 Vaginal bleed Pelvic Ultrasound @ AM tomorrow (07/26/10) July 25, 2010 10:10PM IVF TF: PNSS 1L @ 80 cc/hr July 26, 2010 6:00AM IVF TF: PNSS 1L @ 80 cc/hr 35
  36. 36. 12:30PM (+) for hypogastric pain May give Ketorolac 30mg IV TT now 7:20PM Althea 1 tab once and P.O 8 AM 10:00PM PNSS 1L @80 cc/hr July 27, 2010 7:00 AM IVF: PNSS 1L @ 80 cc/hr 12:00 PM IVF: PNSS 1L @ 80 cc/hr 4:00 PM MGH Meds: • Tranexamic acid 50 g 3x a day (1 week) (8am– 11am – 7pm) • Althea 1 tab once a day at 8 AM Follow up. Aug. 4, 2010 at 2 PM, clinic • Magniferron 1 cap, OD at 7 PM Advised:  Bed Rest  No work load 36
  37. 37. PROGNOSIS FACTORS PROGNOSIS JUSTIFICATION Medication Regimen Good The client is able to follow the treatment regimen that was given by the attending physician. Activity Good The client is able to comply with the advise of bed rest & no work load. GENERAL PROGNOSIS: Patient general prognosis is good since the disease of the patient could be managed through different varied treatments with the help of her family. She has knowledge of what is medication is she taking & what it is for. She follows religiously the attending physician’s prescribed treatments and takes willingly the doctor’s prescription medication. The case of her abnormal uterine bleeding is easier to treat than any other cases of abnormal uterine bleeding. 37
  38. 38. HEALTH TEACHINGS 1) Advised to take medicines religiously as prescribed by the doctor 2) Instructed to avoid strenuous activities such as heavy lifting for it may aggravate vaginal bleeding 3) Advised to increase foods rich in iron 4) Instruct client to comply with the physicians advice for follow-up check-up NURSING IMPLICATIONS A. NURSING EDUCATION It helps the nursing profession gain more information regarding different symptoms, different causes, different etiologies and different treatments and nursing actions related to this case and to impart this information to the younger batches of nursing students of Notre Dame of Kidapawan College. It also helps the nursing profession to be aware of the different terminologies used so that it would be imparted to the future incoming nursing students. It also helps the nursing students of Notre Dame of Kidapawan College to be more knowledgeable in dealing with patients who have abnormal uterine bleeding. B. NURSING PRACTICE It helps the nursing profession to be more aware in dealing with this kind of cases in different fields and hospitals. It also helps the nursing students of Notre Dame of Kidapawan College to be more skillful in doing the different nursing actions to the patients in different hospitals, to have safe and quality nursing care that the patient needs. It also helps the nursing profession to prevent any clinical errors that can harm the patient and may result to mal-practice or globally known as negligence. 38
  39. 39. C. NURSING RESEARCH It helps the nursing profession to gain more knowledge regarding this case and to impart this data to the incoming researchers who may need the said information. It also helps the researchers to gather more reference to strengthen the validity of the different information of the said case. It also helps to make the gathered information to be more truthful in terms and learning that may found in the papers. 39
  40. 40. BIBLIOGRAPHY A. Books Andreasen, Charlotte and Aris Jr. Andrews. Et al. © 2006. Mosbys’s Pocket dictionary of Medicine, Nursing and Health Professions 5th Edition. Elsevier Pte. Ltd. Singapore. Berman, Audrey and Shirlee Synder. © 2008. Kozier and Erb’s Fundamentals of Nursing 8th Edition. Pearson Education Inc. Jurong, Singapore. Bullock, Barbara and Henze, Reet. © 2000. Focus on Pathophysiology. Lippincot Williams and Wilkins. Philadelphia. Doenges, Marilyn E. and Mary Frances Moorhouse, et al. © 2008. Nurse’s Pocket Guide Diagnosis, Prioritized interventions and Rationales. L.A. Davis Company, Philadelphia. Thomson Learning Asia. Singapore. Fischbach, Frances. © 1988. A manual of Laboratory diagnostic Tests 3rd Edition. J. B. Lippincot Company. Philadelphia. McCann, Judith A. and H. Nancy Holmes. et al. © 2008. The Nursing 2008 Drug Handbook. Lippincot Williams and Wilkins. Philadelphia. McCann, Judith Schilling. © 2007. Assessment. Lippincot Williams and Wilkins. Philadelphia. Pilliteri, Adele. © 2003. Maternal and Child Health Nursing. 4th Edition. Lippincot Williams and Wilkins. Philadelphia. B. Internet http://findarticles.com/p/articles/mi_m0689/is_3_58/ai_n31438489/ http://emedicine.medscape.com/article/795587-overview http://www.acog.org/publications/patient_education/bp095.cfm http://www.uptodate.com/patients/content/topic.do?topicKey=~.p55Sh88wWX6eG http://familydoctor.org/online/famdocen/home/women/reproductive/menstrual/470.html http://www.gynalternatives.com/abnormal_uterine_bleeding.htm 40
  41. 41. http://www.medicines.org.uk/emc/medicine/21712/SPC/tranexamic%20acid%20500mg %20tablets%20(sandoz%20limited)/ http://www.nativeremedies.com/ailment/symptoms-of-hormone-imbalance.html http://www.medicine.uic.edu/UserFiles/Servers/Server_442934/File/OBGYN%20Med %20Ed/STUDENTS/Lectures/ELAM%20-%20AUB%20talk.pdf http://www.medicine.uic.edu/UserFiles/Servers/Server_442934/File/OBGYN%20Med %20Ed/STUDENTS/Lectures/ELAM%20-%20AUB%20talk.pdf http://members.aapa.org/aapaconf2006/syllabus/6253TaylorDUB.pdfc 41

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