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Abnormal uterine bleeding is a condition in which a woman bleeds from

her uterus at an unexpected time or in a way that is unusual for her. For

example, bleeding between periods, a period that is heavier longer-lasting than

normal, bleeding after sexual intercourse, clots or spots in the menstrual blood

and any bleeding after menopause may all be considered abnormal uterine

bleeding.

The most common reason for irregular uterine bleeding is pregnancy.

Spotting or very light bleeding may occur with no real significance, but you

should always check with your doctor if you’re bleeding while pregnant. Another

common reason for abnormal menstrual bleeding is having too much or too little

of certain hormones. This often occurs during adolescence, when hormone levels

fluctuate. Intrauterine device (IUD) can cause abnormal bleeding by irritating the

uterine lining. The bleeding is usually accompanied by cramping. Also called

Stein-Leventhal syndrome, Polycystic Ovarian Syndrome occurs when you don’t

ovulate regularly. If your period comes with pain or foul-smelling greenish

discharge you may have an infection of a pelvic organ, such as your uterus,

cervix or ovaries. Bleeding would commonly follow sex or douching. These

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infections are often caused by sexually transmitted diseases. Fibroid tumors are

non-cancerous tumors that grow in the uterine muscle. They usually affect

women in their 30s or 40s. most common among black women, they are also

fairly common among white women, but extremely rare in Asian women. Other

possible reasons for abnormal menstrual bleeding include polyps, small growths

that develop in the cervix or uterus. Their causes are unclear, but are related to

an excess of estrogen, which may be result of an infection, hormone treatment or

some types of ovarian tumors.

The most probable etiology of abnormal uterine bleeding relates to the

patient’s reproductive age, as does the likelihood of serious endometrial

pathology. The specific diagnostic approach depends on whether the patient is

premenopausal, perimenopausal or postmenopausal. In premopausal women

with normal findings on physical examination, the most likely diagnosis is

dysfunctional uterine bleeding (DUB) secondary to anovulation, and the

diagnostic investigation is targeted at identifying the etiology of anovulation.

Abnormal uterine bleeding (AUB) in nonpregnant women is a common

problem. In fact, AUB accounted for almost 4 million outpatient visits (mostly to

physicians’ offices) in the United States in 1996. Indeed, this problem may

prompt more than 20% of all visits to OB/GYNs, and may account for more than

one fourth of all hysterectomies. AUB is rare in prepubertal females. Newborn

girls occasionally have a slight bloody vaginal discharge secondary to withdrawal

of placental estrogens. AUB is common in adolescents because of the 1- to 5-

year delay in development of regular ovulatory menstrual cycles after menarche.

AUB also tens to be more common during the fifth decade of life (the

perimenopausal years). In the worst case, AUB may be a sign of atypical

endometrial hyperplasia, which, if undiagnosed and untreated, can progress to

uterine cancer-the most common female genital cancer. In 1998, estimated

36,100 women were diagnosed with uterine cancer, which led to approximately

6,300 deaths.

One popular form of treatment for abnormal uterine bleeding is birth

control pills, which contain hormones that can prevent the uterus lining from

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thickening. If birth control pills are’nt stopping the bleeding, a doctor may

prescribe an intrauterine (IUD) device. An IUD is a plastic device that is inserted

into a woman’s uterus to prevent pregnancy. In rare cases, surgery may be

needed to stop abnormal bleeding. Two surgical procedures are recommended:

hysterectomy and endometrial ablation.

OBJECTIVES

General Objectives

This study attempts to examine the case of the client with abnormal

uterine bleeding, specifically it attempts:

1. To obtain clients data

2. To perform thorough physical assessment to the client

3. To discuss the anatomy and physiology of the reproductive system

4. To trace the pathophysiology of abnormal uterine bleeding

5. To present laboratory results and its interpretation

6. To formulate appropriate nursing diagnosis who has abnormal uterine

bleeding

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7. To develop nursing care plan for client based to identifies nursing

problems.

8. To present drug studies as medications given to client as a part of

treatment regimen.

9. To provide health teaching to patient and significant others about

prevention of recurrence of AUB.

PERSONAL DATA

Name: Cristy Joy Lactason

Address: Brgy. Naje, Arakan, Cotabato

Date of Birth: August 7, 1990

Birthplace: Brgy. Naje, Arakan, Cotabato

Age: 19 years old

Sex: Female

Civil Status: Single

Religion: Roman Catholic

Educational Status: Second year high school

Nationality: Filipino

MEDICAL DATA

Hospital: Kidapawan Medical Specialists Center Inc.

Ward: NS 2

Room & Bed No. Room 218-A

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Chief Complaints: Profuse menstruation/Menometrorrhagia

Date & Time Admitted: July 25, 2010, 4:30 pm

Physicial: Dr. Phillen Drama Ureta

Admitting Diagnosis: T/C abnormal uterine bleeding

Final Diagnosis: Abnormal Uterine Bleeding

FAMILY BACKGROUND

I. History of Present Illness

The condition started about 1 month prior to admission as onset of

prolonged vaginal bleeding lasting for 15 days soaking 4-6 pads per day

associated with dysmenorrhea. No consultation done and no medications taken.

Two days prior to admission patient’s vaginal bleeding spontaneously

regressed.

