O U R L A D Y O F F A T I M A U N I V E R S I T Y

College of Nursing





I n Partial Fulfilment of Requirements for RLE 107b

DYSF UCNTI ONAL
UTERI NE BL EEDI NG
A Individual Case Study

Presented To:
MAAM EDWINDA YAP MAN, RN
Submitted By:
MAGAT, JESSIE BOY S.











GROUP of 4Y2-1C
August 07, 2014
I. INTRODUCTION

Patient Nene has been admitted in July 22, 2014 5:06pm. The patient is
16 years old has been reported with a heavy vaginal bleeding. Her final diagnosis is
Dysfunctional Uterine Bleeding.

As a nursing student of OLFU provide this case study as for the purpose
of this case is to be familiar with Dysfunctional Uterine Bleeding. ; How it is start,
what the causes are and what are the signs and symptoms; especially how to
prevent, treat and manage the patient by giving medication for treatment and
providing rapport. .I chooses this case study because this is the first time weve
encountered in the entire rotation and because some of the patient in OB Female
rooms are Normal Spontaneous Delivery (NSD). I is also fond to know about the
important things to consider and word to discuss about this case.

II. PATIENT HEALTH HISTORY
A. Patient Biographical I nformation

Name: Patient Nene

Age: 16 years old

Gender: Female

Birthday: March 23, 1998

Birthplace: Quezon City, Lagro

Civil Status: Singel

Address: #199 purok 1, Quezon City, Lagro

Educational Level: High school

Occupation: None

Race/ Ethnic Group: Tagalog

Religion: Roman Catholic

Nationality: Filipino

Source of information: Patient A

Reliability: 99%
B. Chief Complaints: Vaginal Bleeding
Final diagnosis: Dysfunctional Uterine Bleeding

C. History of Present Illness:
5 day prior to admission- unusual bleeding described as messy lasting only for
2 days, consuming 2 pads.

3 days prior to admission- vaginal bleeding noted to be profuse, consuming 9 pads
fully and with pain in lumbosacral region

2 days prior to admission- still with bleeding, with lumbosacral pain and headache

D. Past Medical/ Health History

Problems at birth- none

Childhood illnesses- none

Immunization Fully immunized

E. Family Medical/
Illness

Family History
In her father side, her father is recently been diagnosed with Hypertension and an
alcoholic drinker.. In her mother side; her mother has a history of hypotension,
and anemia.

F. Review of System

Skin, Hair & Nails-

Skin Pallor

Hair- Black

Nails- Pinkish


Head and Neck

Head- No headache reported

Neck- No stiffness of neck felt, with melasma at back of neck

EENT & Sinuses

Ears- No drainage or ringing ears reported

Eyes- Blurred Vision when reading (Farsighted)

Nose- No discharges

Throat- No pain or hoarseness of voice felt

Chest and Lungs

Chest- No pain reported

Lungs- No shortness of breath or pain reported

Breast & Regional Lymphatics

Breast

no feeling of tenderness, and dark areola

Regional Lymphatics- Lymph nodes are not enlarged nor tender

Heart, Neck Vessels & Central CVS

Heart- No pain, distress or palpitations felt

Neck vessels- are not distended.

Cardiovascular System- No tightness, edema, or orthopnea reported

Abdomen

No abdominal pain, bowel movements are good, with linea nigra

Genitalia and Reproductive System

With Vaginal discharge (Lochia rubra)

