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COLEGIO DE KIDAPAWAN
QUEZON BOULEVARD KIDAPAWAN CITY
COLLEGE OF NURSING

IN PARTIAL FULFILLMENT OF
RELATED LEARNING EXPERIENCE
IN NCM 101

A CASE STUDY ON
PROLAPSED UTERINE MYOMA

PRESENTORS
AIZA F. TADO
BAI-ALI D. SALAKUB
MARY ANN C. BLANCO
BSN 2

PRESENTED TO
ROSALIND P. RIGA, RN
RANDY M. TORIO, RN
ROSALIA R. VICENTE RN, MAN
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ACKNOWLEDGEMENT

For with God nothing is impossible

We, the members of this group make this case study possible with the help,
knowledge and skills of a certain individuals who spend their precious time in helping
us. Before we formally begin, the group would like to give thanks and
acknowledgethoseindividuals who made this study complete.

We would like to first give thanks to the patient, and her family for cooperating
with us in providing necessary information in completing the family history and
allowingus to do the physical assessment completely.

We would like to thank the staff of Cotabato Provincial Hospital (CPH), who
helped us clarify such information from the chart concerning the patient and
hermedications.

We would also like to give a specialthank you to our dear clinical instructor, Ms.
Rosalind P. Riga, RN for giving her advice on how we are going to do the
casepresentation and in guiding us always.

And last but not the least, To the God Almighty, for although this case study was
made and passed at such a turbulent time, it was through Gods will that it will
befinished and completed whole-heartedly with much eagerness and passion.
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TABLE OF CONTENTS

ACKNOWLEDGEMENT
I. INTRODUCTION
II.OBJECTIVES
III.PATIENTS PERSONAL DATA
IV.FAMILY BACKGROUND/ HEALTH HISTORY
V.PHYSICAL ASSESSMENT
VI.DIAGNOSTIC AND LABORATORY PROCEDURE
VII.REVIEW OF SYSTEMS
VIII.ANATOMY AND PHYSIOLOGY
IX. PATHOPHYSIOLOGY
X.DRUG STUDY
XI.NURSING THEORIES APPLICABLE TO THE CASE PRESENTED
XII.NURSING CARE PLAN
XIII.DISCHARGED PLANNING
XIV.PROGNOSIS
XV.LEARNING DERIVED
XVI.REFERENCES
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I:INTRODUCTION
In the field of nursing, one encounters a wide-array of various diseases and
conditions. In order to give adequate and holistic care to individuals, it is necessary that
nurses be equipped with the proper knowledge and skills for dealing with different
health states. A case study is a means of continuing such learning, the students
dealsinto the question, what is this disease condition? They learn, from
continuousinteraction with the patients alongside with inquiries into books and
informative journals of the disease process, it symptoms, and corresponding treatments.

Myoma is a condition where there is a benign growth or tumor of smooth

musclein the wall of the uterus. The said growth is made up of fibrous tissue; hence it is
oftencalled a fibroid tumor. Uterine fibroids can be present and be in apparent. Fibroids
vary in size and number, and are most often slow-growing and usually cause no
symptoms.

STATISTICS:
There are 22 million women suffers from myoma all over the world.
In the Philippines, the estimated number of women is 86, 241, 6972 squared, and
the 4,312,084 had been affected of Myoma.
In the province of Cotabato, the total population is 271,786 and 10,239 are
women suffering from myoma in 2012.
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II:STUDENT NURSE-CENTERED OBJECTIVE

General Objectives:
After how many days of interaction with the patient and completing the case
study, the student nurses will be able to:
Know and understand the disease process and concept of Prolapsed Uterine
Myoma.
Specific Objectives:
After 3 weeks of duty at Cotabato Provincial Hospital, the student nurses will be
able to:
Cognitive:
Review the proper physical assessment (IPPA) and how to do them
efficiently.
Understand the disease process: the causes, effects, management,
treatment, and possible preventions.
Trace the pathophysiology of the condition with their rationale for occurrence
of each manifestation.
Determine why certain management and medications are given and provided
for the condition.
Understand how and why certain diagnostic tests are done for the condition;
Pelvic ultrasound, Blood chemistry, Complete blood count.
Review the concepts about the anatomy and physiology with regards to the
condition.
Psychomotor:
Perform efficiently physical assessment (IPPA) to the patient.
Perform thorough health history from patient and significant others.
Participate in the course of care of patient.
Provide health teachings to the patient about certain interventions in the
maintenance of healthcare.
Affective:
Establish rapport and therapeutic interaction with the patient and significant
others to obtain necessary information and positive compliance to care being
provided.
Provide care and health teachings necessary for the betterment of the
condition of the patient.
Share the learning acquired to co-student-nurses to increase awareness and
help them if ever they will encounter patient with the same condition
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III:PATIENTS PERSONAL DATA:

Lady M., a 38-year old female, stands as a mother of 6 children. She is living with
her husband and children. She lives in Aroman Carmen North Cotabato. Her nationality
is Filipino and was born in Bukidnon on the 16th day of October, 1976.
She was admitted in a public hospital in Amas Kidapawan City on July 03, 2014
at 2:45pm with the initial diagnosis of Prolapsed Uterine Myoma and chief complaint of
Vaginal Bleeding. She was never hospitalized ever since and this is herfirst time to be
admitted in the hospital.
Lady M. was not able to finish her high school due to financial problem. Husband
and wife are both farmer and this is their source of income for their daily needs. Lady
M.is aCatholic.She usually wakes up at 5:30 in the morning and usually drinks her
coffee and does the household chores. She usually takes her breakfast at 7:30 in the
morning and then went to their farm. She usually takes her lunch at 11:30 in the
morning and eats her dinner usually at 7:00 in the evening. Sheusually sleeps at 8:30 in
the evening.
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IV: Family background/health history

Lady M. had been fully immunized during her childhood stage and has no known
history of allergies. She takes over-the-counter drug whenever she has experiencing
common diseases such as fever, cough and colds like paracetamol, mefenamic and
amoxicillin. Her menarche starts at the age of 13. At the age of 5 the client fell down in
carabao.

