Introduction

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

uterus at an unexpected time or in a way that is unusual for her. Abnormal bleeding
may happen in between periods or during periods which can be described as heavier
and/or longer-lasting than normal, bleeding after coitus, clots found in the menstrual
blood and any bleeding after menopause can occur at any age. However, at certain
times in a womans life it is common for periods to be somewhat irregular. They may not
occur on schedule in the first few years after menarche (around age 9-16 years). Cycle
length may change as a woman nears menopause (around age 50 years). It also is
normal to skip periods or for bleeding to get lighter or heavier at this time.

The most common reason for irregular uterine bleeding is pregnancy. Spotting or
very light bleeding may occur with no real significance. 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. Cramping usually
accompanies the bleeding. Also, called Stein-Eventual syndrome, Polycystic Ovarian
Syndrome occurs when you dont 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.
Sexually transmitted diseases often cause these infections. 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 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 patients
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 non-pregnant women is a common

problem. In fact, AUB accounted for almost 800,000 outpatient visits (mostly to
physicians offices) in the United Kingdom in 2015 Indeed, this problem may prompt
more than 20% of all visits to OB/GYNs, and may account for more than one fourth of all

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hysterectomies. Heavy menstrual accounts for 5% of visits to GP. Between 9 and 30% of
reproductive-aged women have menstrual irregularities requiring medical evaluation.

One popular form of treatment for abnormal uterine bleeding is birth control pills,
which contain hormones that can prevent the uterus lining from thickening. If birth
control pills arent stopping the bleeding, a doctor may prescribe an intrauterine (IUD)
device. An IUD is a plastic device that is inserted into a womans uterus to prevent
pregnancy. In rare cases, surgery may be needed to stop abnormal bleeding. Two
surgical procedures are recommended: hysterectomy and endometrial ablation.

Hysterectomy. This type of surgery removes the uterus. If you have a

hysterectomy, you won't have any more periods and you won't be able to get
pregnant. Hysterectomy is major surgery that requires general anesthesia and a hospital
stay. It may require a long recovery period. Endometrial ablation is a surgical procedure
that destroys the lining of the uterus. Unlike a hysterectomy, it does not remove the
uterus. Endometrial ablation may stop all menstrual bleeding in some women. However,
some women still have light menstrual bleeding or spotting after endometrial ablation.
A few women have regular menstrual periods after the procedure. Women who have
endometrial ablation still need to use some form of birth control even though, in most
cases, pregnancy is not likely after the procedure.

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I. Statement of Objectives
a. General Objectives

This case analysis aims to increase the understanding and knowledge of

student nurses on how to care for patients with Abnormal Uterine Bleeding-
Myoma effectively and efficiently. To define what Abnormal Uterine Bleeding is
and its effects to the body as a whole and its relation to each sign and symptom
it presents. Furthermore, this case will enhance the critical thinking skills and
interpersonal relations of student nurses with regards to the nursing process of
formulating and understanding cases based on Abnormal Uterine Bleeding.

b. Specific Objectives

The Students Nurses aim to achieve the following objectives within 2 hours
case presentation:
1. Accurately present thorough general health assessment of the client
which includes the physicians assessment, family history taking, and
head to toe assessment.
2. Efficiently provide appropriate nursing diagnoses in line with the
clients medical condition.
3. Skillfully formulate nursing care plans for the different problems
identified.

4. Illustrate the pathophysiology of Abnormal Uterine Bleeding in relation

to the patient.
5. Discuss the medical interventions for the client based on the
assessment and findings.
6. To present drug studies on medications given to client as a part of
treatment regimen.
7. Identify care measures to be given to the patient and family to
promote continuity of care and independence after discharge.

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 I. Patients Profile

Name :Patient M
Age :32 years old
Birthdate :June 03,1984
Gender :Female
Address :Padre Zamora, Baguio City
Nationality :Filipino
Ethnicity :Pangasinense
Civil Status :Single
Religion :Roman Catholic
Occupation :Housemaid
Date of Admission :March 5, 2017 10:20 AM
Admitting Physician :Jennifer Mary Joy V. Chui, M.D.
Admitting Diagnosis :G5P4 (4014) Abnormal Uterine
Bleeding-Myoma
Final Diagnosis : G5P4 (4014) Abnormal Uterine Bleeding -
Myoma
Dates of Interaction :March 6-8 Shift 7-3

II. Chief Complaint

Prolonged Menses.