No pain during sexual intercourse reported

Anus, Rectum & Prostate

Anus- No itchiness or lesion reported

Rectum- No itchiness or lesion reported

Musculoskeletal System and Extremities

No muscle pain, stiffness or swelling felt

Neurologic

No dizziness and weakness as reported

III. ANATOMY AND PHYSIOLOGY




















A. External Structures:
1. Mons Veneris/Pubis Pad of fat which lies over the symphysis pubis where dark
and curly hair grow in triangular shape that begins 1-2 years before the onset of
menstruation. It protects the surrounding delicate tissues from trauma.
2. Labia Majora Two (2) lengthwise fatty folds of skin extending from mons veneris to
the perineum that protect the labia minora, urinary meatus and vaginal orifice.
3. Labia Minora 2 thinner, lenghtwise folds of hairless skin extending from clitoris to
fourchette.
Glands in the labia minora lubricates the vulva
Very sensitive because of rich nerve supply
Space between the labia is called the Vestibule
4. Clitoris small, erectile structure at the anterior junction of the labia minora that
contains more nerve endings. It is very sensitive to temperature and touch, and secretes a
fatty substance called Smegma. It is comparable to the penis in its being extremely
sensitive.

5. Vestibule the flattened smooth surface inside the labia. It encloses the openings of the
urethra and vagina.
6. Skenes Glands/Paraurethral Glands located just lateral to the urinary meatus on
both sides. Secretion helps lubricate the external genital during coitus.
7. Bartholins Gland/Vulvovaginal Glands located lateral to the vaginal opening on
both sides. It lubricates the external vulva during coitus and the alkaline pH of their
secretion helps to improve sperm survival in the vagina.
8. Fourchette thin fold of tissue formed by the merging of the labia majora and labia
minora below the vaginal orifice.
9. Perineum muscular, skin-covered space between the vaginal opening and the anus. It
is easily stretched during childbirth to allow enlargement of vagina and passage of the
fetal head. It contains the muscles (pubococcygeal and levator ani) which support the
pelvic organs, the arteries that supply blood and the pudendal nerves which are
important during delivery under anesthesia.
10. Urethral meatus external opening of the urethra. It contains the openings of the
Skenes glands which are often involved in the infections of the external genitalia.
11. Vaginal Orifice/Introitus external opening of the vagina, covered by a thin
membrane called Hymen.




















B. Internal Structures:






















1. Fallopian tube/Oviduct 4 inches long from each side of the uterus (fundus). It
transports the mature ova form the ovaries to the
uterus and provide a place for fertilization of the
ova by the sperm in its outer 3rd or outer
half. Parts:
Interstitial lies within the uterine wall
Isthmus portion that is cut or sealed in a tubal ligation.
Ampulla widest, longest portion that spreads into fingerlike projections/fimbriae
and it is where fertilization usually occurs.
Infundibulum - rim of the funnel covered by fimbriated cells (hair covered
fingerlike projections) that help to guide the ova into the fallopian tube.
2. Ovaries Oval, almond sized, dull white sex glands on either side of the uterus that
measures 4 by 2 cm in diameter and 1.5 cm thick. It is responsible for the production,
maturation and discharge of ova and secretion of estrogen and progesterone.
3. Uterus hollow, pear-shaped muscular organ, 3 inches long, 2 inches wide, weighing
50-60 grams held in place by broad and round ligaments, and abundant blood supply
from the uterine and ovarian arteries. It is located in the lower pelvis, posterior to the
bladder and anterior to the rectum. Organ of menstruation, site of implantation and
provide nourishment to the products of conception.
Layers:
1. Perimetrium outermost layer of the uterus comprised of connective tissue, it offers
added strenght and support to the structure.
2. Myometrium middle layer, comprised of smooth muscles running in 3 directions;
expels fetus during birth process then contracts around blood vessels to prevent
hemorrhage.
3. Endometrium Inner layer which is visibly vascular and is shed during menstruation
and following delivery.
Divisions of the Uterus:
1. Fundus upper rounded, dome-shaped portion that can be palpated to determine uterine
growth during pregnancy and the force of contractions and for the assessment that the
uterus is returning to its non-pregnant state following child birth.
2. Corpus body of the uterus.
3. Isthmus area between corpus and cervix which forms part of the lower uterine
segment. It enlarges greatly to aid in accommodating the fetus. The portion that is cut
when a fetus is delivered by a caesarian section.
4. Cervix lower cylindrical portion that represents 1/3 of the total uterus. Half of it lies
above the vagina; half of it extends to the vagina. The cavity is termed the cervical
canal. It has 2 openings/Os: internal os that open to the uterine cavity and the external os
that opens to the vagina.
5. Vagina a 3-4 inch long dilatable canal located between the bladder and the rectum, it
contains rugnae which permit considerable stretching without tearing. It acts as a organ
of intercourse/copulation and passageway for menstrual discharges and fetus.
Doderleins bacillus is the normal flora of the vagina which makes the pH of vagina
acidic, detrimental to the growth of pathologic bacteria.















