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H O LY A N G E L U N I V E R S I T Y

College of Nursing

In Partial Fulfilment of Requirements for RLE 104

“UTERINE LEIOMYOMA ”

A Case Study

Presented To:

Leonor S. Lumanlan MAN, RN

Submitted By:
Joven, Michelle Anne L.
Lacsamana, Claire D.
Laquindanum, Philein S.
Liwanag, Ma. Kristina T.
Lopez, Ruchia D.
Magcamit, Cindy F.
Maniulit, Joe Anne Mae A.
GROUP 3 of N-404

September 20, 2010


Uterine Leiomyoma: A Case Study 2

“All things are possible with God…”

In completing this case study, the members of this group encountered many individuals
who helped by offering their time, knowledge, and skills.

Before the formal beginning, the group would like to give thanks and acknowledge those
individuals who made this study complete.

We would like to first give thanks to the patient, and her family, in being more than
hospitable in providing necessary information in completing the family history and allowing the
physical assessment to be done completely.

We would like to thank the staff of St. Raphael Foundation Medical Center, who helped
clarify many things from the chart and also help give information concerning the patient and his
treatments.

We would also like to give a special thank you to our clinical instructor, Ms. Leonor S.
Lumanlan for giving their advice based on case studies presented in previous rotations, so that
ours may be strengthened somehow.

And last but not least, To the God Almighty, for although this case study was made and
passed at such a turbulent time (with preliminary examinations underway with concurrent data
collection from our own individual thesis), it was through God’s will that it had been completed,
and completed whole-heartedly with much eagerness and passion.

The Members of Group 3 St. Raphael rotation 


September 20, 2010

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TABLE OF CONTENTS

INTRODUCTION

BRIEF DESCRIPTION OF THE DISEASE 4

NURSE-CENTRED OBJECTIVES 6

NURSING HISTORY

PERSONAL HISTORY 7

FAMILY HEALTH-ILLNESS HISTORY 8

HISTORY OF PAST ILLNESS 9

DIAGNOSTIC & LABRATORY PROCEDURES 10

PHYSICAL ASSESSMENT 16

ANATOMY & PHYSIOLOGY 34

PATHOPHYSIOLOGY

BOOK-BASED 44

CLIENT-CENTERED 50

MEDICAL MANAGEMENT 53

SURGICAL MANAGEMENT 60

NURSING CARE PLAN 69

DISCHARGE PLANNING 71

LEARNING DERRIVED 72

REFERENCES

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“W e learn more by looking for the answer to a question

and not finding it than we do from learning the answer itself .”


~Lloyd Alexander, American Author, 1924

In the field of nursing, one encounters a wide-array of various diseases and conditions. In

order to give adequate and holistic care to individuals, it is necessary that nurses be equipped

with the proper knowledge and skills for dealing with different health states. It is only through

continuous learning that nurses acquire the necessary skill. A case study is a means of continuing

such learning. In doing a case study, the students delve into the question, “what is this disease

condition?” Student nurses learn actively and will be able to handle patients and experience what

it means to care for a patient with that particular condition. They learn, from continuous

interaction with the patients along side with inquires into books and informative journals of the

disease process, it symptoms, and corresponding treatments.

Myomas are one of the conditions which student-nurses encounter during their exposure

at the clinical setting. The disease comprises of complexities of the anatomical concepts that

surveys a thorough description to understand its manifestations and formulate interventions. It is

interesting on our part to learn its definition, causes, and proper management. The student-

nurses chose the case to be able to have an insight about the condition.

Brief Description

Myoma is a condition where there is a benign growth or tumor of smooth muscle in the

wall of the uterus. The said growth is made up of fibrous tissue; hence it is often called a fibroid

tumor. Uterine fibroids can be present and be in apparent. Fibroids vary in size and number, and

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are most often slow-growing and usually cause no symptoms. It may grow as a single nodule or

in clusters, and may range in size from 1 mm to more than 20 cm in diameter. Myomas are the

most frequently diagnosed tumor of the female pelvis, and the most common reason for

hysterectomy. Although they are often referred to as tumors, they are not cancerous.