III. History of Present Illness

The condition started 1 month prior to admission as onset of profuse menstrual

bleeding lasting for 14 days consuming 3-4 pads of fully soaked napkins per day
associated with dizziness. No experiences of pain, nausea, vomiting, sudden
weight loss and no palpable masses. Patient consulted Baguio General Hospital
and Medical Center and was admitted and treated for Abnormal Uterine
Bleeding; Curettage was done and was discharged eventually with tranexamic
acid and pills as home medications.
1 week prior to admission patient had intermittent menstrual bleeding
consuming 3 moderately soaked pads per day associated with a stabbing
continuous pain at the Right Lower Quadrant radiating towards the back rated
as 3/10, aggravated by moving. Few days after patients condition persisted,
patient was prompted to seek follow up consult at BGH-MC. A few hours later
she was then admitted to the Gyne ward.

IV. Past History of Illness

Menarche was at age 13. Her usual menstruation had an interval of 28-30
days and duration of 4-6 days. Amount of blood is heavy soaking usually 3-4
pads per day accompanied by mild dysmenorrhea.

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 V. Family History

No heredofamilial diseases such as hypertension, diabetes, asthma, and

cancer were reported in the family.

VI. Developmental History

According to Erick Ericksons development theory she falls under the

category of Intimacy vs. Isolation. She states that she is the 5th child in her family; she
currently has a live-in partner and 4 children (2 boys and 2 girls) whom stay in her
hometown. She states that they were separated due to her work. On her free times
she hangs-out with her friends.

VII. Social and Environmental History

Since she is a housemaid she stays in her employers home together with
the children of her employer. They live in a two-storey concrete house with 3
bedrooms. She commutes daily by public transportation. As the breadwinner of
her family with a low-pay-salary, she has trouble paying her bills.

VIII. Lifestyle and Health Practices

She is a non-smoker, but an occasional alcohol drinker. She mostly eats

foods high in cholesterol like meat and canned goods. Water intake is 1 liter a
day and was not taking any medications prior to diagnosis. She stated that she
doesnt go for regular check-ups.

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VII. Health Assessment

a. General Survey
Received patient awake lying on bed with ongoing IVF of D5LRS 1L x 8 hours
infusing well at the right arm. With complains of pain. Masakit po talaga yung
puson ko. Rated as 10/10. Grimacing and guarding behavior noted.
Client needs assistance when performing activities of daily living, such as
toileting and changing in position. Able to determine the time and date. She is
conversant. Her speech is well formulated and her answers are relevant to the
questions asked.

b. 13 Areas of Assessment

1. Psychosocial Status
She is under Erick Ericksons intimacy and isolation stage of development (ages
18-40 years old).
Patient X stated that she was separated with her children and live in partner
as she works here in Baguio. However, she stated that she loved going out with friends
and occasionally travels to her hometown to visit her family, which shows the
development of intimacy.

2. Mental and Emotional Status

She is oriented about the time, and place. Conversant and can follow directions
when asked. During interview, she was able to express and verbalize her feelings
regarding her condition. Also she is responsive wherein she identifies names of things
being asked without difficulty.

3. Environmental Status
Patient was admitted at Baguio General Hospital and Medical center at
Gyne Ward. The ward contains approximately 20 beds for patients; has inadequate
space, not enough for all the patients, considering that they also have their watchers
and student nurses to take care of them. Her bed was located near the entrance
which provides adequate ventilation for rest and comfort.

4. Sensory Status
Eyes are symmetrically aligned and showed equal movement when asked
to raise and lower eyebrows. Pupils of the eyes are black and equal in size. Pupils are
round and reactive to light and accommodation. Pupils converge when object is
moved towards the nose. No yellowing of sclera, pale conjunctiva. Has no difficulty in
classifying fragrant and sour odor. Can differentiate taste of sweet and sour upon giving
orange and malagkit. Hearing are normal, the patient have no difficulties in

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understanding and can hear spoken language. The patient can identify sharp or dull
when elicited to the patient.