IV. PATHOPYHSIOLOGY












MODIABLE FACTORS:

Lifestyle:
Diet: High in fiber,
Low in Iron.


NON-MODIABLE FACTORS:

Age: Adult (16 years old)
Gender: Female
Heavy Menstruation
History of having Anemia

Continues bleeding
Blood loss/ Hemorrhage

Decreased intravascular volume

TheThe compensatory increase in iron absorption causes an increase in iron-binding capacity
(TIBC/Transferrin level)

Serum iron falls to < 50 g/dL and transferrin saturation to <
16%. The serum ferritin receptor level rises (> 8.5 mg/L)

Erythropoiesis is impaired

Serum ferritin will become low (< 20-30 mcg/L)

Depletion of iron stores in bone marrow
Low Hemoglobin (below 12mg/dL)
Low Hematocrit (Below 33%)

Reduction in oxygen-carrying
capacity of Red Blood cell

Small Red Blood cell
(Microcytic)

Less Hemoglobin than Average
Red Blood cell (Hypochromic)

Signs and Symptoms:
Fatigue/ Generalized weakness
Headache/Dizziness Pale skin color
or Pallor Sore tongue Light-
headedness.

V. Diagnostic Test
I. LABORATORY EXAM

A. Urinalysis (7-03-12)
Lab test Result Normal Interpretation
Macroscopic
Color Straw Varying degrees of yellow Normal
Transparency Clear Clear Normal
Specific Gravity 1.000 Variable but 1.023 Low concentration of urine
pH 6.0 Variable (usually acidic) Normal
Chemical Tests
Sugar Negative Negative Normal
Albumin Negative Negative Normal
Microscopic
RBC 0-4/ HPF 0-1/ HPF High due to underlying disease
condition
WBC 0-2/HPF Female: 0-5/HPF
Male: 0-2/HPF
Normal
Epithelial cells Few Few
Mucous threads Occasional common
Bacteria Occasional common
Amorphouserates Occasional Many

A. Hematology (7-03-12)
Lab Test Result Normal Interpretation
Components
WBC 8.4 x 10^g/L Adult:5-10 x 10^g/L Normal
Hemoglobin 120 g/L M: 140-170 gm/L Low, due to hemorrhage
brought about by underlying
disease condition (H.mole)
Hematocrit 0.382 gm/L F: 120-140 gm/L Low, due to hemorrhage
brought about by underlying
disease condition (H.mole)
Differential
count

Neutrophils 0.61% Adult: 0.45-0.65% Normal
Lymphocytes 0.30% Adult: 0.25-0.5% Normal
Monocytes 0.06% 0.02-0.06% High, a sign of infection
Eosinophils 0.03% 0.02-0.04% Normal
Platelet 246 x10^g/L 150-450 x 10^g/L Normal
MCV 80.6 fL 80-100 fL Normal but close to being low
which indicates anemia
MCH 25.4 pg 21.31pg Normal
MCHC 315g/L 320-340 g/L Normal
RDW 12.5% 11.6-14.6% Low, due to hemorrhage
brought about by underlying
disease condition (H.mole)


B. Chemistry Test (7-03-12)
Lab Test Result Normal Interpretation
BUN 2.3 mmol/L 3.0-9.2 mmol/L Low caused by pregnancy
Creatinine 52 umol/L 63.6-110.5 umol/L Low caused by loss of muscle
mass and pregnancy
Sodium 138 mmol/L 137-144 mmol/L Normal
Potassium 3.7 mmol/L 3.5-5 mmol/L Normal
Chloride 108 mmol/L 98-107 mmol/L High caused by acidosis
A-AST 26 U/L 5-34 U/L Normal
A-ALT 16 U/L 0-55 U/L Normal

