CHAPTER I
Introduction
Abnormal uterine bleeding is defined as bleeding between monthly periods,
prolonged bleeding or an extremely heavy flow or also called as condition
of DUB (dysfunctional uterine bleeding. Results in irregular shedding of
endometrium lining. AUB and its sub group, heavy menstrual bleeding (HMB),
are common conditions affecting 14–25% of women of reproductive age and
may have a significant impact on their physical, social, emotional and
material quality of life.
It can occur at any time during your monthly cycle, including during normal
menstrual period. There is a wide range of normal when talking about
menstrual period but it shouldn’t be a problem for you time after time.
If it keeps you from doing your daily activities or makes you miss work
or school, it may be worth going to the doctor and get it checked out.
Menstrual cycle should be fairly regular. The length of each cycle should
not change more than a week meaning it should not be less than 3 weeks and
more than 5 weeks per cycle. Another sign of abnormal uterine bleeding is
the length of your menstrual cycle.
If it last less than 2 days or lasts more than a week indicates it is abnormal.
Another way to tell if you have abnormal bleeding is if the amount of blood
is more than 5 tablespoon. Usually women lose about 2 tablespoons of blood
each period. Another way to check for abnormalities is you have spotting
between periods or bleeding after having sex (assuming his penis is not
too big). There is no definite statistical prevalence data worldwide. But
on a study at Beijing Shijitan Hospital there is a total of 1053 women aged
15 to 55 years of age with chronic abnormal uterine bleeding were evaluated
between November 2016 and May 2017. This statistical data tackles the causes
of those abnormal uterine bleeding cases.
Ovulatory dysfunction was the most frequent finding in women with chronic
AUB accounting for 608 (57.7%) cases. Polyp was found in 171 (16.2%) cases,
Leiomyoma was found in 130 (12%) women, Adenomyosis is found in 52 (4.94%)
women, Endometrial cause found in 28 (2%) women, Latrogenic is found in
23 (2%) women, Malignancy and Hyperplasia is found in 20 (1.9%) women,
Coagulapathis found in 10 (1%) women and Not yet classified in 10 (0.9%)
women.
M.B. is a 44 year old woman who just got married and had abnormal uterine
bleeding for 10 years. She has been advised to get check up on a doctor
but she doesn’t want to because she is afraid to know her problem. Two weeks
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Vaginal bleeding still persisted to the point that she have to use 3-5
perineal pads per day. Sometimes she uses diapers to keep it from leaking
at night.
We group two chose this case because we observed that this case will
improved our understanding on the patient and further enhanced our nursing
care services in accordance to patient’s wellness and well-being.
M.B. is a 44 year old woman who just got married and had abnormal uterine
bleeding for 10 years. She has been advised to get check up on a doctor
but she doesn’t want to because she is afraid to know her problem. Two weeks
prior to admission, she had an onset of vaginal spotting and hypogastric
pain. Since she doesn’t want to go to the doctor she tolerated her condition.
More than a week later the pain is still there so she went to the local
hospital to consult her condition. CBC was done which showed that her
hemoglobin of 3.2 g/dl thus she referred to the NOPH.
Vaginal bleeding still persisted to the point that she have to use 3-5
perineal pads per day. Sometimes she uses diapers to keep it from leaking
at night.
We group two chose this case because we observed that this case will
improved our understanding on the patient and further enhanced our nursing
care services in accordance to patient’s wellness and well-being.
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OBJECTIVES
To further understand, learn and gain more information about the dengue
fever. This study accomplished and created for a comprehensive analysis
related to a specific illness/disease.
Knowledge:
Skills :
1. Assess the general health status of the patient and gather data needed
for care.
4. Apply the knowledge, skills and attitude we learned from our Clinical
Instructor and experience to the nursing field in providing health care
and wellness for the patient.
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Attitude:
Scope
In this study we are tackling about the biographical data to know personal
information of the patient. Nursing history that aid to gather data about
her past, present and family illnesses. Physical assessment that aid to
assess the general condition and possible manifestation related to the
condition of the patient. Functional health pattern that aid to trace or
to know the way of living of the patient with regards about the religion
and culture. Diagnostic test and lab results to determine or help the patient
and health care provider understand and analyze the condition of the
patient.Nursing care plan provides direction on the type of nursing care
the patient may need. To facilitate standardized, evidence-based and
holistic care.