One day prior to admission patient’s vaginal bleeding recurred and

completely soaked several pads associated with pallor and dizziness prompting

to consult an OB-Gynecologist (Dr. Phillen Drama Ureta) and subsequent

admission.

II. History of Past Illness

Patient was hospitalized last March 2010 at Antipas Hospital due to

profuse vaginal bleeding and was treated with Diane pills taken with poor

compliance. She is non-asthmatic, non-diabetic, non-hypertensive with no known

food and drug allergies.

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III. Medical History of Family

No heredofamilial diseases such as hypertension, diabetes, asthma and

cancer were reported in the family.

X,

IV. Personal and Social History

Patient is a second year high school student at Arakan National High

School. She is the second child among 3 siblings. Her father is a farmer and her

mother is a plain housewife. She is a non-smoker, an occasional alcohol

beverage drinker and denies any use of prohibited drug. She has a boyfriend but

denies coitus at her age. She spends most of her time watching television.

V. Menstrual History

She started her menarche at the age of 13 years old, with an interval of

28-30 days and duration of 4-6 days. Amount of blood is heavy soaking 3-4 pads

per day accompanied with dysmenorrhea.

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DEVELOPMENTAL DATA

Age/Stage Description according to Theories Analysis• 19 y/o

Havighurst-Adolescence

Erikson-Adolescence (12-20)

Kohlberg-Adolescence and Adulthood

Havighurst Erikson KohlbergOn Havighurst theory, the patient has met the indicators of an adolescent except achieving assurance of economic independence.

On Erikson’s theory, client indicates positive resolution, she has a sense of self and plans to actualize her abilities.

On Kohlberg’s theory, the client is concerned in maintaining expectations and rules of the family group.

Adolescence1. Achieving new and more mature relations with age-mates of both sexes2. Achieving masculine or feminine social role3. Accepting one’s physique and using the body effectively4. Achieving emotional independence from parents and other adults.5. Achieving assurance of economic independence.6. Selecting and preparing for an occupation7. Preparing for marriage and family life.8. Developing intellectual skills and concept necessary for civic competence9. Desiring and achieving socially responsible behavior10. Acquiring a set of values and ethical system as a guide to behavior.

Central task-Identity vs. Role Confusion

Indicators of Positive Resolution-Coherent sense of self; Plans to actualize one’s abilities

Indicator of Negative Resolution-feelings of confusion. Indecisiveness and possible anti-social behavior

Conventional Level-Person is concerned in maintaining expectations and rules of the family group, nation or society. A sense of guilt has developed and affects behavior. The person values conformity, loyalty and active maintenance of social order and control. Conformity means good behavior or what pleases or helps another and is approved.

Law and Order Orientation-The person wants established rules from authorities, and the reason for decision and behavior is that social and sexual rules and traditions demand the response.

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PHYSICAL ASSESSMENT

Date of Assessment:

I. General Apperance

Date: July 26, 2010 Time: 9:45AM

Received client conscious and coherent on bed with PNSS 1L @ 20

gtts/min at the level of 200 cc infusing well @ right metacarpal vein. Patient appeared

ungroomed with uncombed hair and wrinkled clothes with black nail polish. When nail

polish was removed, client’s nail bed showed pallor. Client was generally pale.

II. Vital Signs and Clinical Measurements

Weight: 43 kg Height: 5’1”

Vital Signs upon Assessment:

BP: 110/90 mmHg PR: 70 bpm

RR: 18 cpm Temp: 36.2℃III. Hair

Hair is black, straight and well distributed. No presence of lice and

dandruff noted.

IV. Head

Normocephalic. No deformities noted.

V. Eyes

Eyes are symmetrically aligned and equal in movement, eyelashes are

evenly distributed and curled. Pupils are equally reactive to light and accommodation on

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examination (using a penlight). She has good visual acuity based on snellen’s test.

Conjunctivas are pale and eyeballs are in good position and alignment.

VI. Ears

Hearing is normal upon assessment using Weber’s test, no gross

deformities noted. She is able to locate the direction of the sound of her ringing

celphone.

VII. Nose

No asymmetry, no nasal discharges noted and can identify odors.

VIII. Neck/Throat

No neck vein engorgement, no lymphadenopathy, tonsils are in normal

size, no difficulty on swallowing. The neck can move from left to right and can be flexed,

extended and hyper extended.

IX. Chest and Lungs

Equal chest expansion, no retractions noted, clear breath sounds and with

bilateral chest movements. RR: 18 cpm

X. Heart and Circulation

Distinct heart sounds, regular rhythm, BP: 110/90mmHg

PR: 70 bpm.

XI. Breasts

Breast size and symmetry are relatively equal with slight variation. Shape

is round and firm. Color is flesh and skin surface is smooth. Nipples are pink in color

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with no discharges noted. She uses brassieres, no lumps or masses noted upon

palpation.

XII. Abdomen

No scars noted, soft, normoactive bowel sounds noted. No tenderness.

XIII. Genito-urinary

Normal external genitalia, abundant pubic hair with moderate bleeding.

No alteration in urinary and bowel habits. She experiences 15 days of menstruation

and soaks 4-6 sanitary napkins a day. She also urinates every 20 minutes during this

period.

XIV. Extremities

A. Upper Extremities

No skin lesion is noted. No growth deformities. She can move her upper

extremities freely and are both symmetrical in size and length. With PNSS 1L @ 20

gtts/min at the level of 200 cc infusing well @ right metacarpal vein.