C. Serology Thyroid Function Test (7-04-12)
Lab Test Result Normal Interpretation
FT 4 1.08 ng/dl 0.71-1.85 ng/dl Normal
TSH 3
rd

generation
0.74 uIu/ml 0.47-4.64 uIu/ml Normal

D. Complete Blood Count
Examination
CBC

Normal Result Result Interpretation
Hemoglobin 130-180 117.0 Decrease result could
pertains to anemia or
bleeding due illness.
Hematocrit 0.40-0.50 0.35 Decreased result
could pertains to
anemia or bleeding
due illness.
RBC Count 4.5-6.2 4.37 Decrease levels of
RBC could also be
secondary to anemia
or bleeding
WBC Count 4.0-10.0 13.10 Increase in WBC
count could represent
an ongoing infection
Segmenters/
Neutrophils
0.55-0.65 0.77 Increase levels of
your neutrophils
usually represent and
ongoing infection, an
inflammation,
malignancy, cause by
some drugs.
Lymphocytes 0.25-0.35 0.08 Decrease level of
lymphocyte count is
usually not
significant.
Eosinophils 0.02-0.04 0.05 Increase in cases of
allergy, asthma and in
parasitic infections.
Basophils 0.00-0.01 0.00 Normal
MCV 80-100 78.9 Decreased average
size of the red blood
cell.
MCH 26-32 26.8 Normal
MCHC 32.0-36.0 34 Normal
RCW 11.0-15.0 18.21 Increase in
accordance with
variation in red cell
size (anisocytosis).
Platelet Count 130.0-400.0 354 Normal
















VI. Drug Study
Physicians Order Ascorbic acid 1cap BID P.O.
Generic Name Ascorbic Acid
Brand Name Apo-C, Ascorbicap, Cebid, Cecon, Cenolate, Cemill, C-Span,
Cetane, Cevalin, Cevi-Bid, Ce-Vi-Sol, Cevita, Flavorcee,
Redoxon, Schiff Effervescent, Vitamin C, Vita-C.
Classification Vitamin
Mechanism of Action Vitamin C or L-ascorbic acid, or simply ascorbate (the anion of
ascorbicacid), is an essential nutrient for humans and certain
other animal species. Vitamin C refers to a number of vitamers
that have vitamin C activity in animals, including ascorbic acid
and its salts, and some oxidized forms of the molecule
like dehydroascorbic acid. Ascorbate and ascorbic acid are both
naturally present in the body when either of these is introduced
into cells, since the forms interconvert according to pH.
Vitamin C is a cofactor in at least eight enzymatic reactions
including several collagen synthesis reactions that, when
dysfunctional, cause the most severe symptoms of scurvy.
Side Effects
GI disturbances in high doses (nausea,
vomiting, and diarrhea).



Bright yellow discoloration of urine
Nursing Management

Instruct Client to take the medication

after meals to avoid GI upset.

Instruct client to measure and follow

the prescribed dosage of the
medication to avoid overdosing.

Advise the client that yellow

discoloration of urine is normal
Adverse Effects
Rarely, hypersensitivity reaction

Flatulence, constipation
Nursing Management

Instruct the client to discontinue the

medication, and refer to the doctor.

Instruct the client to discontinue the

Heartburn
medication, and refer to the doctor.

Instruct the client to take the

medication after meals to avoid
adverse reactions.