5. Motor Status
During assessment, difficulty in abducting, flexing, extending in upper and lower
extremities is observed. Motor status scale as 3/5.

6. Nutritional Status
The patients food is being served in the hospital and in diet as tolerated.
Appetite is poor as evidenced by eating only 50 % of the food served. She eats
porridge often because she stated that when she eats solid foods it causes pain on her
abdomen. On the third day, Nurses informed us that we must pay attention to the food
the client eats since they found out that she has ulcer. Ms. M weighs 50 kg with a height
of 52 ft (1.524 m). A normal BMI of 32 years old female is ranging 26 to 27.

7. Fluids and Electrolytes Status

Has IVF of D5LRS x 8 hours using a macro set infusing well on the right arm.
Drinks 5-6 glasses of water per day. She stated that she doesnt drink any beverage
aside from water.

8. Elimination Status
She usually defecates once a day when not yet hospitalized. During our
shift patient defecates 4-5 times characterized as watery and yellow in color. Patient
Urinates four to five times, yellow colored urine. No change in urine output since day
one to day three.

9. Circulatory Status
Capillary refill goes back 2-3 seconds and orthostatic hypotension noted taken
when the client is sitting down. Patients blood pressure ranges from 90/70-110/80 since
day 1 to day 3. Reports dizzy when standing and walking.

Heart Rate
Time First Day Second Day Third Day
10 am 85 91 91
2 pm 91 97 85
Blood Pressure
Time First Day Second Day Third Day
10 am 110/70 90/70 110/80
2 pm 100/80 110/70 100/70

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10. Respiratory Status
Patient is tachypnic during the first and second day of shift. No use of accessory
muscles has been observed to the patient.

Respiratory Rate
Time First Day Second Day Third Day
10 am 29 22 20
2 pm 27 20 18
Oxygen Saturation
Time First Day Second Day Third Day
7 am 97% 90% 93%
10 am 92% 94% 95%
2 pm 95% 96% 93%

11. Temperature Status

Patients temperature ranges from 38.9-36.9. Episodes of fever have been
assessed during the first shift on the patient.
Temperature rate
Time First Day Second Day Third Day
10 am 38.5C 36.8C 36.8C
2 pm 37.8C 36.9C 36.9C

12. Integumentary Status

Skin is pale, no presence of yellowish discoloration on the skin of the patient, not
dry, capillary refill of 2-3 seconds and good skin turgor as evidenced by pinching then
goes back 1-2 seconds. There are no rashes noted, no wounds, lesions or redness noted
absence also of pruritus in any area.

13. Rest and Comfort Status

Prior to admission patient usually sleep 6-7 hours during night time. As a
housemaid she usually wakes up early to do household chores. During the admission
sleeping pattern has been disturbed and shortened to 4-5 hours due to the noises
outside. Patient also interacts to student nurses and other patient as an additional to
her comfort despite her condition.

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C. HEAD TO TOE

Head Head: The head of the client is rounded and symmetrical.

Skull: There are no palpable nodules or masses and
depressions upon palpation.
Face: The face of the client appeared smooth and has
uniform consistency. No presence of nodules or masses.
Client had shallow wrinkles.
Hair: The hair is evenly distributed and medium length,
with oil and sweat present. No parasites or dandruff noted

Eyes Pupils are equally round and reactive to light and

accommodation. Ocular movement noted, able to
follow a penlight with glaze. Pale conjunctiva and mucus
membrane.
Ears Ears are parallel, in line with the inner cantus of the eyes,
bean shaped, firm cartilage and with minimal presence
of cerumen.
Nose and Sinus No deviation in terms of shape and size, no discharges
were seen during assessment. According to the patient,
she does not have any history of sinus infection.
Mouth Patients lips were moist and pale, symmetrical in shape,
complete set of adult teeth, no dentures noted. Oral
mucosa is dry and pinkish, no lesions noted, tonsils are not
inflamed, uvula located midline.
Neck With smooth head movement from side to side, no
discomfort noted, The lymph nodes are not palpable. The
thyroid gland is not visible.
Chest Shape of the chest is elliptical, symmetrical chest wall
expansion, with abnormal respiratory rate ranges from 20-
29. Fast breathing noted.