B. Lower Extremities

No skin lesion is noted. No growth deformities. Her lower extremities are

both symmetrical in size and length with limitation of movement because movement and

straining or any forceful activity can aggravate profuse vaginal bleeding.

XV. Food Preference

Patient verbalizes fondness of eating meat, fish and vegetables.

XVI. Identified Needs

The patient needs to maintain fluid and electrolyte balance, needs to keep

body clean and well groomed and protect the integument and needs

performance of activities of daily living.

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XVII. Nursing Diagnoses

• Risk for Fluid Volume Deficit R/T Uterine Bleeding

• Risk for Activity Intolerance related to decreased hemoglobin

• Self-care deficit: bathing/ hygiene related to decreased motivation

• Easy fatigability related to decreased hemoglobin

TERMINOLOGIES

Abnormal Uterine Bleeding – excessive and prolonged menstruation.

Endometriosis – ectopic growth and function of endometrial tissue.

Fibroids – a fibroma or myoma particularly of the uterus

Fibroma – a benign neoplasm consisting largely of fibrous or fully developed

connective tissue.

Menometrorrhagia - excessive menstrual and uterine bleeding other than that caused

by the menstruation.

Menorrhagia - abnormally heavy or long menstrual periods. Menorrhagia occurs

occasionally during the reproductive years of most women’s lives.

Metrorrhagia – uterine bleeding other than that caused by menstruation. It may be

caused by uterine lesions and may be a sign of uro-genital malignancy.

Myoma – a common benign fibroid tumor of uterine muscle.

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Polyps – small, tumor like growth that projects from a mucous membrane surface.

Proliferation – the reproduction or multiplication of similar forms.

Retroverted uterus- titled or tipped backwards.

Snellen’s Chart - an eye chart used by eye care professionals and others to measure

visual acuity. It is printed with eleven lines of block letters. The first line consists of one

very large letter, which may be one of several letters, for example E,H or N. subsequent

rows have increasing numbers of letters that decrease in size.

Snellen’s Test – a test wherein a person covers one eye and reads aloud the letters of

each row beginning at the top. The smallest row that can be read accurately indicates

the visual acuity in that eye.

Withdrawal bleeding – the passage of blood from the uterus, associated with the

shedding of endometrium that has been stimulated and maintained by hormones.

Weber’s Test – a test for differentiating conductive hearing impairment from

sensorineural hearing impairment. A vibrating tuning for is applied to one of several

points in the middling of the forehead; if the sound is heard better in the impaired ear,

the middle-ear apparatus is at fault; if the sound is heard better in the normal ear, the

hearing impairment is caused by diseased sensorineural apparatus.

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ANATOMY AND PHYSIOLOGY

Vagina:

The vagina is a fibro muscular tubular tract leading from the uterus to the

exterior of the body in female mammals. The vagina is the place where semen from the

male is deposited into the female's body at the climax of sexual intercourse, commonly

known as ejaculation.

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Cervix:

The cervix is the lower, narrow portion of the uterus where it joins with the

top end of the vagina. It is cylindrical or conical in shape and protrudes through the

upper anterior vaginal wall. Approximately half its length is visible, the remainder lies

above the vagina beyond view. The vagina has a thick layer outside and it is the

opening where baby comes out during delivery. The cervix is also called the neck of the

uterus.

Endometrium

Is the inner membrane of the mammalian uterus. The endometrium

functions as a lining for the uterus, preventing adhesions between the opposed walls of

the myometrium, thereby maintaining the patency of the uterine cavity. During the

menstrual cycle or estrous cycle, the endometrium grows to a thick, blood vessel-rich,

glandular tissue layer. This represents an optimal environment for the implantation of a

blastocyst upon its arrival in the uterus. The endometrium is central, echogenic

(detectable using ultrasound scanners), and has an average thickness of 6.7mm.During

pregnancy, the glands and blood vessels in the endometrium further increase in size

and number. Vascular spaces fuse and become interconnected, forming the placenta,

which supplies oxygen and nutrition to the embryo and fetus.

Ovary

Is an ovum-producing reproductive organ, often found in pairs as part of

the vertebrate female reproductive system. Ovaries in females are homologous to

testes in males, in that they are both gonads and endocrine glands. Ovaries are oval

shaped and, in the human, measure approximately 3 cm x 1.5 cm x 1.5 cm (about the

size of a Greek olive). The ovary (for a given side) is located in the lateral wall of the

pelvis in a region called the ovarian fossa. The fossa usually lies beneath the external

iliac artery and in front of the ureter and the internal iliac artery.

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Uterus or Womb

Is a major female hormone-responsive reproductive sex organ of most mammals

including humans. It is a flattened, pear-shaped, hollow organ in the pelvis of the human

female. The uterus consists of a body, a base or fundus, a neck or cervix, and a mouth.

Suspended in the pelvis, it lies with the base directed upward and forward and the

cervix directed slightly backward. It is connected to the vagina by the cervix. On either

side of the uterus lies an ovary. Eggs produced by the ovaries reach the uterus through

the fallopian tubes.