Physicians Order Ferrous Fumerate 1cap, TID P.O.
Generic Name Ferrous Fumerate
Brand Name Femiron, Ferretts, Ferro-Sequels,
Ferrocite, Hemocyte, Ircon
Classification Antianemic/ Supplement
Mechanism of Action Iron is an essential component in the physiological formation of
hemoglobin, adequate amounts of which are necessary
for effective erythropoiesis and the resultant oxygen transport
capacity of the blood. A similar function is provided by iron in
myoglobin production. Iron also serves as a cofactor of several
essential enzymes, including cytochromes that are involved in
electron transport. Iron is necessary for catecholamine
metabolism and the proper functioning of neutrophils.

Side Effects
Stomach upset

Diarrhea (Black or darker than normal appearing stool).



Temporary Staining of teeth
Nursing Management

Instruct Client to take the medication

after meals to avoid GI upset.

Instruct client not to take with milk

or antacids

Inform patient the color stool black

may be black

Inform patient that temporary

staining of the teeth is normal
Adverse Effects
Nausea and Vommiting

Epigastric pain
Nursing Management

Instruct client to take the medication

after snack or meal

Instruct client to take the medication

2 hours prior to or 4 hours after
antacids

















VII. Nursing Care Plan
Assessment Diagnosis Planning Implementation Rationale Evaluation
Subjective Data:

Nanghihina ako mula
kagabi, sobra ata kasi
pagdurugo ng puson ko
kaya siguro ako
nanghihina. bata pa kasi
ako as verbalized by the
patient.

Objective Data:

Pallor,
Generalized weakness
Vital signs:
T: 37.3 C
RR: 23 bpm
PR: 88 cpm
BP: 100/60 mm/Hg


Fatigue
related to
the bloods
decreased
hemoglobi
n and
diminished
oxygen-
carrying
capacity
secondary
to anemia

Long term Goal:
After 16 hours
of duty the
patient will be
able to enhance
her knowledge
about her
disease, and to
facilitate health
promotion.

After 4 hours
of health
teaching, The
patient will be
able to identify
foods rich in
iron and the
patient will be
able to
verbalize the
dosage of her
medication.


Short Term Goal:
After 16 hours
of duty, the
patient will be
able to
verbalize the
Independent
Intervention:

Explain to the client

the procedures and its
purpose

Assess vital signs.

Evaluate need for

individual assistance
or assistive device.

Encourage client to
do whatever possible

To reduce anxiety of the

patient.
To prepare the patient for the
procedure.

To evaluate fluid status

and cardiopul onary
response to activity.

To determine the need for

doing activities or
movement.

To increase activity level

as tolerated


The patient is able
to improve her
activities of daily
living as evidenced
by the use of
assistive devices
and support
system. The
patient is able to
verbalize the foods
and diet which are
rich in iron as
evidence by eating
1 egg
yolk, 1 small liver
and small slice of
red meat.
Goal met:

understanding
of individual
therapeutic
interventions
medications.
And its
purposes.

After 4 hours
of health
teaching, the
patient will be
able enhance
her activities of
daily living as
evidenced by
report of
improved
sense of
energy.

Encourage use of
assistive devices like
wheelchair

Instruct patient to sit

instead of stand
during care and other
activities.

Provide diversional
activities like
having her to talk
with her relatives



Instruct patient to
eat Iron rich foods
(e.g. liver or animal
organs, egg, fish,
poultry, leafy
vegetables and
dried fruits)

Instruct patient to
increase her fluid

To conserve energy for

other task

To conserve energy:

Pleasurable activities can

refocus energy and
diminish feelings of
unhappiness and
sluggishness.

To Increase the Total

Body iron of the patient.
To prevent anemia and to
help in producing more
red blood cells.

To rehydrate the patient.

intake.

Observe and
measure fluid losses
(e.g. bleeding)

Provide Oral care

Instruct the Family

to bath the patient
everyday or other
day.

Give/administer
medications as
instructed by the
doctor.

Administer Blood
transfusion as
ordered by the
Doctor.

Replace electrolytes
as ordered (Inserting

To determine
replacement needs

For patients comfort and

to prevent dryness of
mucous membrane.

To provide optimal skin

care and to prevent
dryness of skin.