Family history
Lady M. has 5 siblings, with 2 sisters and 3 brothers. Her older brother is
asthmatic and her younger sister has undergone appendectomy last January 2011. Her
older sister died of a heart attack of age 59.
Lady M. has 6 children and 2 of them are married and her youngest child is also
asthmatic. Her father died due to old age and her mother is still alive living with them.

Psychosocial profile:
Lady M. usually takes a bath once a day and drink water for at least 6-8 glasses
per day. She spends her days in their farm together with her husband. Usually wake up
at 5:30 in the morning and usually sleep at 7:30 oclock in the evening.
Sometimes the patient liked towatch television with her family and talks about family
members and current events like upcoming weddings, birthdays, etc.
*Nutritional Patterns:
Eats 3 meals a day and take her snack twice. Usually eats vegetables and
nutritious fruits and sometimes she drinks milk if theres an extra budget for the milk.
*Activity/exercise pattern:
Lady M. had her exercise daily by means of walking to their farm. Other than that
she is doing farmers work.
*Sleep/rest pattern:
Usually sleeps through the night. Get her rest as soon as they arrived to their
home from the farm.
*Personal habit:
Lady M. takesover-the-counter (OTC) medications whenever she has acute
illness. She usually drinks at least 3- 4 cup of coffee a day and drink alcoholic
beverages occasionally and does notsmoke.

History of present illness:

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Lady M. is experiencing vaginal bleeding for almost 2 week and suffering in

nausea and vomiting prior to admission. She never seeks any medical assistance
thinking that it was not a serious problem and she can handle it.

V: PHYSICAL EXAMINATION & ASSESSMENT

Upon Admission, Lifted From the Chart:
Assessed on July 03, 2014 @ 2:45 pm
Chief Complaint: Vaginal Bleeding
Complete history:
Start of menses age 13
Experienced menstruation twice in the month of June; in the first week and
last week of that month.
2 weeks Vaginal Bleeding prior to admission
Consulted physician and advised for surgery, hence admitted.

Obstetrical score:
(TPAL) TERM, PRE-TERM, ABORTION, LIVING
Term: 6
Pre- term: 0
Abortion: 1
Living: 6

Initial diagnosis: Prolapsed Uterine Myoma

Attended physician: Marie Hazel Tuvida-Talja
Initial vital signs:
Blood Pressure- 90/50mmHg
Pulse Rate 75bpm
Respiratory Rate 26cpm
Cardiac Rate 76
Temperature 37.1 Degrees Celsius
Pale Conjunctiva
(+) Murmurs, (-) Rales, (-) Wheezes

Weight: 46 Kg.
Height: 5 feet
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PHYSICAL EXAMINATION & ASSESSMENT (Cephalocaudal Assessment)

The patient received with ongoing D5LR 1L IV fluid with 35 drops per minute.
She is a 38 year old woman, wearing a set of white pajamas and talking to her
daughter. The patient is alert, oriented responsive to all of the questions asked. She is 5
feet tall with black hair slightly turning grey at the roots. Vital Signs were taken and
recorded as follows:
Vital Signs for 10:00am
Temperature- 36.1 degree Celsius
Cardiac Rate- 80bpm
Respiratory Rate- 16cpm
Blood Pressure 100/60 mmHg
Pulse Rate- 78bpm

First Nurse Patient Interaction: July 07, 2014 @ 10: am

Skin, Hair, and Nails:
Inspection
Skin is dark brown in color
Skin is smooth without lesions or scars; no visible masses.
Fine scaling of dry skin on lower inferior portion of legs and on outer
portion of arms.
Presence of fissuring of skin on inferior portion of the feet
Hair and Scalp:
Hair is black slightly turning grey at the roots
Scalp is clean and dry
Nails:
Nails are pale pink in color
Capillary refill 3-4 seconds

Palpation
Skin:
Skin is smooth and even, except for at the base of the feet
Presence of calluses on the base of feet
With a Skin turgor of 3 seconds
Skin is dry and warm to touch.
Skin is wrinkled and mobile in most areas except in areas of skin folds
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Hair and scalp:

Smooth with no presence of masses or lesions
Scalp is dry to touch.
Hair is thick and fine; Black and grey in color
Nails:
Nails are smooth and firm. Nail plate is firmly attached to nail bed.
With a capillary refill of 3 seconds.
Head and Neck:
Inspection
Head:
Head is round, symmetric, proportional, and midline to the clients body; no
presence of visible lesions
Head is held still and upright
Face is symmetric with an oval appearance.
Neck:
Neck is symmetric with head centered and without bulging masses.
Thyroid cartilages move symmetrically as the client swallows.
. Neck movement is smooth and controlled
Palpation
Head:
No swelling, tenderness or crepitation with movement of the jaw.
Jaw can move laterally in each direction.
Neck:
Trachea is midline
Thyroid gland is not palpable
No swelling or tenderness of the lymph nodes; lymph nodes are not enlarged.
Eyes and Ears:
Inspection
Eyes:
White sclera is seen around the iris
Pupils are equally rounded and respond to light and accommodation.
The upper and lower eyelids close easily and meet completely when closed.
Eyes are able to move smoothly.
The lower eyelids are upright
No inward or outward turning eyes
No presence of swelling, redness, or lesions of the eye.
Upper and lower palpebral conjunctiva are free of swelling or lesions.
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Iris is round, flat, and evenly colored.