ETIOLOGY

PREDISPOSING FACTOR

ACTUAL RATIONALE

1. Age

- Abnormal uterine bleeding is one of the most common reasons women see their doctors. It can occur at any age and has many causes. (http://www.acog.org/publications/patient_education/bp095.cfm)

Age: 19 years old.2. Gender

- The uterus or womb is a major female hormone-responsive reproductive sex organ of most mammals including humans. (http://en.wikipedia.org/wiki/Uterus)

Female

PRECIPITATING FACTOR

ACTUAL RATIONALE

1. Poor compliance to treatment

Noncompliance and poor compliance may lead to relapse, aggravation of the disease state, hospitalization,

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escalating health care costs, and even death.(http://www.pharmacytimes.com/issue/pharmacy/2003/2003-07/2003-07-7310)

Complying only for 1 month and stopping thereafter.

SYMPTOMATOLOGY

SYMPTOMS ACTUAL RATIONALE1. More than 4 to 6 days of menstruation.

Causes may be due to disruption of normal hormonal regulation of periods or disorders of the endometrial lining of the uterus.(http://en.wikipedia.org/wiki/Menorrhagia)

She experiences 15 days of menstruation.

2.Blood loss of greater than 80 ml.

Without subsequent progesterone secretion, estrogen secretion continues and causes extreme proliferation in the endometrium. (Maternal and Child health Nursing, Volume 2, 4th edition , Pillitteri)

Easily soaks 4 to 6 sanitary napkins a day. ( 1 sanitary napkin is equal to 25 ml)

3.Anemia

> Dizziness > Pallor

Bleeding causes loss of blood. This causes an abnormally low number of red blood cells which causes anemia. Red blood cells, also called erythrocytes, contain hemoglobin, a red, iron-rich protein that carries oxygen in the blood to the body’s tissues. These symptoms include pale skin, shortness of breath, rapid heartbeat, low

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vitality, dizziness, and, if left untreated, stroke or heart failure. (Microsoft ® Encarta ® 2008. © 1993-2007 Microsoft Corporation.)

Client has pale conjunctiva and nail beds. She experiences dizziness

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Pathophysiology

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Predisposing Factors Gender – Female Age - Adolescent

Precipitating Factors Poor medical

Compliance

OVULATORY

Irregular Sloughing of Endometrial Basalis Layer

No Corpus Luteum is formed

Estrogen levels remain the same

No production of progesterone

Hyperplasia of Endometrium

As follicles degenerate, estrogen levels decreases

NURSING CARE PLANS

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Heavy Prolonged Bleeding (Duration of 15 days Menstruation

and soaking 4-6 Pads per day).AnemiaDecreased Serum

Hemoglobin(Hgb Lab. Result 102)

Abnormal Uterine Bleeding

Decreased O2 Carrying Capacity of Blood

(Dizziness)Dizziness and Pallor

If not treated

Complications

Death

If treated:

Back to normal Homeostasis

Meds. ALTHEA 1 Tab.

O.D X3 months

FeSO4 Tab. 200 mg BID

Prognosis Good

Date: July 26, 2010

Assessment Needs Diagnosis Goal Intervention Rationale Expected/Outcome

Subjective Cues: > “Gagawas pirmi akoang dugo. Gamens ko ug 15 days” as verbalized.

Objective Cues:> Pallor of conjunctiva and nail beds.>Consumes 4-6 sanitary napkin per day> Menstruation lasting for 15 days

PHYSIOLOGICNEEDS

To facilitate in the

maintenance of fluid and

electrolyte imbalance.

According to: Abraham Maslow’s Hierarchy of Needs

>Risk for Fluid Volume Deficit R/T Uterine Bleeding

Scientific Basis: Blood is composed of blood cells suspended in a liquid called blood plasma. Plasma, which constitutes 55% of blood fluid, is mostly water (90% by volume) (http://www.wikipedia. org)

After 8 hours of nursing care, patient will be able to maintain fluid volume within functional level as evidenced:

a. cessation of bleeding

b. V/S within normal range

c. Good skin turgor and moist mucous membrane.

Independent

1. Monitored Vital Signs for changes

2. Counted number of pads consumed to monitor actual fluid loss.

3. Encouraged increase oral fluid intake

4. Promoted high water content fruits.

Dependent

1. IVF PNSS 1L @ 80cc/hr

2. Tranexamic Acid 500mg QID as ordered by physician

>Indirect indicators of fluid status.

>Serves as baseline data

> To provide volume to volume replacement

> To replacefluid lost.

> Fluid replacement.

>It stops bleeding.

>Goal met.

After 8 hours of nursing care, patient was able to: Show good fluid volume status as evidenced by

a) Minimal bleeding

b) Vital Signs within normal range

c) Lips and mucous membranes are moist with good skin turgor.

Date: July 26, 2010

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Assessment Needs Diagnosis Goal Intervention Rationale ExpectedOutcome

Subjective Cues: >No subjective cues

Objective Cues:> Pale conjunctiva> Pale nail beds> Hgb = 102(normal value: 120-140)> Weakness> Dizziness

PHYSIOLOGIC NEEDS

- need for activity

(Maslow’s Hierarchy of

Needs)

>Risk for Activity Intolerance related to decreased hemoglobin

Scientific Basis: Hemoglobin in the blood is what transports oxygen from the lungs or gills to the rest of the body (i.e. the tissues) where it releases the oxygen for cell use.