Cardiac There were no visible palpitations on the aortic and

pulmonic areas. There are no presence of heaves or lifts.
No accessory muscles used.
Breast Skin color is similar with the rest of the body, nipple and
areola is darker compared to the skin, no discharges.
Abdomen No enlargement of the abdomen, with hyperactive
bowel sound heard in all the quadrant upon auscultation
of 5 minutes every quadrant.

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Genitals Presence of pubic hair noted. Napkin soaked with blood
90%, bright red in color. Able to consume 2-4 pads per
day.

Musculoskeletal Extremities are bilaterally proportional in size and length.

Muscles are firm. Difficulty in moving and changing
position shows reluctance to move extremities and needs
assistance in doing ADL.

Integumentary Pale complexion with good skin turgor. Nails beds are
pinkish in color.

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 XI. DIAGNOSTIC PROCEDURE

Description of the Significance/Purpose Date of Findings and Implications

Procedure procedure of procedure procedure
Complete Blood A blood test used to To detect abnormal February 5, 2017 Test Name Result Range Implication
Count (CBC) evaluate your overall increases or Hemoglobin 129 g/L 120 160 g/L Normal
health and detect a decreases in cell
wide range of counts as revealed in Hematocrit 0.39 g/L 0.36- 0.48 g/L Normal
disorders, including a complete blood
anemia, infection count which may WBC count 12.61 g/L 5.0 - 10.0 g/L Increased:
Indicates
and leukemia. indicate that you
leukocytosis due to
have an underlying infection.
medical condition
that needs for further Neutrophils 0.82 g/L 0.50 - 0.70 g/L Increased:
evaluation. Indicates presence
http://www.mayoclin of infection.
ic.org/tests-
Lymphocyte 0.11 g/L 0.20 0.40 g/L Decreased:
procedures/complet indicates
e-blood- immunosuppressan
count/home/ovc- t due to presence
20257165 of infection.

Monocytes 0.06 0.0 0.10 Normal

Eosinophil 0.01 0.0 0.07 Normal

Basophil 0.00 0.0 0.01 Normal

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RBC count 4.38 4.69 6.13 Decreased:
indicates anemia
due to blood loss.
Platelet count 285 150 400 Normal

RBC indices

MCV 88.80 80 100 Normal

MCH 29.40 27 31 Normal

MCHC 330 310 360 Normal

RDW-CV 359.0 310 360 Normal

RDW-SD 11.40 11.6 14.6 Normal

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 Procedure Description of the Significance/Purpose of Date of procedure Findings and Implications
procedure procedure
Urinalysis Urinalysis is a test that It is used to look for February 6,2017 Test Findings Indications
evaluates a sample of abnormalities such as an Color Yellow Normal
your urine. Urinalysis is excess amount of protein, Appearance Turbid Normal
used to detect a wide
blood, pus, bacteria or Protein Negative Normal
range of disorders, such
as urinary tract infections, sugar. A urine test can Glucose Negative Normal
kidney disease, tumors help detect a variety of Ketones Negative Normal
and diabetes. kidney and urinary tract Hgb Negative Normal
disorders, including Puss cells 0-3/hgf Normal
A urinalysis involves chronic kidney disease, RBC Too numerous to High count of red
checking the diabetes, bladder count blood cells can
appearance,
infections and kidney indicate presence of
concentration and
content of urine. stones. tumors.

http://www.mayoclinic.or
g/tests-
procedures/urinalysis/ho
me/ovc-20253992

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 XII. TREATMENT/MANAGEMENT
Drugs Classification and Mechanism of Action Contraindications
dosage
Generic name: Antifibrinolytic Inhibits activation of
Tranexamic acid plasminogen (via
10 mg IVq8 binding to the kringle
Brand name: domain), thereby
Hemostan reducing conversion of
plasminogen to plasmin
(fibrinolysin), and an
enzyme that degrades
fibrin clots, fibrinogen,
and other plasma.
Adverse effect Nursing Responsibilities
Hypersensitivity GI:Diarrhea Before:
Presence of CNS: Hypotension Monitor blood pressure, pulse,
blood clots or Thromboembolic: and respiratory status as
has a history of arterial, venous, indicated by severity of
blood clots, or embolic; bleeding.
are at risk for Neurologic, visual Monitor for bleeding every 15
blood clots. impairment, 30 minutes.
Subarachnoid convulsions, mental Monitor neurologic status
hemorrhage. status changes; (pupils, level of consciousness,
motor activity)
Assess for thromboembolic
complications. (Especially in
patients with history). Notify
physician of positive
hemorrhage.
Monitor platelet count and
clotting factors prior to and
periodically throughout therapy
in patients with systemic
fibrinolysis.
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During:
Stabilize IV catheter to minimize
thrombophlebitis. Monitor site
closely.
After:
Instruct patient to notify the
nurse immediately if bleeding
reoccur or if thromboembolic
symptoms develop.
Caution patient to make
position changes slowly to
avoid orthostatic hypotension.