20/20 vision

Ears:
Ears are equal in size bilaterally. The auricle aligns with the corner of each eye.
Earlobes are attached.
Skin is smooth with no lesions; color is evenly distributed and consistent with
facial color.
Canal walls are pink and smooth and without nodules.
Both ears can hear clearly
Palpation
Eyes:
No drainage noted upon palpation of the nasolacrimal duct.
No palpable masses
Ears:
No tenderness upon palpation of the auricle and mastoid process.
No palpable masses along the pinna
Mouth, Nose, and Sinuses:
Inspection
Mouth:
Lips are cracked and dark brown in color.
Teeth have a yellowish discoloration
No presence of dental carries
Gums are pink in color
With moist pale-pink buccal mucosa.
Tonsils and uvula show no presence of swelling.
Tonsils pink in color
Nose:
Color is the same as the rest of the face
Nasal structure is both smooth and symmetric
Client is able to sniff through each nostril while the other is occluded
Nasal mucosa is pink, moist, and free of exudates
Sinuses:
Sinuses do not appear enlarged or swollen
Palpation
Mouth:
No lesions, ulcerations, or nodules upon palpation
Sinuses:
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Frontal and maxillary sinuses are non-tender to palpation

Percussion
Sinuses:
Sinuses are not tender upon percussion.
Thoracic and Lung:
Inspection
Skin is even in color
Chest moves symmetrically with breathing with a respiratory rate of 19 breaths
per minute.
Palpation
Skin surface and lesions are free of masses
Percussion
Resonance is heard throughout all lung fields.

Auscultation
Clear breath sounds noted
Heart and Neck Vessels:
Inspection
Jugular venous pulse is not normally visible when the client sits upright, apical
impulses are not visible.
Palpation
Carotid artery pulses are equally strong.
Radial and apical pulses are identical.
No pulsations or vibrations are palpated at the apex and the base of the heart.
Auscultation
With a BP of 100/60 mmHg
With a pulse rate of 75 beats per minute.
No murmurs or extra heart sounds are heard.
S1 and S2 sounds are clearly heard.
Peripheral and Vascular:
Inspection
Arms are bilaterally symmetric with minimal variation in size and shape because
the left arm is slightly dislocated.
No edema of the hands or prominent venous patterning throughout all
extremities
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Veins are flat and barely seen under the surface of the skin.
Consistent with skin color on the rest of the body.
Legs have equal distribution of hair
The skin tone of the legs are consistent with those of the rest of the body
Legs are free of lesions and ulcerations

Palpation
Skin is warm to touch
With a skin turgor of 3 seconds
With a capillary refill of 3 seconds.
Radial and brachial pulses have equal strength bilaterally
Skin of the feet and toes are cold to touch.
No presence of enlarged lymph nodes upon palpation
Abdominal:
Inspection
Color is consistent with the color of the rest of the body
No visible veins of the abdomen are present upon inspection
No presence of ulcerations
No presence of rashes
Skin tone of umbilicus is similar with that of abdominal skin tone.
Umbilicus is located on midline of the abdomen
Abdomen has a protruded contour and is round in shape.
Abdomen is symmetric
Auscultation
Soft gurgles are heard at a rate of 15 sound per minute upon respiration
Percussion
Tympany is percussed over the abdomen.
Palpation
No palpable masses
No signs of swelling of the umbilicus; no bulges, or masses.
Musculoskeletal:
Inspection
Client cannot be able to stand on heels and toes alone.
Toes point straight point forward and lie flat, aligned with the lower leg.
Client is able to move without limitation
The spine is straight when observed from behind
Joints are symmetric without signs of redness.
Client has full range of motion without limitation.
Hands are symmetric in size; fingers lie in a straight line.
Palpation
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No presence of joint swelling or tenderness on other areas of the body

Hands and fingers are symmetric, non-tender, and without nodules.
Hips are non-tender.
No heat, swelling or nodules noted on the fingers and toes.

VI: REVIEW OF SYSTEMS

Integumentary:
For her hair, the client takes baths at least once or twice a day. She uses
whatever shampoo is available.
Cleans and cut nails at least once a week.
Client does not make use of styling products for the hair.
Client says she has no history of other skin problems such as lesions,
drainage or swelling.
Does not feel pain upon light or deep palpation.
The client and his family have no history of skin allergies or skin cancer.
Does no any birthmarks or tattoos.
No problems with perspiration or odor.
Has no current history of excessive hair loss, infestations, or change and
appearance in the hair (such as excessive dryness or brittleness).
Client is not constantly exposed to chemicals which may harm the skin
such as paint, weed killers, insect repellents, and bleach.
Musculoskeletal:
Patient has history of dislocation in joints.
No family history of gout, arthritis, or osteoporosis.
Does not experience back pain or pain in the joints during movement.
On a typical day, she usually spends 4-6 hours in the sunlight.
Client does not experience neck pain.
Client does not feel any facial pain.
No difficulty with moving the head and the neck.
No history of lumps or lesions of the neck.
Hearing, Vision, Sinuses:
The client has no problems with vision.
The client has no problems with hearing.
No past history of ear infection, ringing of the ears (tinnitus), or drainage from
ears.
Cleans ears regularly twice a week, usually after he bathes.
No problems with sinuses
At times, experiences colds, especially during the rainy season.
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Respiratory system:
The client has no history of smoking
She has the history of asthma.
She has no history of lung cancer and has no family history of lung cancer.

Lymphatic System:
No familial history of breast cancer.
No history of problems concerning the lymphatic system.

