I.

Demographic Data

My client is Mrs. JA, she lives in Antipolo City. She is 51 years old, Female and married
to Mr. X. Her religion is Catholic. She was admitted with a chief complaint of body
weakness and uterine bleeding with a provisional diagnosis of Dysfunctional Uterine
Bleeding secondary to Anemia under the service of Dra. Leyble.

II. History of Present Illness

The client was diagnosed with Myoma two years ago and her physician referred her for
a surgery but she refused, because according to her daughter the client verbalizes fear
on surgeries that’s why she doesn’t want to undergo. The client is experiencing bleeding
for about a year, and she has regular check-ups on her OB. She was given a
maintenance medication of Iveret which the client says that it is for minimizing her
bleeding.

III. Family History

The client’s sister is diagnosed of a heart Disease and died a week ago. The client has
history of asthma. She said that sometimes she experiences difficulty of breathing when
she is at rest. According to her, her asthma triggers seldom.

IV. Physical Assessment

General Appearance

The client is pale in appearance. She has some complains of body weakness and
headache. The client stated hat she maintains her proper hygiene while she is in the
hospital. The client appears to be neat and good in posture.

Analysis: Good posture, Well groomed, and Quantity/quality of speech is in moderate

pace.
(Fundamentals of Nursing, 7th edition by Barbara Kozier)
Interpretation: the client should be in a bed rest to restore energy and to minimize her
discomfort.

HEENT

Head is round in shape.Eyeballs are round, symmetrical, sclera is white and moist and
eyes are coordinated. Ears are symmetrical to the outer canthus of the eye. Nostrils are
patent.

Analysis:
Head: face is symmetrical, centered-head position
Eyes: Eyelid color is the same is the same as surrounding skin color. White sclera is
visible through conjunctiva.
Ears: Symmetric and straight; no discharge or flaring; Uniform color
Nose:Nasal mucosa is pinkish red with no visible lesions and no purulent drainage.
Throat:There is normal rising of the larynx, trachea as the patient swallows.

(3 minute assessment, Lippincott Williams, p. 212;232)

Interpretation: HEENT assessment I done to know if there are contributing factors that
are related to the client’s present illness. Since there are no deviated findings, the
client’s HEENT is in good condition.

Chest and Back

Equal chest expansion, clear breath sounds, deep inspiration noted.

Analysis: Position of sternum is level with ribs it should be no masses and lungs should
be clear upon auscultation.
(3 minute assessment, Lippincott Williams, p. 52)

Interpretation: The client has deep inspiration since she is in a supine position when
assessment is done.

Abdomen

Abdomen rises with inspiration in synchrony with chest. It is uniform in color and in
symmetric contour.

Analysis: Abdomen should be no rashes or lesions the umbilicus is centrally located and
abdomen should be rounded and symmetrical.
(Fundamentals of Nursing, 7th edition by Barbara Kozier p.425)
Interpretation: There are no signs and symptoms that may be associated to GI disorder.

Extremities

Upper and Lower extremities are symmetrical. Nail beds are pinkish in color
And skin color is the same as the other part of the body. Upon assessing the client’s
movement there is some weakness noted.

Analysis:
Interpretation: Although the client’s extremities have no significant findings, there is
weakness noted upon assessment it may be due to the bleeding she experiences.
(Fundamentals of Nursing, 7th edition by Barbara Kozier)
V. Patterns of functioning

Psychosocial

Cognitive

The client is oriented to time, place and person. She has no sensory deficits. The client
also responds appropriately to verbal and physical stimuli.

Analysis:Cognitive reappraisal is based on the assumption that a major factor in stress is

the individual’s perception of the event or experience as a stressor.

(Medical Surgical Nursing, Black, p.15)

Interpretation: The client is aware on what is going on to the surrounding.

Self-perception

The patient views herself as a kind and loving person. She also thinks positively. Her
daughter describes her as a caring person and very responsible. She states that she is
very happy with her life today. She states that she thinks that there is nothing wrong with
her body and that her illness didn’t change the way she looked at her self. The client
verbalized “Sa tingin ko hanging kaya pa ng katawan ko ay wala naman problema sa
akin.” She also stated that she is experiencing some discomfort when her bleeding
occurs. She verbalized that “ Matagal narin naman itong sumusumpong, sa katagalan
nasanay na rin ako”. She added “Pero nitong nakaraan hindi ko na talaga kaya,
nanghihina ako kaya ako nagpa check up at na confine.”

Analysis: Risk identification and risk management can prevent illness.

(Medical Surgical Nursing, Black, p.16)

Interpretation: It is the client’s perception on how she view herself and how she handles
what she feels.