Limitation
In the study there are different circumstances that we are dealing. The
hindrances that we encountered during this case study is limited patient
since other patients are not related in Ob-gyn case. Also due to schedule
of clinical duty. Sometimes the patient don’t have enough diagnostic and
lab results that may interfere in tracing the pathophysiology of the
condition of the patient to go deep what is really the cause of the condition.
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Name: M.B
Nick-name: Lyn2x
Phone#: 093671022317
Sex: Female
Religion: S.D.A
Spouse: F.B
Contact: E.B
Relationship: Employer
OB-Gyne/Physician:Dr. C.A.C
Source of information:
Client - 60%
Sister - 10%
Husband -10%
Chart - 20%
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Health History
Chief Complaint
Patient had an onset of fever and productive cough 4 days prior to admission.
Patient looks fatigue, sleepy and tired. Because of his cough he cant sleep
well and every cough there’s a presence of pain in his upper quadrant of
abdomen with a pain scale of 5/10(average). And got his CBC result his
platelet is 60 thus the physician’s admitting impression is dengue fever
without warning signs; URTI.
Base on her medical history,he was admitted in the same hospital and
diagnosed as pneumonia when he was 5 months old. Prior to admission he was
experiencing fever and cough so he took paracetamol and
Gynecology History
She started her first menstruation at the age of 15 years old,with a regular
interval every month that lasted usually for 8 - 10 days,in a moderate flow
with dysmenorrhea every month. Recently her last menstrual period was Feb.
9, 2019 and still persisted to weeks after.
Prior to admission: patient stated that general health has been OK. No colds
noted in the past few years. Patient said that to keep her body healthy,
she always eats nutritious foods and stated that no time for exercise because
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she’s a domestic helper. Not using any cigarettes, alcohol and drugs. No
accidents noted. Hard for her to follow the doctor’s order just like in
getting an ultrasound. She thinks that she’s in menopausal stage that’s
why she had bleeding. 10 years ago, she started to have dysmenorrhea, heavy
bleeding and longer periods of menstruation for 8- 10 days. No actions taken
when symptoms perceived.
Prior to admission- Daily food intake depends on what her employer wants
to eat but usually her breakfast is egg with coffee. During lunch they always
eat foods that has soup especially “tinola” because that’s the favorite
food of her employer. Snacks is usually fried banana and “balanghoy.” Meat
is restricted on her religion. She drinks a lot of water with a maximum
of 12 glasses per day. Weight is 56 kg and no weight gain nor weight loss,
height is 5’1. Appetite is good no discomforts in swallowing and no diet
restrictions. Wound healing is fast. Skin is dry with no lesions and exposed
areas are darker than the unexposed ones. Mole is present in the face. There
are 30 teeth and 2 are missing, no dentures, dental carries are noted as
well as plaques.
3.Elimination Pattern
Prior to admission: Defecates for at least twice a day. The color depends
on the food that she ate on that day as well as the consistency but usually
it is yellowish with a little brown on it and stool is soft with no difficulty
in defecating. Not using any laxatives and there’s no problem in controlling.
Urinates for at least 6 times in a day with no pain and problem in controlling.
Yellowish in color. No excessive perspiration because house is well
ventilated.
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glass. Sweats a lot because of poor ventilation and room is crowded. Body
odor is present also.
Prior to admission: Energy is more than enough for desired and required
activities. No exercise because of the type of her work. Spends her
spare-time in watching television and sometimes if she feels going out,
she’ll watch basketball and socialized with her friends. She can take care
of herself fully like in feeding, bathing, toileting, dressing, grooming,
cooking, shopping, bed mobility, home maintenance and general mobility.
During hospitalization: She likes to lie in bed the whole day and sleeps
whenever she wants to. Stands only when urged to urinate or defecate. Sits
on bed when eating and drinking. No exercise and if she’s awake she prefers
to have her phone with her to do things like games and watching videos on
YouTube. She requires assistance or supervision from others in feeding,
bathing, toileting, bed mobility, dressing, grooming, and general mobility.
Pulse rate is 84 bpm and regular, respiratory rate is 18 cpm and regular,
blood pressure is 110/70 mmHg. Patient is not well groomed, poor hygiene
and energy level is low.