>After 8 hours of nursing care, patient will be able to identify alternative ways to maintain desired activity level and endure performance of Activities of Daily Living(ADL)

Independent

1. Discussed with client the relationship of illness to inability to perform desired activities.

2. Assisted client in doing basic activities

3. Encouraged patient to take foods rich in iron.

Dependent

1. FeSO4 1tab BID as ordered by physician.

>Understanding these relationships can help with acceptance of limitations or reveal opportunity for changes of practical value.

>to conserve energy and promote safety.

>to replace iron lost

> Provides elemental iron an essential component in the formation of hemoglobin.

>Goal met. Client was able to endure & sustain basic activity such as moving to and from the bathroom without assistance.

Date: July 26, 2010

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Assessment Needs Diagnosis Goal Intervention Rationale Expected Outcome

Subjective Cues:> “Wala pa koy ligo” client verbalized

Objective Cues:> dirty nail noted> unfixed hair noted.

PHYSIOLOGIC NEEDS

- need to keep body clean and well groomed

and protect the integument (Maslow’s

Hierarchy of Needs)

>Self-care deficit: bathing/ hygiene related to decreased motivation.

Scientific Basis: Motivation is the psychological feature that arouses an organism to action toward a desired goal.(http://www.thefreedictionary.com/motivation)

.After 8 hours of nursing care, patient will be able to:Perform proper hygiene

Independent

1. Monitored vital signs.

2. Performed cleansing bed bath to patient.

3.Encouraged patient to take a bath explain the possible risks for infection.

4. Encouraged patient to do oral care.

5. Trimmed patients nails.

> Serves as baseline data.

> To promote comfort and reduce risk for infection.> To denote importance of proper hygiene.

> To promote taste and decrease bacteria.

> To prevent microorganism from staying under nails.

>Goal met.

After 8 hours of nursing care, patient was able to perform proper hygiene and good grooming.

Date: July 27, 2010

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Assessment Needs Diagnosis Goal Intervention Rationale Expected/Outcome

Subjective Cues: >” Ginakapoy gud ko” client verbalized.Objective Cues:> Pale conjunctiva> Pale nail beds> Always lying on bed.>Feeling of weakness.> Hgb = 102> 15 days of menstruation> 4 to 6 sanitary pads a day.

PHYSIOLOGIC NEEDS

- need for activity

(Maslow’s Hierarchy of

Needs)

>Easy Fatigability R/T decreased hemoglobin.

Scientific Basis: Hemoglobin in the blood is what transports oxygen from the lungs or gills to the rest of the body (i.e. the tissues) where it releases the oxygen for cell use

In the 8 hours of nursing care, patient will be able to:>Participate willingly in necessary desired activities such as going to the bathroom, eating, standing and walking without ambulatory.

Independent

1. Noted client reports of weakness and/or fatigue.

2. Adjusted activities according to client’s condition.

3. Assisted client with activities.

Dependent

1. FeSO4 1tab BID.

> Symptoms may be result of/or to contribute to Intolerance to activity.> To prevent Overexertion

> To prevent client from injury.

>Provides elemental iron an essential component in the formation of hemoglobin.

>Goal met.

After 8 hours of nursing care, patient was able to:

> Perform the desired activities such as going to the bathroom with assistance.

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LABORATORY RESULTS

Diagnostic Test

Purpose Result Interpretation Nursing Implication

Complete Blood CountDate: July 25, 2010

Complete Blood Count: General survey of bone marrow functions and evaluates all three cell lines (WBCs, RBCs, platelets)White Blood Cells (WBC): total WBC countHemoglobin: (Hgb): delivers O2 through circulation to body tissues and returns CO2 from tissues to lungsHematocrit (Hct): indicates relative proportions of plasma and RBCs ( volume of RBCs/L whole blood)Platelet: total number of platelets in circulationLymphocytes: integral component of immune systemSegmenters:Monocytes:

Test Result Normal ValuesThe Hemoglobin levels are below the normal range.

The Hematocrit levels are below than the normal levels.

Below than normal levels of Hemoglobin are found in iron-deficiency anemia (Fischbach, 1988).Below than the normal of hematocrit are found in Acute, massive blood loss. (Fischbach, 1988).

WBCHgbHctPlt.ctLymphoSegsMono

9.4 (10 e g/L)1020.353020.300.660.04

5 – 10120-1400.37-0.43

150-350 x10 g/L0.25-0.350.55-0.650.03-0.06

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Diagnostic Test

Purpose Result Interpretation Nursing Implication

Bleeding Time and Clotting TimeDate: July 25, 2010

Bleeding time: measures the primary phase of hemostasis: the interaction of the platelet with the blood vessel wall and the formation of the hemostatic plug. This is one of the four primary screening test for coagulation disorders. (Fischbach, 1988).Clotting time: the time required for blood to form a clot, tested by collecting 4 mL of blood in a glass tube and examining it for clot formation. The first appearance of a clot is noted and timed. The normal coagulation time in glass tubes is 5 to 15 minutes. This simple test has been used to diagnose hemophilia, but it does not detect mild coagulation

disorders. (http://medical-dictionary.thefreedictionary.com/clotting+time)

Test Result Normal Values The Bleeding time

higher is than normal.

A single prolonged bleeding time does not prove the existence of hemorrhagic disease because a larger vessel may have been punctured. (Fischbach, 1988).