Role Relationship

In her family, she takes the maternal role as a full time mother to her children and as the
loving wife of her husband. She states that it usually her husband who makes the
decision in the home but she always trust her husband’s decisions because it works out
for the best. The client verbalized “wala naman akong problema sa aing pamilya at mga
anak, kung magkaron man, mapag uusapan naman namin ito”.

Analysis: Client's pattern of role engagements and relationships.

Interpretation: The client as a mother considered herself of having a major role in the
family especially on raisig their child and handling the problem with her husband.

Elimination

The client verbalized that “ Pag umiihi ako may kasamang dugo”. The client stated that
she voided four times on the second day of her admission. And according to the client
her urine output is approximately 30cc everytime she urinates. Her urine is amber in
color with presence of bright red bloody discharge. She also stated that she did not
defecated yet.

Analysis: urine should be pale yellow and clear and have the faintest odor of ammonia.
These characteristics can change depending on disease states and hydration.
(Medical Surgical Nursing, Black, p.675)

Interpretation: It can be a presenting manifestation of the client’s disease.

Rest and Activity

Upon admission, the client is on bed rest to minimize her bleeding. She only get out of
bed when she is going to the bathroom. She verbalized “Ayos naman ako ditto, parang
lagi ako nagpapahiga sa kakahiga.” The client also verbalized “ Medyo nahihirapan din
ako sa pagtulog kasi minsan nararamdaman ko na malakas yung dugong lumalabas at
kailangan ko magpalit ng napkin.” The client’s takes much of her rest after having lunch.
She usually sleeps at 9:00 PM and wakes up 5:00 in the morning. The client stated that
she used to wake up early in the morning.
Analysis: Sleep is known to have a restorative and protective function. Sleep also
appears to serve as an energy-conserving measure for most of the body except the
brain.

(Medical Surgical Nursing, Black, p.349)

Interpretation: The client is having enough hours of sleep but I is interrupted because of
the heavy bleeding.

Safe environment

Health Perception and Health Management

The client verbalized “Kapag may simpleng sakit ako, nagpapahinga ako at iinom ng
gamot. Pero kung may ibang nararamdaman, nagpapa check up ako”. She usually self
medicates when she has cough and colds, fever and headache and takes Neozep and
Biogesic at an unrecalled dose. Before hospitalization, she rates her health as 9, 1 as
the lowest and 10 as the highest. The client also verbalized “Dati na diagnosed ako na
may Myoma, sabi ng doctor operahan daw ako, pero hindi ako pumayag. The daughter
of the client verbalized “natatakot kasi siya, kaya ayaw nya”. The client also added “bago
ako labasan ng dugo, sumasakit ang paa ko, at medyo sumasakit din ang aking ulo”.
The client is scheduled for Dilatation and Curettage on the second day of her admission
and she is quite anxious about the procedure.

Analysis: Individuals personal definitions and perception s of health must be taken into
account when addressing health promotion and disease prevention.
(Medical Surgical Nursing, Black, p.5)

Interpretation: Client’s perception about health may change and that will depend on their
experiences.

Nutritional Status

The client has good appetite before and during hospitalization. She was ordered not to
take any food and any liquid before her trans vaginal ultrasound and dilatation and
curettage.

Her 24 hour diet recall includes 1 pc longganisa and egg, and 1 cup rice for breakfast, 1
cup rice for lunch and fried fish and chicken adobo for lunch and 1 serving of vegetables
and I cup of rice for dinner. The client sated that she consumes 1 ½ glass of water after
each meal. She also verbalized “Mahilig ako kumain ng gulay at prutas”.
Analysis: Nutritional health results when body’s nutrient requirements are constantly
met. To meet the body’s nutrient requirements, adequate and appropriate nutrition must
be delivered to, transported by, and absorbed by the GI tract.

(Medical Surgical Nursing, Black, p.556)

Interpretation: The client has her own preference of food, therefore eating vegetables
and fruits makes her maintain a good appetite before and during hospitalization.
VII. List of Prioritize Problems
Nursing Diagnosis
Risk for Imbalanced Fluid
Volume related to rapid loss
blood (uterine bleeding)
Acute pain related to
headache and leg cramps
during heavy bleeding.
Fatigue related to body
weakness secondary to
anemia
Risk for Infection related to
inadequate secondary
defences
Risk for imbalanced body
temperature related to
body’s exposure to cold
environment
Priority Justification
1 This is considered as a high priority
problem because it is an actual
problem. Providing appropriate
nursing interventions for this problem
will relieve the etiologies of other
problems like fluid and electrolyte
imbalance. This problem will need
immediate actions to prevent other
problem to develop into a high
priority problem.
2 This is considered as a second
priority problem because if not
relieved it may lead to any other
problem.
3 It is a 3rd priority problem
4 It is a 4th priority problem because
treatment of high priority problem will
relieve several etiologies of this
problem
5 It is considered as 5th priority
because treatment of high priority
problem will relieve several etiologies
of this problem and it does not need
immediate intervention.
IX. Introduction to the Disease