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Drugs Classification and Mechanism of Action Contraindication Adverse Effects Nursing responsibilities
dosage
Generic name: NSAID Analgesic and anti- Contraindicated CNS: Headache, Before:
Celecoxib inflammatory activities with allergies dizziness, somnolence,
200 mg 1 cap related to inhibition of to sulfonamides,cel tiredness, dizziness, Assess renal impairment,
Brand name: BID the COX-2 enzyme, ecoxib, NSAIDs, or impaired hearing, allergies,
Celebrex which is activated in aspirin; significant Hematologic: thromb hepatic and Cardiovascular
inflammation to cause renal impairment. ocytopenia, agranulo conditions.
the signs and Use cautiously with cytosis, granulocytop
symptoms associated impaired hearing, enia, aplastic anemia. During:
with inflammation hepatic, and
cardiovascular Administer drug with food or
conditions. after meals if GI upset occurs.
Establish safety measures if CNS
occurs.

Provide further comfort

measures to reduce pain (e.g.
Positioning, environmental
warmth, positioning, and rest).

After:

Inform that client may

experience these side effects:
Dizziness, drowsiness.
Report sore throat, fever, rash,
itching, weight gain, swelling in
ankles or fingers; changes in
vision.

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 Drugs Classification and Mechanism of Action Contraindication Adverse effect Nursing Responsibilities
Dosage
Generic name: Iron preparation Elevates the serum iron Hypersensitivity GI:, stomach Before:
Ferrous sulfate concentration, which Severe Hypotension cramping, diarrhea.
1 cap then helps to form Hg Obtain baseline assessment of
Brand name: OD or trapped in the Genitourinary: iron deficiency before starting
Discoloration of urine. therapy.
Feosol reticuloendothelial
Evaluate hemoglobin,
cells for storage and
hematocrit, and reticulocyte
eventual conversion to count during therapy.
a usable form of iron. Assess bowel elimination,
increase water, bulk, and
activity.
Assess diet and nutrition:
amount of iron in diet.
Identify cause of iron loss or
anemia, (salicylates,
sulfonamides, antimalarials,
quinidine).

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During:

Give between meals for best

absorption; may give with juice;
do not give with antacids or
milk, delay at least 1 hour;
Give at least 1 hour before
bedtime because corrosion
may occur in stomach

After:

Give for < 6 months for anemia

Store in airtight, light-resistant
container

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XIV. Nursing Care Plans
a. Prioritization of problems

A. List of Problems

Actual
1. Acute Pain
2. Impaired Tissue Perfusion
3. Activity Intolerance
Potential
4. Risk for injury
5. Risk for hypovolemic shock

Nursing Diagnosis Justification

1. Acute pain We made this as the highest priority because

according to Maslow hierarchy of needs. The first
need in the pyramid is the physiologic need in
which patient experience pain. In relation to
Comfort Theory by Katherine Kolcaba she
defined Comfort Care as immediate experience
of being strengthened by having needs for relief,
ease, and transcendence. Thus, needs to
alleviate pain and provide comfort for the
optimum level of functioning of individual.

2. Impaired tissue Second priority because according to ABC,

perfusion circulation in the body is necessary for the
distribution of oxygen in care. Ineffective Tissue
Perfusion manifested by pale conjunctiva and
mucus membrane.