Bleeding time: Clotting time:

4 mins

7 mins

1-3 mins

2-8 mins

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Diagnostic Test

Purpose Result Interpretation Nursing Implication

UrinalysisDate: July 25, 2010

Urinalysis: The urinalysis is used as a screening and/or diagnostic tool because it can help detect substances or cellular material in the urine associated with different metabolic and kidney disorders. It is used to detect urinary tract infections (UTI) and other disorders of the urinary tract. (http://www.labtestsonline.org/understanding/analytes/urinalysis/test.html)

Physical ExaminationColor: Yellow

Transparency: Cloudy

Yellow is the normal color of urine. Glucose is normally not present in urine.Normal Urine can be clear or cloudy.

The protein test pad measures the amount of albumin in the urine. Normally, there will not be detectable quantities.The ph reaction of the urine is alkaline.Specific gravity is normal.Pus cells are within normal range.

HCG is not found in urine.

"Normal" urine can be clear or cloudy. Albumin is smaller than most other proteins and is typically the first protein that is seen in the urine when kidney dysfunction begins to develop. A vegetarian diet, a low-carbohydrate diet, or the ingestion of citrus fruits will tend to make the urine more alkaline. (http://www.labtestsonline.org/understanding/analytes/urinalysis/ui_exams.html)Normal urine ranges from 1.010 to 1.025.(Kozier & Erb’s, 2007)Normal value for pus cells in urine is 0-5/hpf(http://www.medhelp.org/posts/Urology/Urinalysis-interpretation/show/731397)The girl is not pregnant. The human chorionic gonadotropin (hCG) test is done to check for the hormone hCG in blood or urine. Some hCG tests measure the exact amount and some just check to see if the hormone is present. HCG is made by the placenta during pregnancy. The hCG test can be used to see if a woman is pregnant or as part of a

Chemical ExaminationAlbumin: Trace pH reaction: 5.0Sugar: Negative Specific Gravity: 1.020

Microscopic findingsPus cells: 1-3/hpf Red Blood Cells: Packed

SerologyUrine HCG - Negative

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Pelvic UltrasoundDate: July 26, 2010

Ultrasonography is an ultrasound-based diagnostic imaging technique used to visualize subcutaneous body structures including tendons, muscles, joints, vessels and internal organs for possible pathology or lesions. Obstetric sonography is commonly used during pregnancy and is widely recognized by the public. (http://en.wikipedia.org/wiki/Medical_ultrasonography)

The uterus is retroverted. It measures

4.2x3.6x3.9 cm and is normal in size for

nullipara. No myoma or adenomyosis is

noted. Endometrial stripe hyperechoic

measuring 0.6 cm. adnexae are free.

Minimal pelvic fluid is seen.

Impression: Normal studies save for

minimal pelvic fluid.

Retroversion of the uterus is not normal

screening test for birth defects. (http://www.nlm.nih.gov/medlineplus/ency/article/003619.htm)

A retroverted uterus is usually diagnosed during a routine pelvic examination.

Lower back pains

It usually does not pose any medical problems, though it can be associated with dyspareunia (pain during sexual intercourse) and dysmenorrhea (pain during menstruation). (http://en.wikipedia.org/wiki/Retroverted_uterus)

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DRUG STUDIES

Name Dosage and Indication

Mechanism of Action

Adverse Effects Contraindication Nursing Responsibilities

Generic Name: Ferrous Sulfate

Brand Name:Magniferron

Classification:Hematologic Drugs: Hematinics

Iron Deficiency 200 mg

P.O BID

Provides elemental iron an essential

component in the formation of

hemoglobin.

GI: Nausea, epigastric pain, vomiting, constipation, black stools, diarrhea, anorexia.Other: temporarily stained teeth in liquid forms

Contraindicated in patients with Hemosiderosis, primary hemochromatosis, hemolytic anemia (unless patient also has iron deficiency anemia), Peptic ulceration, ulcerative colitis or regional enteritis and in those receiving repeated blood transfusions.Use cautiously on long term basis.

1. Identify the client correctly using the appropriate means of identification, such as checking the identification bracelet or asking the clients name.2. If the client is unfamiliar with the medication, the nurse should explain the intended action as well as any side effects or adverse effects that may occur.3. Administer drug in the prescribed dosage by the route intended and the correct time.4. Record the medication given, dosage, time, any complaints or assessments and your signature.5. Explain to the client that she may have black stool as effect of the drug.6. Administer the drug with juice for faster absorption.

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Name Dosage and Indication

Mechanism of Action

Adverse Effects Contraindication Nursing Responsibilities

Generic Name:Tranexamic AcidBrand Name:Hemostan Classification:Hematologic Drugs: Hematinics amino acid antifibrinolytics.

Indicated for short term use for hemorrhage or risk of hemorrhage in those with increased fibrinolysis or fibrinogenolysis. Local fibrinolysis as occurs in menorrhagia.

1tab 500mg QID

Tranexamic acid competitively inhibits activation of plasminogen (via binding to the kringle domain), thereby reducing conversion of plasminogen to plasmin (fibrinolysin), an enzyme that degrades fibrin clots, fibrinogen, and other plasma proteins, including the procoagulant factors V and VIII.

GI: nausea, vomiting, diarrhea may occur but disappear when the dosage is reduced.

In patients with acquired defective color vision, since this prohibits measuring one endpoint that should be followed as a measure of toxicity.In patients with active intravascular clotting.