Circulatory System:
Does not have any past history of heart problems.
Skin is often dry, however, she does not use any forms of moisturizer for it might
irritate her skin.
Does not experience any pain or cramping in the legs.
She does not have any sores or open wounds on his leg and foot.
Household chores and working in the farm are her daily forms of exercise.
Gastrointestinal:
Sometimes she is experiencing nausea and vomiting due to long exposure in
sunlight when working at their farm.
Usually the main dish includes mainly vegetables and fish. The client does not
like to eat meat because she said it is difficult to chew.
Usually drinks 3 cup of coffee a day, made from pure freshly grounded coffee.
Genitourinary:
Had menarche at age thirteen.
Urinates every one or two hours at least once
Has no history of difficulty of urination.
Neurological System:
Does not experience numbness or tingling.
No history of seizures.
Has no current problem with the sense of smell.
No difficulty in speaking or swallowing.
Does not experience muscle weakness or tremors
No problems with memory loss.
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VII:DIAGNOSTIC AND LABORATORY PROCEDURES:

Diagnostic Indications or Purpose Date Results Normal Analysis

procedure Ordered & Values and
Released interpretation
HGB To measure the July 06, 2014 79 120- Abnormal. Patient was not
(g/dL) hemoglobin 160g/dl able to compensate with
decreased of oxygen carrying
capacity and availability of
oxygen increased
HCT (%) To aid diagnosis of July 06, 2014 0.27 36.0 47.0 Abnormal. The ratio of solid
abnormal states of particles in the blood of the
hydration, polycythemia patient is not in proportion to
and anemia and aids in the liquid part of the blood
calculation of erythrocyte signifying that the blood is n
indices too diluted or too
concentrated.
Platelet To evaluate platelet July 06, 2014 325.000 150 400 Normal
Count(x10 9/L) production
WBC (x109/L) To determine for July 06, 2014 19.8 4.8 10.8 Abnormal count. It means the
presence of for further patients immune function is
tests such as WBC not intact and not functioning
differential infection and in its optimum. Proximity of the
also for determination WBC count to the high limits
count core means the body is trying
to fight present developing
infection or there is presence
of bleeding insome parts of
the body
Lymphocytes To check for immune July 06, 2014 0.07 25-35% The result is below normal
(%) responses range indicating infection.
Eosinophil (%) July 06, 2014 0.5 2-4% The result is not in normal
To determine presence range indicating the presence
of multicellular parasites of a parasitic infection.
and certain infections
Monocytes (%) To determine presence July 06, 2014 0.5 2-6% The result is not in normal
of Chronic inflammatory range. It means macrophages
disease, Parasitic not activated
infection, Viral infection
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Basophils (%) July 06, 2014 1.00 0%-3% The result is normal.

PELVIC ULTRASOUND DATE ORDERED: July 07, 2014

UTERUS: 5.0 X 4.7 X 5.3 cm anteverted
Abnormalities noted:
Myoma: none seen

Adenomyosis: none seen

Others:
ENDOMETRIUM: thickness 2.0 cm Hyperechoil
Compatible with:-____________phase of the cycle
ADNEXAE:
Right ovary: 3.4 x 2.1 x 1.6 cm vol:
Located: Lateral to the uterus
Follicles:

Left ovary: 3.0 x 2.1 x 1.6 cm vol:

Located: Lateral to the uterus
Follicles:
CERVIX: 3.3 X 1.8 X 2.2 cm Nabothian cyst: none
Abnormalities noted:
Within the cervical cavity is a pendunculated complex mass measure 5.6 x
6.3 x 4.5 cm with moderate vascularity with a single pedicle artery at the
posterior area seemingly attached at the lower segment endometrium
suggestive of a Prolapsed Submucous Myoma with a cystic degeneration
vspolyp
OTHERS:
(-) fluid in the cul de sac
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BLOOD CHEMISTRY DATE: July 07, 2014

Diagnostic Indications or Date Results Normal values Analysis and

procedure purpose ordered interpretation
and
released
Creatinine To evaluate July 06, 1.2 0.6 to 1.2 Normal. The
kidney 2014 milligrams (mg) kidney of the
function per deciliter patient is
(dL) in adult properly
males and 0.5 functioning.
to 1.1
milligrams per
deciliter in adult
females.
Potassium To detect July 06, 3.4 3.7 to 5.2 Abnormal.
concentrations 2014 mEq/L. The patient is
that are too hypokalemia;
high this means
(hyperkalemia) that she has
or too low not enough
(hypokalemia) potassium on
her diet.
Sodium The sodium July 06, 136 135 to 145 Normal. This
blood test 2014 milliequivalents means that
measures the per liter there is
amount of (mEq/L). balance
sodium in the between the
blood. sodium and
water in the
patients
body.
RBC To measure July 06, 3.9 4.2 to 5.4 Abnormal.
how many red 2014 million This means
blood cells cells/mcL that the
(RBCs) you patient has
have. low RBC
counts.
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VIII: ANATAOMY AND PHYSIOLOGY

FEMALE REPRODUCTIVE SYSTEM: (External)
The External Genitalia:
Vulba- The front view of
female reproductive system.
Mons pubis- Is the skin
covered with curly hair which
serves as fat filled pad over
the symphysis pubis.
Labia majora- two prominent
folds of fat tissue continues to
the mons pubis and extends
poisteriorly.
Clitoris- rich in nerve endings
and is made up of erectile
tissue.
Vestibule of the vagina-
space between the labia minora.

FEMALE REPRODUCTIVE SYSTEM: (Internal)

Ovaries-The two ovaries are small
organs suspended in the pelvic cavity by
ligaments. The outer part of the ovary is
made up of dense connective tissue and
contains the ovarian follicles. Each of the
ovarian follicles contains an oocyte, the
female sex cell. Loose connective tissue
makes up the inner part of the ovary,
where blood vessels, lymphatic vessels,
and nerves are located.
Uterine Tubes- serves as the
passage way from the ovary to the uterus
in which the ova passes through the
uterus if no fertilization occurs.
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Uterus- the uterus is as big as the size of a medium-sized pear. It is oriented in

the pelvic cavity with the larger, rounded portion directed superiorly. The part of
the uterus superior to the entrance of the fallopian tubes is called the fundus.