To Follow patients
therapeutic regimen to
stabilize her wellness
of health.

To replace Blood volume

loss.

To replace electrolytes to
IV fluids as ordered)



Collaborative
Intervention:

Refer patient to
Radiology
Technician for X-
ray as ordered by
the doctor.





prevent dehydration and
further complications.

For further evaluation

and analysis of the
patients disease.













Assessment Diagnosis Planning Implementation Rationale Evaluation
Subjective
Data:

Dinudugo ako
nagiging kulay
brown siya as
verbalized by the
patient.

Objective Data:

Generalized
weakness, with
lochia rubra
Pale in
appearance
Vital signs:
T: 37.3 C
RR: 23 bpm
PR: 88 cpm
BP: 100/60
mm/Hg



Fluid volume
deficit related to
blood loss
secondary to
anemia

After 4 hours of
nursing intervention
the patient will be
comfortable and
understand the
situation
Assess skin
turgor and
moisture of
mucous
membranes.

Monitor Vital
signs. Evaluate
peripheral
pulses, capillary
refill.



Monitor I&O;
include all
output sources
(e.g., emesis,
diarrhea.


Observe for
bleeding
tendencies; Note
the amount,
lochia/color of
the vaginal
discharge.


Encourage rest.

Indicators of
hydration status/
degree of
deficit.


to have a
baseline data,
reflects
adequacy of
circulating
volume.

Decreasing renal
output and
concentration of
urine suggest
developing
dehydration and
need for fluid
replacement.
Early
identification of
problems (which
may occur as a
result of cancer),
allows for
prompt
intervention.

Prevent
unnecessary
The patient is able
to demonstrate a
behaviour of
correcting her fluid
deficit as evidenced
of increased fluid
intake by 500cc and
was able to
understand the
situation.

energy
expenditure
related to
vomiting (as
may trigger) and
bleeding (loss of
blood/RBC).




Assessment Diagnosis Planning Implementation Rationale Evaluation
Subjective Data:

Natatakot akobigla na
langakong dinugo as
verbalized by the patient.

Objective Data:

Restlessness.
Increased tension.
Feelings of
helplessness
Vital signs:
T: 37.3 C
RR: 23 bpm
PR: 88 cpm
BP: 100/60 mm/Hg

Fear related
to change in
health
status as
manifested
by
increased
tension.

After 4 hrs. Of
nursing
interventions, the
patient will report
fear and anxiety
are reduced to a
manageable level.
Independent:

Identify patients
perception of threat
represented by the
situation.


Encourage patient
to acknowledge and
express fears.


Provide opportunity
for discussion of
personal feelingsor
concerns and future
expectations.



Defines scope of
individual problem,
separate from
physiological causes, and
influences choice of
intervention.
Provides opportunity for
dealing with concerns,
clarifies reality of fears,
and reduces anxiety to
manageable level.
Family members have
individual responses to
what is happening, and
their anxiety may be
communicated to patient,
intensifying this emotion.
After 4 hrs off
nursing
interventions, the
patient was able
to report fear and
anxiety are
reduced to a
manageable level.

Identify previous
coping strengths of
the patient and
current areas of
control or ability
Encourage use of
relaxation
technique like deep
breathing, guided
imagery.

Focuses attention on own
capabilities, increasing
sense of control.


Provides active
management of situation
to reduce feelings of
helplessness.

VIII. Discharge Planning
Management
Instructed the patient to take the following home medication as ordered by the physician.

Exercise / Activity
Inform patient that there are no restrictions in activity as long as her condition becomes
okay. She can go back to her daily activities whenever she thinks she can.
Treatment
Remind patient to take iron supplements as doctors ordered.
Health Teaching
Advice patient to increase protein and iron reach food intake.
Increase oral fluid intake.
OPD
Instruct patient to have a follow up check-up as advised by her doctor.
Spiritual
Advise the family to help the patient to express her anger and sense of unfairness at this
situation. She may feel inadequate because something went wrong with her body. She