6.Cognitive-Perceptual Pattern
Prior to admission: No hearing difficulty and not using any hearing aids.
Vision is good, not wearing any glasses and haven’t had her first check
up on her eyes. No changes in memory noted. She stated that in terms of
making important decisions, she thinks of it overnight and found it hard
for her. To learn new things, she prefers to watch it first and then do
it the next time. She complains of dysmenorrhea and heavy bleeding every
menstruation without taking any actions on it. The daughter of her employer
is a nurse and advised her to take Ferrous because she looks so pale already.
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Prior to admission: Describes self as a blessing from above and she feels
good about it. 10 years ago, her menstrual pattern was changed. She started
experiencing dysmenorrhea, heavy bleeding and long periods of menstruation
that will last for 10 days and more. She said that whenever her menstruation
is fast approaching, she gets annoyed easily and gets mad after all. This
triggers when her boyfriend which is now her husband teases her for simple
things or if he has done something that makes her mad. She’s afraid of having
check ups because of the possible outcomes. She doesn’t feel in losing hope
because her employer is very supportive because she has been living with
them for 28 years already as well as her husband.
Prior to admission: She lives with her employer in Tayasan for 28 years
but now she’s married, she’s living now in Jimalalud with the sons and
daughters of her husband. She’s having difficulty in adjusting to a new
environment and there are conflicts between them and the children. No one
is depending on her but now she depends on her husband’s salary because
she’s out of work already. She has close friends and socialized with them
for once in a while. She doesn’t feel any loneliness or emptiness at all.
She said that everything is going well. Income is sufficient for daily needs.
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least twice. On their first intercourse, she said that she felt pain and
it bleeds a little but was gone the next time they had their intercourse
without the use of contraceptives. Menstruation started at the age of 15
and having no problems with it but 10 years ago, she started to have problems
in menstruation like heavy bleeding that she was able to consume 3-5 pads
per day and sometimes uses diaper.
During admission: Heavy bleeding was noted and did pelvic examination in
the delivery room.
Prior to admission: The only change that happened on her is marriage. Her
husband is always there for her in everything she does and supports in doing
big and important decisions. She’s always relaxed and if tense she breathes
in and out to relax without the use of medicines, drugs and alcohol. If
there are big problems that will happen to her, she doesn’t lose hope and
will do everything to handle it well and of course with the grace and guidance
of God. So far, she’s making good decisions.
During hospitalization: it’s her first time being admitted that’s why she
was afraid of what will happen to her but luckily her husband was always
there to support. She said that she always prays to God for her fast recovery.
Prior to admission: Patient said that it’s hard for her to get things from
life easily because of her educational attainment but she added that as
long as she’s happy as well as the people around her makes her realized
that she’s contented already. She has plans on conceiving a child someday.
Religion is very important for her and always go to church every Saturday.
She said that their Pastor will give advises on her.
GENERAL CONDITION
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Review of System
B.Assessment of Systems:
Temperature: 35.8 C
1. Integumentary System:
Skin color is brownish; darker on the exposed areas and lighter
on the unexposed ones, warm with no lesions, no contractures and
skin breakdowns noted. Skin is smooth, dry and even. Calluses are
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Ears: Ears are equal in size bilaterally. The auricle aligns with
the corner of each eye. Earlobes are attached to the sin with no
apparent lobe. Skin is smooth without lesions, lumps, or nodules.
Color is consistent with facial color. No discharges noted. A small
amount of odorless cerumen is the only discharge present which has
a color of yellow and is soft. Canal walls are pink and smooth without
nodules. Tympanic membrane has no bulging or retraction
Nose: Color is the same as the rest of the face, nasal structure
is smooth and symmetric, and no tenderness. Able to sniff through
each nostril. Nasal mucosa is dark pink, moist and free of exudate.
Nasal septum is intact and free of ulcers or perforations.
Sinuses: Frontal and maxillary sinuses are non-tender to palpation,
and no crepitus is evident.
Mouth and Throat: Lips are smooth, and dry without lesions or
swelling. There are 30 teeth and 2 are missing, no dentures, dental
carries are noted as well as plaques. Buccal mucosa is pinkish, smooth
and moist without lesions. Tongue is pink, moist and moderate size
with papillae present. The tongue’s ventral surface is smooth and shiny
with visible veins and no lesions noted. Frenulum is in the midline.