The Uterine wall is composed of three layers: a serous layer or perimetrium of the
uterus consists of smooth muscle is quite thick and accounts for the bulk of the uterine
wall. The inner most layer of the uterus is called the endometrium. The endometrium
consists of simple columnar epithelium tissues with an underlying connective tissue
layer. Simple tubular glands, called endometrial glands, are formed by folds of the
endometrium. The superficial part of the endometrium is sloughed off during
menstruation. The uterus is supported by the broad ligament and the round ligament. In
addition to these ligaments that support the uterus, much support is provided inferiorly
to the uterus by skeletal muscles of the pelvic floor. If ligaments that support the uterus
or the muscles of the pelvic floor are weakened such as in childbirth, the uterus can
extend inferiorly into the vagina, a conditiontermed as a prolapsed uterus. Severe cases
require surgical correction.
Vagina:The vagina is the female organ of copulation and functions to receive the
penis duringintercourse. It also allows menstrual flow and childbirth. The vagina
extends from the uterus tooutside the body. The superior portion of the vagina is
attached to the sides of the cervix so that a part of the cervix extends into the
vagina.The wall of the vagina consists of an outer muscular layer and an inner
mucous layer. Themuscular layer is smooth muscle and contains many elastic
fibers. Thus the vagina can increasein size to accommodate the penis during
intercourse, and it can stretch greatly during childbirth.The mucous membrane is
moist stratified squamous epithelium that forms a protective surfacelayer.
Lubricating fluid passes through the vaginal epithelium into the vagina.
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HORMONES AND FEMALE CYCLES

Four structure involve in menstruation

1. Hypothalamus
2. Pituitary gland
3. Ovary
4. Uterus

The hypothalamus produces Luteinizing hormone releasing factor which initiate for
menstrual cycle transmitted to anterior pituitary gland to begin the production of
gonadotropic hormones.
Pituitary gland has two anterior lobes that produce luteinizing hormone and follicle
stimulating hormone that acts in ovary. Production of luteinizing hormone releasing
factor is cyclical since menstrual period has cycle.
Follicle stimulating hormone- active early in the cycle and responsible of maturation
of ovum.
Luteinizing hormone- active at midpoint of the cycle and responsible for ovulation.
The influence of these two hormones causes growth of the ovary.
The uterus is responsible from stimulation from the ovary causes changes in the
uterus every month.
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Menopause:
When a woman is 40-50 years old, the menstrual cycles become less regular and
ovulation does not consistently occur during each cycle. Eventually, the cycles stop
completely. The cessation of menstrual cycles is called menopause, and the whole time
period from the onset of irregular cycles to their complete cessation is called the female
climacteric. The major cause of menopause is age-related changes in the ovaries. The
number of follicles remaining in the ovaries of menopausal women is small. In addition
to this, the follicles that remain become less sensitive to the stimulation of FSH and LH.
As the ovaries become less responsive to stimulation by FSH and LH, fewer mature
follicles and corpus luteum are produced.
Gradual changes occur in women in response to the reduced amount of estrogen and
progesterone produced by ovaries. During the climacteric, some women experience
hot flashes, irritability, fatigue, anxiety, temporary decrease in libido, and occasionally
severe emotional disturbances. Many of these symptoms can be treated successfully
with hormone replacement therapy, which usually consists of small amounts of estrogen
or progesterone. A potential side effect of HRT is a slightly increased possibility of the
development of breast cancer, uterine cancer, heart attacks, strokes, and blood clots.
HRT does slow the decrease in bone density that can become sever in some women
after menopause, and decreases the risk of developing colorectal cancer.
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IX:PATHOPHYSIOLOGY

Predisposing
Factors:
*gender (female) Precipitating
*early menarche factors:
(Menarche of patient *Anxiety/Stress
Is 13) *Coffee/ Caffeine
*reproductive years intake
(Age of patient is 38)

Estrogen Dominance
or increase in
Estrogen production

Proliferation of
cells in uterus

Overgrowth of the
endometrial lining

Myoma:
Development of
uterine fibroid

Uterine Cavity
Signs/symptoms: begins to stretch
*Swelling of breasts or increase in size
*Abnormal bleeding
*enlargement of
abdominal area Interference in the
*pain vascular supply
*increased pelvic
pressure
Degeneration of
*dysmenorrhea
the interior part of
fibroid
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Medical management:
Complications: *medication
*Hydration
*anemia Myoma *Blood transfer
*infertility Surgery:
*hemorrhage *myomectomy
*Total Abdominal
Bilateral Hysterectomy
Salpingo Operectomy

If not treated:
If treated:
*can cause
*provides
death
wellness
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SYNTHESIS OF THE DISEASE

Definition of the Disease:
Uterine myomas are themost
common pelvic tumors of
reproductive-age women (Ling& Duff,
2009). They occur inup to 50 % of
patients inautopsy series, and are
morecommon in African-
Americanwomen. They are
composed of smooth muscle cells
within afibrous tissue matrix and
areunicellular in origin. Thegrowth of
these benign tumors tends to be
promoted by estrogen and other
growth factors. Uterine fibroids are
myoma of the uterine smooth muscle.
They may vary in size andlocation.
Leiomyomas may be submucous, subserous, intraligamentous, pedunculated or
parasitic (Ling &Duff, 2009) As other leiomyoma, they are benign, but may lead to
excessivemenstrual bleeding (menorrhagia), often cause anemia and may lead to
infertility. Enucleation isremoval of fibroids without removing the uterus (hysterectomy),
which is also commonly performed. Laser surgery (called myolysis) is increasingly used,
and provides a viable alternativeto traditional surgeries. Oral contraceptive pills can be
used to decrease excessive menstrual bleeding and pain associated with uterine
fibroids. Uterine myomas originate in the myometrium and are classified by location:
*Submucosal lie just beneath the endometrium.
*Intramural lie within the uterine wall
*Subserosal lie at the serosal surface of the uterus or may bulge out from
themyometrium and can become pedunculated. The tumors become malignant in less
than 0.1 % of patients, which should serve as comfort towomen concerned with the
possibility of uterine malignancy in association with a fibroid. (McCann & Holmes,
2003)The actual cause of uterine myomas/ leiomyoma are unknown, however, they are
seen to beincreased with the presence of the following factors.The incidence is higher
on women during the reproductive years where estrogens and other hormones are
actively produced by the body.
`