3. Activity intolerance According to ABC, circulation in the body is

necessary for distribution of oxygen. Activity
Intolerance occurs

4. Risk for Injury According to Maslows needs, safe is important

to humans as physiologic need. Injury may
possibly arise as there is mobility intolerance to
the patient or if there is an occurrence of cardiac
arrest. Faye Abdellah identified the 21 nursing
problem which include the promotion of safety
through prevention of accidents, injury or other
trauma.

5. Risk for hypovolemic Last priority because hypovolemic shock

shock canoccur due to blood loss. Basing from ABC,
circulatory system is too depleted to allow
adequate circulation to the tissues of the body.

20 | P a g e
21 | P a g e
 1 ACUTE PAIN

ASSESSMENT EXPLANATION OF THE OBJECTIVES NURSING INTERVENTION RATIONALE EVALUATION

PROBLEM
S: Unpleasant sensory STO: Dx: STO:
>Masakit po talaga and emotional >After 30 minutes 1 hour > Monitored vital signs. > Vital signs are usually >Goal met, patient
yung puson ko. As experience of nursing intervention altered in acute pain. experienced gradual
verbalized. Rated as arising from actual or
patient will be able to reduction of pain from
10/10. potential tissue
damage experience gradual > Performed >Aids in identifying 10/10 to 8/10 in the pain
or described in terms of reduction of rate of pain comprehensive assessment degree of discomfort scale as evidence of able
O: such damage from 10/10 to 8/10 in the of pain on abdomen to and need for analgesia. having rest and sleep.
>Characterized as (International pain scale as evidences include characteristics. Pain is a subjective
stabbing pain on the Association for the able to rest and sleep. Onset, frequency, quality, experience and must be
abdomen Study of Pain); sudden severity and aggravating described.
aggravated by or slow onset of any
factors.
movement; intensity from mild to
>Grimace and severe with an LTO: LTO:
guarding behavior on anticipated or >After 3 days of nursing >Observed non-verbal > Observations may or >Goal met, patient
the abdominal area. predictable end and a intervention, patient will cues, like how the patient may not be congruent reported comfort and free
duration of less than six report comfort and pain walks and sit, facial with verbal reports from pain.
(6) month. scale will be free from expression and other indicating need for
NDx:
>Acute pain r/t pain. objective defining further evaluation.
uterine contractility, characteristics as noted.
SOURCE:
hypersensitivity.
https://nurseslabs.com/
acute-pain/ Tx:
> Assisted to position of > Positions can affect
comfort. patients ability to relax
and rest/Sleep
effectively.
22 | P a g e
> Provided rest periods to
promote relief, sleep, and
relaxation.
Edx:
>Instructed to use relaxation
techniques such as deep
breathing exercise.
> Instructed to report pain
as soon as it begins.
> Encouraged adequate
rest/ sleep and minimize
unnecessary movements.
> Promotes relaxation,
helps refocus attention
and may enhance
coping activities.
>Promotes relaxation,
helps refocus attention
and may enhance
coping activities.
>Timely intervention is
more likely to be
successful in alleviating
pain.
>To alleviate fatigue
and stimulation of pain.
23 | P a g e
 2. INEFFECTIVE TISSUE PERFUSION
ASSESSMENT EXPLANATION OF THE
PROBLEM
S: Decrease in oxygen,
>Nahihilo ako pag resulting in failure to
tumatayo. nourish tissues at
capillary level. Blood is
O: a connective tissue
>Pale conjunctiva comprised of a liquid
and mucus extracellular matrix
membrane; pale skin; termed as blood
capillary refill of 2-3 plasma which dissolves
seconds; weakness and suspends multiple
noted. cells and cell
fragments. It carries
NDx: oxygen from the lungs
>Ineffective Tissue and nutrients from the
Perfusion r/t Impaired gastrointestinal tract.
transport of oxygen The oxygen and
across alveolar nutrients subsequently
and/or capillary diffuse from the blood
membrane. into the interstitial fluid
and then into the body
cells. Insufficient arterial
blood flow causes
decreased nutrition
OBJECTIVES NURSING INTERVENTION
STO: Dx:
>After 2 hours of nursing >Noted current situation or
intervention patient will presence of conditions such
engage in behaviors or as anemia.
actions to improve tissue
perfusion. >Determined history of
conditions associated with
LTO: thrombus or emboli such as
>After 3 days of nursing abdominal or orthopedic
intervention patient will surgery,.
will engage in behaviors
or actions to improve >Assessed skin color,
tissue perfusion. temperature, moisture, and
whether changes are
widespread or localized.
Tx:
>Administered fluids,
electrolytes, nutrients, and
oxygen, as indicated.
RATIONALE EVALUATION
STO:
>Affecting systemic > Goal partially met, After 2
circulation/perfusion. hours of nursing
intervention, patient
demonstrated moderate
>To identify client at sensations and movements.
higher risk for venous
stasis, vessel wall injury, LTO:
and hypercoagulability. > Goal met, after 3 days of
nursing intervention patient
was able to engage in
>For changes that behaviors or actions to
might indicate improve tissue perfusion.
circulation problem.
>To promote hydration.
24 | P a g e
and oxygenation at the >Collaborated in treatment >To enhance circulation
cellular level. of underlying conditions, and promote general
Decreased tissue such as blood disorders well-being.
perfusion can be
temporary, with few or >Provided foot and ankle >Promotes circulation.
minimal consequences exercises.
to the health of the
patient, or it can be EDx:
more acute or > Encouraged to plan >Enhances venous
protracted, with regular exercise program. return. Studies indicate
potentially destructive exercise training may
effects on the patient. be an effective early
When diminished tissue treatment for
perfusion becomes intermittent
chronic, it can result in claudication.
tissue or organ damage
or death >Discouraged sitting or >To enhance circulation
standing for extended and well being.
periods of time, wearing
constrictive clothing, or
Source: crossing legs when seated.