Sides of the tongue has no lesions, ulcers or nodules. It has strong
resistance and can distinguish between sweet and salty. Hard palate
is pale. No unusual odor is noted. Uvula is in the midline with no
redness of or exudate from uvula or soft palate. Tonsils are present.
They are pinkish and symmetric with no exudate, swelling or lesions.
Throat is pinkish without exudate or lesions.
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5. Cardiovascular System:
Jugular vein is not distended, bulging or protruding. No blowing
or swishing or other sounds are heard. Apical impulse is not visible
and palpated in the mitral area. No pulsations or vibrations are
palpated in the areas of the apex, left sternal border, or base.
Rate is at 89 bpm with a regular rhythm. Radial and apical pulse
rates are identical. S1 corresponds with each carotid pulsation
and is loudest at the apex of the heart. S2 immediately follows
after S1 and is loudest at the base of the heart. No extra sounds
are heard. No murmurs are heard. S1 and S2 heart sounds is present.
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8. Abdomen
Abdomen is lighter in color than the exposed ones. Free from lesions
or rashes. Umbilical skin tones are similar to surrounding
abdominal skin tones. Located in the midline at lateral line. It
is inverted and is round. Abdomen is rounded and symmetric. It does
not bulge when patient raises head. Soft clicks are heard at a rate
of 20 per minute. No bruit sounds were heard. No friction rub over
liver or spleen is present. Tympanic sound predominates over the
abdomen and dullness is heard over the liver and spleen.
9. Genitourinary System
Patient voids 6 times in a day with a yellow color of the urine.
Doesn’t have any discharges as claimed by the patient. No pain noted
upon urinating. Pubic hair is distributed in an inverted triangular
pattern without signs of infestation. No enlargement or swelling
of lymph nodes. Labia majora are equal in size and free of lesions,
swelling, and excoriation. Labia minora appear symmetric, dark pink
and moist. Vaginal opening is positioned below the urethral meatus.
Blood is present due to bleeding.
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Genogram Interpretation
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Laboratory Examinations
Complete blood count (CBC) is a blood test used to evaluate your overall
health and detect a wide range of disorders, including anemia, infection
and leukemia.
A complete blood count test measures several components and features of
your blood, including:
Red blood cells, which carry oxygen
White blood cells, which fight infection
Hemoglobin, the oxygen-carrying protein in red blood cells
Hematocrit, the proportion of red blood cells to the fluid component,
or plasma, in your blood
Platelets, which help with blood clotting.
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Interpretation: CBC noted that WBC is high may indicate that the immune
system is working to destroy an infection. While RBC is lower than normal
range that could lead to symptoms or complications like pale skin, fatigue,
dizziness and etc. And with very low levels of haemoglobin can also be due
to blood loss, which can occur because of Menorrhagia (heavy menstrual
bleeding) and hematocrit low another term for low hematocrit is anemia due
to bleeding (ulcers, trauma, colon cancer, internal bleeding).High platelet
count infections are the most common cause of an elevated platelet count.
This elevation can be extreme, with platelet counts greater than one million
cells per micro-liter.
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Interpretation: CBC noted normal findings of WBC and very low levels of
RBC, hemoglobin and hematocrit with high platelet count.
Urinalysis Results
Date: February 24, 2019
A urinalysis is a test of your urine. A urinalysis is used to detect and
manage a wide range of disorders, such as urinary tract infections, kidney
disease and diabetes.
A urinalysis involves checking the appearance, concentration and content
of urine. Abnormal urinalysis results may point to a disease or illness.
Leukocyte ++ -
Nitrite - -
Urobilingen - -
Protein + -
pH 6.5 6.0-7.5
Blood +++ -
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Ketonuria - -
Billirubin - -
Glucose - -
Casts - 0-2 -
Bacteria moderate -
Interpretation: slightly turbid transparency of urine can occasionally
occur as a result of mild dehydration, which is determined in the absence
of other symptoms. This type of turbid urine goes away rapidly without
significant complications or consequences. The turbidity, which can vary
more or less depending on the case and on the patient, is usually due to
the presence of pus, crystals, bacteria, blood or lipid material in the
urine that cause the urine to appear persistently cloudy or foamy. Positive
leukocytes may occur cause of bladder infection, UTI, kidney stones,and
holding in urine.