Many women opt to use oral contraceptives as a birth control method. Oral
contraceptives promote estrogen dominance and eventually influencethe growth of the
cells in the uterus. High-fat diet is also considered a source of estrogen whereas diets
rich in fiber and low in fat decreases estrogen reabsorption. Leiomyoma formation is
also possible because of hyperestrogenism due to progesterone deficiency that is
caused by lutealinsufficiency. Apart from estrogen stimulation, heredity is a factor in the
occurrence of leiomyoma. Fibroids formation is 4.2 times more common in first-degree
relatives than withfibroids without genetic influence.Estrogen is vital in the regulation the
menstrual cycle. Presence of this hormone during the first phase influences the
proliferation of smooth muscle cells in the uterine walls. Overstimulationincreases the
size of the uterine lining and further develops into a fibroid. During menstruation,the
excessively thickened endometrium does not desquamate (shed its lining) easily (or
evencompletely) at the end of the cycle, resulting in prolonged and/or excessive
menstrual bleedings.Following the degeneration of the interior part of the fibroid, are the
degenerative changes thateventually replace smooth muscle cells by fibrous connective
tissue. The fibroid continuallygrows and its size puts pressure on the adjacent organs,
the bladder and rectosigmoid. Urinaryfrequency and constipation, respectively, are the
results of the compression of these organs.

Predisposing Factors
Age and reproductive years- is a risk factor in the disease process of uterine
leiomyoma. This is due to the differencesof estrogen and progesterone levels in
females as they get older and undergo the processes of menopause.
Early Menarche Studies have suggested that an early start of menarche(less
than the average age of 13) contribute to the development of a uterine
leiomyoma, however, how this connection or relationship between the risk factor
and thedisease processes are still unknown (Faerstein, 2001). It is believed that
these factors are precipitated because of the estrogen and progesterone levels in
the body.

Precipitating Factors:
Anxiety/ Stress The stress levels of the individuals can influence the
production of estrogenand progesterone in the body. Stress causes adrenal
gland exhaustion as well as reducedprogesterone levels. This tilts the estrogen
to progesterone ratios in favor of estrogen. Excessive estrogen in turn causes
insomnia and anxiety, which further taxes the adrenalglands. This leads to a
further reduction in progesterone output and even more estrogendominance.
After a few years in this type of vicious cycle, the adrenal glands
`

becomeexhausted. This dysfunction leads to blood sugar imbalance, hormonal

imbalances, andchronic fatigue.
Caffeine or Coffee intake- Increase in coffee consumption. Caffeine intake from
all sourcesis linked with higher estrogen levels regardless of age, body mass
index (BMI), caloricintake, and smoking, alcohol, and cholesterol intake. Studies
have shown that women whoconsumed at least 500 milligrams of caffeine daily,
the equivalent of four or five cups of coffee, had nearly 70% more estrogen
during the early follicular phase than women whoconsume no more than 100 mg
of caffeine daily, or less than one cup of coffee. Tea is notmuch better as it
contains about half the amount of caffeine compared to coffee. Theexception is
herbal tea like chamomile, which contains no caffeine.

Signs & Symptoms with Rationale

Swelling of breasts Enlargement of the breast and tenderness results from a
fluctuation of the hormones progesterone and estrogen.
Dysmenorrhea Due to imbalanced levels of estrogen in the body.
Pain Due to the stretching of the uterus and the proliferation of cells which
damages theendometrial wall.
Increased pelvic pressure Due to the growth of the tumor.
Abnormal Bleeding Due to the growth of the tumor as well as thedeterioration
of the surrounding tissues which may come from the ischemia due to thetumors
growth.
 `

X:DRUG STUDY
Drug name Action Indication Contraindication Adverse Nursing
reaction Considerations
Ranitidine *Competitive *Duodenal *Contraindicate *Burning and *Assist patient for
*Brand name: -ly inhibits and gastric d in patients itching at abdominal pain. Note
Taladine, action of ulcer hypersensitive injection site. presence of blood in
Zantac histamine on ( short- term to drug and emesis, stool, or
*Generic name: the H2 at treatment); those with acute gastric aspirate.
receptor pathologic porphyria.
Ranitidine
sites of hyper
parietal cells,secretory
decreasing conditions
gastric acid such as
secretion Zollinger-
Ellison
syndrome
Ferrous *Elevates the *Dietary *Contraindicate *CNS: CNS * Warn patient that
fumerate serum iron supplement of d with allergy to toxicity, stool may be dark or
*Brand name: concentratio iron. any ingredient; acidosis, coma green.
Acetaminophen n, and is sulfite allergy and death with
*Generic name: then and hemolytic overdose.
converted to anemias.
Fergon
Hgb.
Paracetamol *Decreases * Relief of *Contraindica- * Stimulation, * Assess patients
*Brand name fever by mild-to- ted with allergy drowsiness, fever or pain: type of
Calpol inhibiting the moderate to acetamino- nausea, pain, location,
*Generic name effects of pain; phen vomiting, intensity, duration,
pyrogens on treatment of abdominal temperature, and
Paracetamol
the fever. pain, diaphoresis.
hypothala- hepatotoxicity,
mus heat hepatic
regulating seizure(overdo
centers & by se, Renal
a failure(high,
hypothalamic prolonged
action doses),
leading to leucopenia,
sweating & neutropenia,
vasodilata- hemolytic
tion anemia (long
term use)
thrombocytope
 `

nia,
pancytopenia,
rash, urticaria,

Hypersensiti-
vity, cyanosis,
anemia,
jaundice, CNS,
stimulation,
delirium
followed by
vascular
collapse,
convulsions,
coma, death.
Folic acid *Required for *Treatment for *Use cautiously *Hypersensiti- *Monitor patient for
*Brand name: nucleopro- megaloblastic during lactation. vity: Allergic hypersensitivity
folvite tein anemias due reactions reactions, especially
Generic name: synthesis to sprue, if drugs previously
and nutritional taken.
Folate
maintenance deficiency,
of normal pregnancy,
erythropoie- infancy, and
sis. childhood.
Hydrocortisone *Enters *Replacement *Contraindicate *EENT: *Do not give IM
Brand name: target cells therapy in d with allergy to Cataracts, injections if patient
Selsun Blue and binds to adrenal any component glaucoma (long has
Generic name: cytoplasmic cortical of the drug, term therapy), thrombocytopenic
receptors; insufficiency. fungal increase IOP. purpura.
Hydrocortisone
initiates infections, and
many amebiases.
complex
reactions
that are
responsible
for its anti-
inflammatory
, immune-
suppressive
and salt
retaining
actions.
 `