Dysfunctional uterine bleeding (DUB) is defined as abnormal uterine bleeding in the absence of
organic disease. Dysfunctional uterine bleeding is the most common cause of abnormal vaginal
bleeding during a woman's reproductive years. Dysfunctional uterine bleeding can have a
substantial financial and quality-of-life burden.1 It affects women's health both medically and
socially.
Dysfunctional uterine bleeding is most common at the extreme ages of a woman's reproductive
years, either at the beginning or near the end, but it may occur at any time during her
reproductive life.

• Most cases of dysfunctional uterine bleeding in adolescent girls occur during the first 2
years after the onset of menstruation, when their immature hypothalamic-pituitary axis
may fail to respond to estrogen and progesterone, resulting in anovulation.
• Abnormal uterine bleeding affects up to 50% of perimenopausal women. In the
perimenopausal period, dysfunctional uterine bleeding may be an early manifestation of
ovarian failure causing decreased hormone levels or responsiveness to hormones, thus
also leading to anovulatory cycles. In patients who are 40 years or older, the number and
quality of ovarian follicles diminishes. Follicles continue to develop but do not produce
enough estrogen in response to FSH to trigger ovulation. The estrogen that is produced
usually results in late-cycle estrogen breakthrough bleeding.

Causes

• Systemic disease,
including thrombocytopenia, hypothyroidism, hyperthyroidism, Cushing disease, liver
disease, diabetes mellitus, and adrenal and other endocrine disorders, can present as
abnormal uterine bleeding.
• Pregnancy and pregnancy-related conditions may be associated with vaginal bleeding.
• Trauma to the cervix, vulva, or vagina may cause abnormal bleeding.
• Carcinomas of the vagina, cervix, uterus, and ovaries must always be considered in
patients with the appropriate history and physical examination findings. Endometrial
cancer is associated with obesity, diabetes mellitus, anovulatory cycles, nulliparity, and
age older than 35 years.
• Other causes of abnormal uterine bleeding include structural disorders, such as
functional ovarian cysts,cervicitis, endometritis, salpingitis, leiomyomas, and
adenomyosis. Cervical dysplasia or other genital tract pathology may present as
postcoital or irregular bleeding.
• Polycystic ovary disease results in excess estrogen production and commonly presents
as abnormal uterine bleeding.
• Primary coagulation disorders, such as von Willebrand disease, myeloproliferative
disorders, and immune thrombocytopenia, can present with menorrhagia.
• Excessive exercise, stress, and weight loss cause hypothalamic suppression leading to
abnormal uterine bleeding due to disruption along the hypothalamus-pituitary-ovarian
pathway.
• Bleeding disturbances are common with combination oral contraceptive pills as well as
progestin-only methods of birth control. However, the incidence of bleeding decreases
 significantly with time. Therefore, only counseling and reassurance are required during
the early months of use.
• Contraceptive intrauterine devices (IUDs) can cause variable vaginal bleeding for the first
few cycles after placement and intermittent spotting subsequently. The progesterone
impregnated IUD (Mirena) is associated with less menometrorrhagia and usually results
in secondary amenorrhea

X. Pathophysiology
XI. Discharge Plan

Medications
- advised to take medications at the right route, dose and time
- advised to take medications as prescribed
- instructed not to stop medication if not prescribed by the doctor

Exercise
-Encouraged to practice deep breathing exercises.

Treatment
-Advised for follow up check-up

Health Teachings
-advised to have adequate rest and sleep
- instructed to take the medications at the right route, route dose and right time.
- encouraged verbalizing when in pain
- instructed to do deep breathing exercise when she feels pain and anxious.
- encouraged eating the proper diet as advised by the doctor.

Out patient follow up

- advised to have things accessible for the client
- instructed to have a clean and quiet home conducive for resting
- advised to listen to light music for relaxation
- advised to have a safe home and free from any health hazards

Diet
- encouraged oral fluids
- advised to follow the proper diet recommended
- instructed to avoid eating foods high in fats and cholesterol

Spirituality
- encouraged praying every day
- encouraged hearing mass every Sunday
- advised to continue with the prayer group
- advised to have confession at least once in every 3 months
 Far Eastern University
Institute of Nursing

Case Study

Quibuyen, Jenny Keight

BSN 131 Group 122-A