Leukocyte ++ -
Nitrite - -
Urobilingen - -
Protein - -
pH 6.0 6.0-7.5
Blood +++ -
Ketonuria - -
Billirubin - -
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Glucose - -
Casts - 0-2 -
Bacteria negative -
Blood Typing
Blood typing is a method to tell what type of blood you have. Blood typing
is done so you can safely donate your blood or receive a blood transfusion.
It is also done to see if you have a substance called Rh factor on the surface
of your red blood cells.
Blood type: AB
Rh: Positive (+)
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Chapter III
Normal anatomy and physiology:
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The female
external structures:
The Mons Verines or commonly called as the Mons Pubis is a pad of adipose
tissue located over the symphysis pubis, the pubic joint. It is covered
by a triangle of coarse and curly hairs. The purpose of the Mons pubis is
to protect the junction of the pubic bone from trauma.
The labia majora are relatively large, fleshy folds of tissue that enclose
and protect the other external genital organs. They are comparable to the
scrotum in males. The labia majora contain sweat and sebaceous glands, which
produce lubricating secretions. During puberty, hair appears on the labia
majora.
The labia minora can be very small or up to 2 inches wide. The labia minora
lie just inside the labia majora and surround the openings to the vagina
and urethra. A rich supply of blood vessels gives the labia minora a pink
color. During sexual stimulation, these blood vessels become engorged with
blood, causing the labia minora to swell and become more sensitive to
stimulation.
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The Vulval vestibule is a part of the vulva between the labia minora into
which the urinary meatus (urethral opening) and the vaginal opening open.
Its edge is marked by Hart's line. It represents the distal end of the
urogenital sinus of the embryo.
The clitoris, located between the labia minora at their upper end, is a
small rounded organ of erectile tissue at the forward junction of the labia
minora. Its covered by a fold of skin, the prepuce. Which is sensitive to
touch and temperature and is the center of sexual arousal and orgasm in
women.
The Skene's glands are glands located on the anterior wall of the vagina,
around the lower end of the urethra. They secrete a fluid that helps lubricate
the urethral opening, and are surrounded with tissue that swell with blood
during sexual arousal.
The Bartholin's glands or also called as the greater vestibular glands are
two pea sized compound alveolar glands located slightly posterior and to
the left and right of the opening of the vagina. They secrete mucus to
lubricate the vagina
The fourchette is the ridge of tissue formed by the posterior joinng of
the labia minora and the laba majora. This structure is prone to lacerations
and is where episiotomy is performed at child birth.
The hymen is a tough but elastic semicircle of tissue that covers the opening
to the vagina during childhood. It is usually torn during the first sexual
intercourse.
The vulvar blood supply, The blood supply of female external genitalia is
mainly from the pudendal artery and a portion is from the inferior rectus
artery.
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The vulvar nerve supply, The anterior portion of the vulva derives its nerves
supply from the ilioinguinal and genitofemoral nerves (L1 level). The
posterior portions and the vagina are supplied by the pudendal nerve (S3
level) such a rich nerve supply makes the area extremely sensitive to touch,
pressure, pain and temperature.
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The vagina is the elastic, muscular part of the female genital tract. It
extends from the vulva to the cervix. The outer vaginal opening is normally
partly covered by a membrane called the hymen. At the deep end, the cervix
bulges into the vagina. The vagina allows for sexual intercourse and birth.
It also channels menstrual flow.
The uterine blood supply, the
uterine artery arises from the
anterior division of the
internal iliac artery. It crosses
above the ureter on its course to
the uterus. The uterine artery
commonly anastomoses with
the vaginal and ovarian
artieries. The uterine artery is
the main blood supply to the
uterus and it enlarges
significantly in pregnancy.
lymphatic drainage of the uterus is via the iliac, sacral, aortic and
inguinal lymph nodes.
The uterine nerve supply, The uterus is supplied by both efferent and
afferent nerves. The efferent nerves arise from the T5 through T10 T10 spina
ganglia, the afferent nerves joins the hypogastric plexus and enter the
spinal column at T11 and T12.