Tranexamic acid * Tranexamic * Tranexamic * Allergic *Contraceptive * Unusual change in

Brand name: acid is a acid is used reaction to the s, estrogen- bleeding pattern
Hemostan, synthetic for the prompt drug or containing, oral should be
Generic name: derivative of and effective hypersensitivity or Estrogens. immediately reported
the amino control of Presence of Concurrent use to the physician.
tranexamic acid
acid lysine. It hemorrhage in blood clots (eg, with tranexamic
exerts its various in the leg, lung, acid may
antifibrinoly- surgical and eye, brain), increase the
tic effect clinical areas have a history of potential for
through the blood clots, or thrombus
reversible are at risk for formation.
blockade of blood clots.
lysine-
binding sites
on
plasminogen
molecules.
`

Nursing Responsibilities for All Drugs

Before the administration of drug:

Verify Doctors order

Remember the 10Rs of Drug administration

During the administration of drug:

Verify patients identification
Inform the patient with regards to drug administration
Clean the IV port prior to administration of the drug

After the administration of drug:

Monitor patient for adverse effects
Inform patient that easy bruising may occur
Caution patient not to stop taking drug abruptly without first consulting prescriber.
`

XI:NURSING THEORIES APPLICABLE TO THE CASE

Virginia Henderson -The Nature of Nursing
"The unique function of the nurse is to assist the individual, sick or well, in the
performance of those activities contributing to health or its recovery (or to peaceful
death) that he would perform unaided if he had the necessary strength, will, or
knowledge and to do this in such a way as to help him gain independence as rapidly as
possible. She must in a sense, get inside the skin of each of her patients in order to
know what he needs".

Dorothea Orem- Self-Care Model

Self-care comprises those activities performed independently by an individual to

promote and maintain person well-being
Self-care agency is the individuals ability to perform self-care activities
Self- care deficit occurs when the person cannot carry out self-care
The nurse then meets the self-care needs by acting or doing for; guiding, teaching,
supporting or providing the environment to promote patients ability
Wholly compensatory nursing system-Patient dependent
Partially compensatory- Patient can meet some needs but needs nursing assistance
Supportive educative-Patient can meet self-care requisites, but needs assistance with
decision making or knowledge

Lydia E. Hall - The Core, Care and Cure

The theory contains of three independent but interconnected circles:

The core,
The care and
The cure

The core is the person or patient to whom nursing care is directed and needed. The
core has goals set by himself and not by any other person. The core behaved according
to his feelings, and value system.
The care circle explains the role of nurse
The cure is the attention given to patients by the medical professionals.
 `

XII:NURSING CARE PLAN

Assessment Nursing Planning Interventions Rationale Evaluation

Diagnosis
Subjective: *Deficient fluid After 4 hours of INDEPEN- After 4 hours of
*Client volume related nursing care,client DENT: -Maintain nursing care, client
verbalized nay to blood loss as will be able to: -Monitor accurate was able to:
dugo nagagawas evidenced by a. Experience active fluid input and A.understands the
sa akoang vaginal bleeding adequate lossfrom output importance of taking
pwerta for 2weeks, fluid volume bleeding. supplements
Objective: decreasedhemo and especially iron and
*decreased globinand electrolyte -Assess skin - To know if eating nutritious
hemoglobin and hematocrit balance. turgor the client is foods.
hematocrit count result. b. Will be able dehydrated B. Has a blood
-decreased BP: to identify pressure within
90/60mmHg some - Monitor for -Dehydration normal limits
management mental May alter
to maintain status mental
health. changes status,
manifesta-
tions my
include
anxiety and
restlessness

-provide -these may

blood replaced
transfusion blood loss
as
prescribed

-Administer -to stop

drug bleeding
(tranexamic
acid) as
ordered
 `

Assessment Nursing Planning Intervention Rationale Evaluation

diagnosis
Subjective: *Self care deficit *After 3 hours *Provide *To reduce After 3 hours of my
*Di ko kalihok ug related to of my span of activities with the fatigue. span of care, the
tarong as decreased care the client adequate rest client was able to
verbalized by muscle strength will be able to period. move safely and
patient. as manifested by move safely independently.
*Pale limited range of and *Encourage *Promotes
*appeared motion. independently. adequate well-being
discomfort. intake of fluids. and maximize
energy
production.

*To develop
*Advice the muscle
patient to strength.
move her legs
and hands
slowly.
*An
*Implement appropriate
measures to level of
facilitate assistive care
independence can prevent
injury from
activities
without
causing
frustrations

*Encourage *To handle

maximum self
independence accurately
 `

Assessment Nursing Planning Nursing Rationale Evaluation

Diagnosis Intervention

Subjective: Abdominal pain After my span *Encouraged *To relieved After how many
*as patient says related to vaginal of care, the patient to do pain hours of nurse-
sakit- sakit akong bleeding as patient will be relaxing patient interaction,
dapit sa tiyan. manifested by relieved and technique the clients pain
grimace face the pain will scale reduced
Objective: decreased *Promote *To promote a from 8/10 to 5/10.
*Dry lips from 8/10 to comfort positive
*weak in 5/10. measures like atmosphere
appearance fixing the conducive to
*Pale looking bedside learning.
*grimace face
*restless *Provide *To promote
Pain scale: adequate rest healing
8/10 periods.