http://nurseslabs.com >Taught client to recognize >Changes in skin,

/ineffective-tissue- signs and symptoms that temperature, color
perfusion/ need to be reported to a sensation or presence
physician. of a new lesion on the
foot should be reported.

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 3. ACTIVITY INTOLERANCE

ASSESSMENT EXPLANATION OF THE OBJECTIVES NURSING INTERVENTION RATIONALE EVALUATION

PROBLEM
S: Insufficient physiologic STO: Dx: STO:
or psychological energy > After 8 hours of > Assessed patients ability > May indicate > Goal met after 8
> nanghihina ako
to endure or complete nursing interventions the to perform normal task or neurological changes hours of nursing
required or desired daily patient will: activities of daily living. associated with B12 interventions, the
activities. report an increase in deficiency, affecting patient is able to carry
O: activity intolerance patient safety or risk of on with activities of
The common etiology including activities of injury. daily living with minimal
>needs assistance of Activity Intolerance is daily living. assistance.
when doing ADL. related to generalized Demonstrated a > Note changes in > To provide proper and
weakness and decrease in balance/ gait disturbance, appropriate nursing
debilitation from acute physiological signs of muscle weakness. intervention.
NDx: or chronic illnesses. intolerance.
Anemia, and side effect
> Activity
medications. > Assessed causative >To identify problems
intolerance related
LTO: problem activity causing it.
to generalized
> After 3 days of nursing intolerance. LTO:
weakness
interventions, the Tx: > Goal met, patient
patient will: > Monitor laboratory > Identifies deficiencies in reveals an increasing
https://nurseslabs.com/ be completely studies, Hb and Hct and RBC components independence wit
activity-intolerance/ independent on RBC count, arterial gases. affecting oxygen transfer
activities of daily living and treatment needs or
response to therapy.

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>Dangle the legs from the >Prevents orthostatic
bed side for 10 to 15 hypotension.
minutes.

>Assist with ADLs while >Assisting the patient with

avoiding patient ADLs allows conservation
dependency. of energy. Carefully
balance provision of
assistance; facilitating
progressive endurance
will ultimately enhance
the patients activity
tolerance and self-
esteem.
Edx:
> Encourage active ROM >Exercise maintains
exercises. Encourage the muscle strength, joint
patient to participate in ROM, and exercise
planning activities that tolerance. Physical
gradually build endurance. inactive patients need to
improve functional
capacity through
repetitive exercises over
a long period of time.
Strength training is
valuable in enhancing
endurance of many
ADLs.

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>Taught the patient and/or >Knowledge promotes
SO to recognize signs of awareness to prevent
physical over activity or the complication of
overexertion.
overexertion.