Menstruation
A menstrual cycle or the female reproductive cycle is episodic uterine
bleeding in response to cyclic hormonal changes. The purpose of menstrual
cycle is to bring an ovum to maturity and renew
a uterine tissue bed that will be necessary for
the ova’s growth should it be fertilized.
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initiates the menstrual cycle. GnRH then stimulates the pituitary gland
to send gonadotropic hormone to the ovaries to produce estrogen.
The Pituitary Gland, under the influence of GnRH, the anterior lobe of the
pituitary gland or the adenohypophysis produces two hormones:
FSH, a hormone active early in the cycle that is responsible for
maturation of the ovum.
LH, a hormone that becomes most active at the midpoint of the cycle
and is responsible for ovulation or release of the mature egg cell
from the ovary. It also stimulates growth of the uterine lining
during the second half of the menstrual cycle.
The Ovaries, FSH and LH are called gonadotropic hormones because they cause
growth in the gonads or the ovaries. Every month during the fertile period
of a woman’s life from menarche to menopause, one of the ovary’s oocytes
is activated by FSH to begin to grow and mature.
As the oocyte grows, its cells produce a clear
fluid called follicular fluid that contains a
high a high degree of estrogen and some
progesterone. As the follicle surrounding the
oocyte grows, it is propelled toward the
surface of the ovary. At full maturity, the
follicle is visible on the surface of the ovary
as a clear blister approximately 0.25 to 0.5
inches across. At this stage of maturation, the
small ovum which is about the size of a printed
period, with its surrounding follicular
membrane and fluid is termed as graafian
follicle.
The Uterus,
The first phase of the menstrual cycle
(proliferative) Immediately after a menstrual
flow (which occurs during the first 4 or 5 days
of a cycle), the endometrium, or lining of the
uterus, is very thin, approximately once cell
layer in depth. As the ovary begins to produce
(in the follicular fluid, under the direction
Above is a Illustration of uterine changes of the pituitary FSH) the endometrium begins to
that occur monthly as a result of stimulation
from estrogen and progesterone produced
proliferate so rapidly the thickness of the
by the ovaries
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THEORETICAL BACKGROUND
AUB and its sub group, heavy menstrual bleeding (HMB), are common conditions
affecting 14–25% of women of reproductive age and may have a significant
impact on their physical, social, emotional and material quality of life.
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Nonstructural Causes:
Clinical Manifestation:
Periods that occur less than 28 days apart or more than 35 days apart
Bleeding that lasts for more days than normal or for more than 7 days.
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Management
Medical Management
Suggested Dose: 25 mg IV
Dose: 20 mg orally
Dose schedule: Three times per day for 5 days (every 8 hours)
Cefuroxime- 500 mg 1 tab BID per oral x 7 days - antibiotic used to treat
certain infections caused by bacteria
Tranexamic Acid - 500 mg 1 tab TID per oral for x3 days - to prevent or
stop blood loss.
Pharmacologic Management
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Route: PO
Classification: Pharmacologic
Mechanism of action
Indication
Contraindications
Adverese effect
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Nursing Responsibilities
Brand name:Ponstan
Maximum dose:500 mg
Route: Oral
Classification: Pharmacologic
Mechanism of action
Mefenamic acid binds the prostaglandin synthetase receptors COX-1 and COX-2,
inhibiting the action of prostaglandin synthetase. As these receptors have
a role as a major mediator of inflammation and/or a role for prostanoid
signaling in activity-dependent plasticity, the symptoms of pain are
temporarily reduced.
Indication
Contraindication
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Adverse Effect
Nursing Responsibility
Maximum dose:750 mg
Route: Oral
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Mechanism of action
Indication
Contraindication
Adverse effect
Dermatologic: flushing
Nursing Responsibilities
Before:
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During:
After:
Route: Oral
Classification: Pharmacologic
For use in patients with hemophilia for short term use (two to eight days)
to reduce or prevent hemorrhage and reduce the need for replacement therapy
during and following tooth extraction. It can also be used for excessive
bleeding in menstruation, surgery, or trauma cases.
Mechanism of action
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Indications
Contraindication
Adverse effect
- retinal thrombosis
- heart attack
- stroke
- blood clot
Nursing Responsibilities
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-if you miss a dose of Tranexamic Acid, take it !hen you remember, then
take your next dose at least 6 hours later. do not take doses at once.