1. Identify the client correctly using the appropriate means of identification, such as checking the identification bracelet or asking the clients name.2. If the client is unfamiliar with the medication, the nurse should explain the intended action as well as any side effects or adverse effects that may occur.3. Administer drug in the prescribed dosage by the route intended and the correct time.4. Record the medication given, dosage, time, any complaints or assessments and your signature.5. Check for presence of spontaneous bleeding.

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Tranexamic acid also directly inhibits plasmin activity, but higher doses are required than are needed to reduce plasmin formation.

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Name Dosage and Indication

Mechanism of Action Adverse Effects

Contraindication Nursing Responsibilities

Generic Name:Cyproterone acetateBrand Name:Althea Classification:Natural and semisynthetic estrogens.

OC, control of acne & hsirsutism, regulation of menstrual cycle, reduction of premenstrual tension, relief from pain & excess bleeding during menstruation.

Take 1 tab starting on the 1st day of menses & throughout the cycle.

Oral contraceptive.

Althea is a combined low-dose oral contraceptive pill with antiandrogenic properties. Each tablet contains cyproterone acetate, a progesterone with antiandrogenic and progestogenic properties and ethinyl estradiol, an estrogen.

Oral Contraceptive: Althea stops ovulation, thins the lining of the uterus and thickens the cervical mucus. In combination, these actions prevent pregnancy.

Antiandrogen: Althea contains cyproterone acetate that works as an antiandrogen. It competes at the receptor sites with androgens and reduces their effects. Cyproterone acetate

GI: Nausea, vomiting, chloasma (melasma) & other skin or hair changes, headache, water retention, slight wt change, breast tenderness, changes in libido. Menstrual irregularities eg spotting, breakthrough bleeding & amenorrhea.

Impaired liver function or cholestasis, Dubin-Johnson or Rotor syndromes, hepatic adenoma, estrogen-dependent neoplasms eg breast or endometrial cancer, CV disease, disorders of lipid metabolism, undiagnosed vag bleeding, pregnancy, history of pruritus or cholestatic jaundice during pregnancy, chorea, herpes gestationis, pemphigoid gestationis, deteriorating otosclerosis, severe or focal migraine, lactation.

1. Identify the client correctly using the appropriate means of identification, such as checking the identification bracelet or asking the clients name.2. if the client is unfamiliar with the medication, the nurse should explain the intended action as well as any side effects or adverse effects that may occur.3. Administer drug in the prescribed dosage by the route intended and the correct time.4. Record the medication given, dosage, time, any complaints or assessments and your signature.5. Report any signs of headache.

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inhibits the influence of the androgens produced in women. Althea reduces the development of acne and seborrhea. It heals existing acne efflorescence after 3-4 months therapy. It also reduces the greasiness of the hair and skin.

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Name Dosage and Indication

Mechanism of Action Adverse Effects

Contraindication Nursing Responsibilities

Generic name:Ketorolac tromethamine

Brand name:Toradol

Classification:Central nerovous system drugs; Nonsteroidal anti-inflammatoy drugs

Short-term management of moderately severe, acute pain

-30mg IV TT

Unknown. May inhibit prostaglandin synthesis, to produce anti-inflammatory, analgesic, and antipyretic effects.

GI: Nausea, dyspepsia, GI pain, diarrhea, peptic ulceration, vomiting, constipation, flatulence, stomatitis.

Contraindicated in patients hypersensitivity to drug and in those with active peptic ulcer disease, recent GI bleeding or perforation, advanced renal impairement, cerebrovascular bleeding, hemorrhagic diathesis, or incomplete hemostasis and those at risk for renal impairment from volume depletion or at risk of bleeding.

1.identify the client correctly using the appropriate means of identification, such as checking the identification bracelet or asking the client’s name

2.If the client is unfamiliar with the medication, the nurse should explain the intended action as well as any side effect or adverse effects that may occur.

3.Check IV patency and observe for complication of Iv therapy such as infiltration and extravasation phlebitis, thrombophlebitis, hematoma, and clotting of the needle.

4.Administer drug in the prescribed dosage by the route intended and the correct time.

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5.Administer the medication slowly

6.Record the medication given, dosage, time, any complaints or assessment and your signature.

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COURSE IN THE WARD

Progress notes Doctor’s order

July 25, 2010 - admit under the service of Dr. Ureta- DAT

- V/S Q4 h- Labs: CBC, PLT Count, HCT, Urinalysis, Pregnancy Test

Soaking 1 – 4 napkin/ day for CT, BTFor pelvic ultrasound in AM- IVF: PNSS at 100 cc/hr

- IVF TF: PNSS in at 80 cc/hr

- Meds: Tranexamic acid 500 mg IM – now

Tranexamic acid 500 mg 1 cap, QID, to start in AM FeSO4 1 cap BID

- AP aware

- Refer accordingly

July 25, 2010 Continue Meds8:30 Vaginal bleed Pelvic Ultrasound @ AM tomorrow (07/26/10)

July 25, 201010:10PM IVF TF: PNSS 1L @ 80 cc/hr

July 26, 20106:00AM IVF TF: PNSS 1L @ 80 cc/hr

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12:30PM(+) for hypogastric pain May give Ketorolac 30mg IV TT now7:20PM Althea 1 tab once and P.O 8 AM10:00PM PNSS 1L @80 cc/hr

July 27, 2010 7:00 AM IVF: PNSS 1L @ 80 cc/hr12:00 PM IVF: PNSS 1L @ 80 cc/hr4:00 PM MGH

Meds:• Tranexamic acid 50 g

3x a day (1 week) (8am– 11am – 7pm)

• Althea 1 tab once a day at 8 AM

Follow up. Aug. 4, 2010 at 2 PM, clinic

• Magniferron 1 cap, OD at 7 PM

Advised:

Bed Rest

No work load

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PROGNOSIS

FACTORS PROGNOSIS JUSTIFICATION

Medication Regimen Good The client is able to follow the treatment regimen that was

given by the attending physician.