*Relaxation *The goal of

exercises, these
breathing techniques is
exercises and to reduced
music therapy tension,
subsequently
reducing pain

*Assess the *Some patient

patients will feel
willingness to uncomfortable
explore a exploring
range of alternative
techniques methods of
aimed at pain relief.
controlling pain
`

XIII:DISCHARGE PLANNING
Medication/ Treatment
Instruct the patient to take the medicines that has been prescribed by the
physician.
Tell the patient to take her medicine on time.
The patient should follow the physicians prescription and should take his home
medication on the right time and right.
Environment
Instruct patients relative to provide the patient anenvironment conducive for her
easy recovery.
Herplace/room in their house must be the most accessiblearea.
Her environment should be free fromcontamination and infection.

Health Teaching
Instruct the patient the importance of proper taking of medicationon time.
Instruct the patient and her family the proper wound care to avoidcontamination
and infection at surgical site.
Instruct the patient to eat nutritious foods.
Encourage ambulation for early recovery.
Good sanitation is advised.
Out-patient Department
The patient should return on the scheduled date of herfollow up check-up.
She should take her home medication as prescribed by her physician.
The patientshould visit her physician whenever she feels any discomfort.
Diet
Diet as Tolerated. In order to attain proper diet, thepatient should be guided to
the prescribed foods as advised by herphysician.
Her meals should include Vitamin C-rich foods forwound healing.
Spiritual
Patient should enhance her spiritual relationship withGod.
Have faith and trust in Gods divine power, and believedthat the lord will help in
her early recovery.
Keep on praying,because praying is the number one key to live a healthy life
andto be close to God.
`

XIV:PROGNOSIS

Poor Fair Good

Lifestyle

Medication regimen

Dietary regimen

Financial Support

Emotional Support

Result: Good
The patient is practicing a healthy lifestyle with proper medications. Although not
on proper diet but still eats nutritious foods that are good for her health. She is also rich
in terms with emotional aspects though they are not that abundant in terms of money.
`

XV:LEARNING DERRIVED

For almost 3 weeks of duty, we have experience many difficulties with regards to
theimplementation of interventions. It was not that easy especially we are dealing
withpeople whohave different health problem.For almost three weeks of multi-tasking
andtime management, our CPH exposure hastaught us how to appropriately deal
withpeople. The idea of caring for them is not too easy.Slightly hard, because some of
the
patients has very serious illness which can put us to danger,that is why we are there
tocare for them properly with tender loving care.We have learned to thoroughly
assessour patient to comply with the requisites.

Also, wehave acquainted ourselves with regards to establishing rapport with our
patient to have a trustingrelationship. We have learned how to be patient; to respect and
accept their beliefs and valueswithout judging them; to communicate with
themtherapeutically. Basically, its the feeling of confidence you have in yourself that
willfacilitate accomplishment and error-freeimplementation of nursing care. The nurse
hasa lot of responsibilities to take in, thus, confidenceis a very important
factor.Theexposure wasnt centered mainly to rendering care. It was also focused to
buildinganddeveloping intrapersonal and interpersonal relationships.

To adjust and adapt with theenvironment is a must. Its not that easy. But
mingling with those patients helps you identify your strength and weaknesses, and itaids
in modifying what is somehow negative in our attitudes. To sum this all up, it was a
SUCCESS! Thanks to GOD.
`

XVI:REFERENCES

http://www.drugs.com/zantac.html for the other information about drug study.

2011 LIPPINCOTTS NURSING DRUG GUIDEfor the information on drug study.
Bordage, G. Conceptual frameworks to illuminate and magnify. Medical
Education. 2009; 43; 312-319.
Alligood M.R, Tomey. A.M. Nursing theory utilization and application. 2nd Ed.
Mosby, Philadelphia, 2002.
Tomey AM, Alligood. MR. Nursing theorists and their work.(5th Ed.). Mosby,
Philadelphia, 2002.
George B. Julia, Nursing Theories- The base for professional Nursing Practice,
3rd ed. Norwalk, Appleton and Lange.
Wills Evelyn, McEwen Melanie (2002).Theoretical Basis for Nursing
Philadelphia.Lippincott Williams and Wilkins.
Meleis Ibrahim Afaf (1997), Theoretical Nursing: Development and Progress 3rd
ed. Philadelphia, Lippincott.
Taylor Carol, Lillis Carol (2001) The Art and Science Of Nursing Care 4th ed.
Philadelphia, Lippincott.
Potter A Patricia, Perry G Anne (1992) Fundamentals Of Nursing Concepts
Process and Practice 3rd ed. London Mosby Year Book for the nursing theories
related to the case study.
NURSES POCKET GUIDE DIAGNOSES, PRIORITIZED INTERVENTIONS,
AND RATIONALES for the nursing diagnoses and interventions.
NURSING CARE PLANS; NURSING DIAGNOSIS AND INTERVENTION for our
nursing care plans.
Wallach, J.B. (2007).
Interpretation of diagnostic tests: Doodys all reviewed collection.
Springhouse, A. Lippincott,Williams, & Wilkins for the diagnostic exams and
information.
Hole, J.W. (1993). Human anatomy and physiology.6thedition. Dubuque, IA.
WmC.Brown Publishers, Inc. for the information about the anatomy and
physiology.
Marshall, L., Spiegelman D., Barbieri R., Goldman M.B., Manson, J., Colditz,
GA,Willet, W.C., Hunter, D. (1997)
Variation in the incidence of uterine leiomyoma among premenopausal women
by age and race.
United States National Library of Medicine, National Institutes of Health.Vol. 90,
Issue. 6. Pg: 967-73 for the information about the disease.
`