Surgical Management
Nursing Management
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CHAPTER IV
Pathophysiology
Precipitating factors
• Abdominal enlargement Predisposing factors:
• (+) mayoma • Age
• (+) ovarian cyst • Sex
• (+) ovarian new growth
• Lifestlye
• environment
Assess lower
extremities for skin
texture , edema and
39 ulceration.
Note client’s
nutritional and
fluid status
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Progress Notes
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- medication
added NaHc03
TID x 5 days
- Received
FFUB Blood
V/S
February 28, - ongoing Vital signs ,
BP: 110/70
2019 following BP are kept
PR-77
medications monitored.
RR- 77
- Blood typing - regulated IV
T : 36.1
and @ 20 gtt/min
crossmatchin - assessed
g done. bleeding.
- Monitored I
& O
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Vein. - assessed
- ongoing with bleeding.
following - Monitored I
medications. & O
V/S
- ongoing IV Vital signs, BP : 110/70
March 2, 2019 therapy PNSS @ BP are kept PR- 87
20 gtt/min @ monitored. RR: 18
Left Cephalic - regulated IV T: 36
Vein. @ 20 gtt/min
- ongoing with - assessed
following bleeding.
medications. - Monitored I
& O
- Vital signs,
- ongoing IV BP are kept V/S
March 3, 2019 therapy PNSS @ monitored. BP : 110/70
20 gtt/min @ - regulated IV PR- 79
Left Cephalic @ 20 gtt/min RR: 17
Vein. - assessed T: 36
- ongoing with bleeding.
following - Monitored I
medications. & O
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Discharge Plan
M- MEDICATION:
E- Exercise:
Advice patient to keep muscles active with through warm ups, stretching,
light exercises, low volume strength training,and yoga.
T-Treatment:
Hydrate
H- Health Teaching
Using Red raspberry tea can also be used to treat this problem. Consume
this tea on daily basis which will help to regulate menstrual flow by
giving strength to the wall of the uterine.
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O-Outpatient:
D-Diet-
Eat foods high in iron each day. Good sources are organ meat (such as
liver), beef, pork, poultry, and seafood.
S- Spiritual
Advice the patient to continually pray and hope for the best. Tell
motivational stories
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CHAPTER V
Conclusions
Therefore this study help us to learn more about the abnormal uterine
bleeding. It was successful since the objectives were met and accomplished.
We are not just learning in analyzing and comprehending the case study but
we also realized that in clinical duty it is very important that we must
integrate the Paulinian core values we have learned in the field. It is
our privilege to be a Paulinian Nurse that we may instill “Rosamonized”
we think, act, and care like Christ. We do believed and realized that we
are already “Rosamonized” because we have the compassion to give extra care
to our patient not to gather data but rather to give holistic care and promote
quality of life. In this study it was fulfilling to help others without
asking in return, the experience was meaningful and fruitful to all of us.
And we believed, to care is to touch the lives of others.
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Recommendations
And as for the nursing administration that work for a while in the
hospital, we recommend that a new nurse should be given enough orientation
period because every hospital has different protocols in giving care. Making
them work by themselves as early as possible is just calling for disaster
like mistakes to happen.
We recommend that nursing students should not extend their service beyond
walls of the clinical area because any activities with the client outside
the are comes with liability and risks that may put the nursing students
in great trouble.
And as for the nursing staff herself who made the mistake, it is very
important to always double check our every action so we can eliminate vital
mistakes.
We also recommend the significant others together with the client and
patient to always ask about any procedure that is done and always clarify
with the nurse about specific instructions like during discharge.
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References
Mayo Foundation for Medical Education and Research (MFMER). (2016) Retrieved
from https:// www.mayoclinic.org/symptoms/low-hemoglobin/basics /causes/
sym-20050760
Charles Patrick Davis, MD, PhD.,William C. Shiel Jr., MD, FACP, FACR. (2011).
Retrieved from https://www.emedicinehealth. com/hematocrit _blood_test
/article_em.htm#what_does_a_low_hematocrit_mean
Amber Yates, MD. ( 2018). Retrieved from
https://www.verywellhealth.com/things-that-elevate-your-platelet-count
-401336
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