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 4. Risk for Injury
5.
Assessment Explanation of the Objectives Nursing Intervention Rationale Evaluation
problem

O: Vulnerable for injury as a STO: Dx: STO:

>Weak in result of environmental >After 3-4 hours of >Performed thorough >Failure to accurately >Goal met, After the
appearance conditions interacting nursing intervention, the assessments regarding assess and intervene or nursing intervention, the
>Dizziness with the individuals patient will verbalize safety issues when planning refer these issues can patient verbalized
>pale skin adaptive and defensive understanding of for client care and/or place the client at understanding of
resources, which may individual factors that preparing for discharge needless risk and creates individual factors that
compromise health. contribute to the from care. negligence issues for the contribute to possibility
NDx: possibility of injury. health care practitioner. of injury.
Risk for injury
>Ascertained knowledge > To prevent injury in
Source: of safety needs/injury home, community, and
prevention and motivation. work setting that may LTO:
http://nurseslabs.com LTO: result in carelessness/ >Goal met, The patient is
/risk-for-injury/ >Within 3 days of increase risk-taking free from injuries.
providing nursing without consideration of
interventions, the consequences.
patient will be free from
injuries. >Assessed the patient >It is helpful to determine
ability to ambulate safely the patients functional
with or without assistive abilities to plan for ways
devices. of improving the problem
area.

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>Assessed clients muscle >To identify risk for fall.
Strength, gross and fine
motor coordination.

Tx:
>Maintained bed in lowest >To prevent the patient
position and raise the side from falling on bed.
rails with wheels lock.

>Instructed the client to >Provides safety.

call for assistance when
moving.

Edx:
>Taught client how to >To prevent from falling
safely ambulate including
using safety measures such
as handrails in bathroom

>Advised to avoid extreme > Patients with

hot and cold around
patients at risk for
injury (e.g., heating pads,
hot water for
baths/showers).
decreased cognition or
sensory deficits cannot
discriminate extremes in
temperature

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>Taught methods to > Decreased ability of
decrease dizziness, such as compensatory
rising slowly, remaining mechanisms to maintain
seated several minutes blood pressure when
before standing, flexing standing up, resulting in
feet upward several times postural hypotension.
while sitting, sitting down
immediately if feeling dizzy,
and trying to have
someone present when
standing.

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 6. Risk for hypovolemic shock
ASSESSMENT EXPLANATION OF THE
PROBLEM
O: A condition that results
>Fully soaked napkin when you lose more
consuming 2-4 pads than 20 percent (one-
a day. fifth) of your bodys the patient will report
>BP>100/ 70 mmhg blood or fluid supply. This
>RR> 26 bpm severe fluid loss makes it
>CR>85 bpm impossible for the heart
to pump a sufficient
NDx: amount of blood to your
> Risk for body, occur because of
hypovolemic shock severe vagina bleeding.
Source:
http://www.health
line.com/health/
hypovolemic-shock
OBJECTIVES NURSING INTERVENTIONS RATIONALE EVALUATION
STO: Dx: STO:
>After 4 hours >Monitor and record vital >To obtain baseline data. > Goal met, After4
of nursing interventions, signs. hours of nursing
interventions the
understanding >Assessed patients > To be aware of patients patients was able to
of causative factors for condition. condition and feelings. report understanding of
fluid volume deficit. causative for fluid
>Maintained adequate > To prevent dehydration. volume deficit.
LTO: hydration
>After 3 days of Nursing LTO:
Interventions, the patient Tx: > Goal met, after 3
will maintain fluid > Administered intravenous >To deliver fluids accurately days of nursing
volume at functional fluid as prescribed. and at its desired rate. intervention the patient
level as evidenced by maintained fluid
well hydrated, and > Oxygen administration > Oxygen is administered to volume at functional
normal skin turgor. increase the amount of level as evidenced by
oxygen carried by available well hydrated and
hemoglobin in the blood. normal skin turgor.
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Edx:
> Encouraged to > To promote hydration
maintained adequate fluid
intake.

> Encouraged to limit >To allow for bowel rest and

eating dry foods. to reduce intestinal
workload.

>Discussed individual risk >To prevent or limit

factors/ potential problems occurrence of fluid deficit.
and specific interventions.

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