Activity Good The client is able to comply with the advise of bed rest &

no work load.

GENERAL PROGNOSIS:

Patient general prognosis is good since the disease of the patient could be managed through different varied

treatments with the help of her family. She has knowledge of what is medication is she taking & what it is for. She follows

religiously the attending physician’s prescribed treatments and takes willingly the doctor’s prescription medication. The

case of her abnormal uterine bleeding is easier to treat than any other cases of abnormal uterine bleeding.

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HEALTH TEACHINGS

1) Advised to take medicines religiously as prescribed by the doctor

2) Instructed to avoid strenuous activities such as heavy lifting for it may aggravate

vaginal bleeding

3) Advised to increase foods rich in iron

4) Instruct client to comply with the physicians advice for follow-up check-up

NURSING IMPLICATIONS

A. NURSING EDUCATION

It helps the nursing profession gain more information regarding different

symptoms, different causes, different etiologies and different treatments and nursing

actions related to this case and to impart this information to the younger batches of

nursing students of Notre Dame of Kidapawan College.

It also helps the nursing profession to be aware of the different terminologies

used so that it would be imparted to the future incoming nursing students. It also helps

the nursing students of Notre Dame of Kidapawan College to be more knowledgeable in

dealing with patients who have abnormal uterine bleeding.

B. NURSING PRACTICE

It helps the nursing profession to be more aware in dealing with this kind of cases

in different fields and hospitals.

It also helps the nursing students of Notre Dame of Kidapawan College to be

more skillful in doing the different nursing actions to the patients in different hospitals, to

have safe and quality nursing care that the patient needs.

It also helps the nursing profession to prevent any clinical errors that can harm

the patient and may result to mal-practice or globally known as negligence.

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C. NURSING RESEARCH

It helps the nursing profession to gain more knowledge regarding this case and

to impart this data to the incoming researchers who may need the said information.

It also helps the researchers to gather more reference to strengthen the validity

of the different information of the said case. It also helps to make the gathered

information to be more truthful in terms and learning that may found in the papers.

39

BIBLIOGRAPHY

A. Books

Andreasen, Charlotte and Aris Jr. Andrews. Et al. © 2006. Mosbys’s Pocket dictionary

of Medicine, Nursing and Health Professions 5th Edition. Elsevier Pte. Ltd.

Singapore.

Berman, Audrey and Shirlee Synder. © 2008. Kozier and Erb’s Fundamentals of

Nursing 8th Edition. Pearson Education Inc. Jurong, Singapore.

Bullock, Barbara and Henze, Reet. © 2000. Focus on Pathophysiology. Lippincot

Williams and Wilkins. Philadelphia.

Doenges, Marilyn E. and Mary Frances Moorhouse, et al. © 2008. Nurse’s Pocket

Guide Diagnosis, Prioritized interventions and Rationales. L.A. Davis Company,

Philadelphia. Thomson Learning Asia. Singapore.

Fischbach, Frances. © 1988. A manual of Laboratory diagnostic Tests 3 rd Edition. J. B.

Lippincot Company. Philadelphia.

McCann, Judith A. and H. Nancy Holmes. et al. © 2008. The Nursing 2008 Drug

Handbook. Lippincot Williams and Wilkins. Philadelphia.

McCann, Judith Schilling. © 2007. Assessment. Lippincot Williams and Wilkins.

Philadelphia.

Pilliteri, Adele. © 2003. Maternal and Child Health Nursing. 4 th Edition. Lippincot

Williams and Wilkins. Philadelphia.

B. Internet

http://findarticles.com/p/articles/mi_m0689/is_3_58/ai_n31438489/

http://emedicine.medscape.com/article/795587-overview

http://www.acog.org/publications/patient_education/bp095.cfm

http://www.uptodate.com/patients/content/topic.do?topicKey=~.p55Sh88wWX6eG

http://familydoctor.org/online/famdocen/home/women/reproductive/menstrual/470.html

http://www.gynalternatives.com/abnormal_uterine_bleeding.htm

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http://www.medicines.org.uk/emc/medicine/21712/SPC/tranexamic%20acid%20500mg

%20tablets%20(sandoz%20limited)/

http://www.nativeremedies.com/ailment/symptoms-of-hormone-imbalance.html

http://www.medicine.uic.edu/UserFiles/Servers/Server_442934/File/OBGYN%20Med

%20Ed/STUDENTS/Lectures/ELAM%20-%20AUB%20talk.pdf

http://www.medicine.uic.edu/UserFiles/Servers/Server_442934/File/OBGYN%20Med

%20Ed/STUDENTS/Lectures/ELAM%20-%20AUB%20talk.pdf

http://members.aapa.org/aapaconf2006/syllabus/6253TaylorDUB.pdfc

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