Most myomas develop in women during their reproductive years. Myomas do not

develop before the body begins producing estrogens. Myomas tend to grow very quickly during

pregnancy when the body is producing extra estrogen. Once menopause as begun, the myoma

generally stops growing and may begin to shrink due to the loss of estrogen. Fibroids may be

removed if they cause discomforts or if they are associated with uterine bleeding. Approximately

25% of myomas will cause symptoms and need medical treatment.

Statistics

Approximately 25 % of the myomas will cause symptoms and need medical treatment.

Myomas that that do not produce symptoms, do not need to be treated. The said 25 % of women

cause significant morbidity, including prolonged or heavy menstrual bleeding, pelvic pressure or

pain, and in rare cases, reproductive dysfunction. In the Philippines, the estimated number of

women is 86,241,697 squared, and the 4,312,084 had been affected of Myoma.

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STUDENT NURSE-CENTRED OBJECTIVES

G E N E R A L
O B J E C T I V E S


After 2 days of interaction with the patient and completing the case study, the student nurses will
be able to:

 Know and understand the disease process and concept of Uterine Leiomyoma

S P E C I F I C
O B J E C T I V E S

After 2 days of duty at St. Raphael Foundation Medical Center, the student nurses will be able to:

Cognitive

 Review the proper physical assessment (IPPA) and how to do them efficiently.
 Understand the disease process: the causes, effects, management, treatment, and possible
preventions.
 Determine the pathophysiology of the condition with their rationale for occurrence of each
manifestation.
 Determine why certain management and medications are given and provided for the condition.
 Understand how and why certain diagnostic tests are done for the condition.
 Review the concepts about the anatomy and physiology with regards to the condition.

Psychomotor

 Perform efficiently physical assessment (IPPA) to the patient.


 Perform thorough health history from patient and significant others.
 Participate in the course of care of patient.
 Provide health teachings to the patient about certain interventions in the maintenance of health
care.

Affective

 Establish rapport and therapeutic interaction with the patient and significant others to obtain
necessary information and positive compliance to care being provided.
 Provide care and health teachings necessary for the betterment of the condition of the patient.
 Share the learning acquired to co-student-nurses to increase awareness and help them if ever they
will encounter patient with the same condition.

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NURSING HISTORY

PERSONAL HISTORY

Ms. Myoma, a 57-year old female, stands as a mother of 6 children. She is widowed for

11 years since her husband had passed away because of Liver Complications. She lives in Davao

City. His nationality is Filipino and was born in Davao City on the 7th of June, 1949. She was

admitted in a private hospital in Mabalacat on September 10, 2010 at (time) with the initial

diagnosis of Submucous Myoma and chief complaint of Vaginal Bleeding.

Ms. Myoma graduated at a public high school and she didn’t continue his college level

due to financial problem. The one who support their family is her daughter who is a wife of a

retired U.S. Navy. Ms. Myoma was raised as a Catholic, where she learned about religious

values. She believes in super natural forces and superstitious beliefs. The client seeks medical

help from a physician for a serious health condition although she admits to seek help from the

“Hoax doctor” or the local “albolaryo” who would prescribe alternative medicine to relieve mild

signs and symptoms and other bodily discomfort.

Ms. Myoma resided at Davao City and occupies a simple house together with her son Mr.

Boy, but due to her illness, her children brought her to live with them in Mabalacat so that they

could watch her health carefully. Ms. Myoma did not report problems regarding her environment

that could interfere with her condition but instead states that he forsake his diet by consuming 4

big cups of black coffee a day. She said that she doesn’t exercise before but now she said that

walking is her exercise. Ms. Myoma would usually wake up at 5:00 in the morning and then she

would drink her coffee. She would clean the house afterwards. She takes her breakfast at 7:00 in

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the morning. He takes his lunch at 11:30 in the morning and his dinner at 7:00 in the evening. He

usually sleeps at 8:30 in the evening.

FAMILY HEALTH-ILLNESS HISTORY

Hereditary disease in the family is Uterine Myoma and Hypertension which her mother, 1

sister and the patient had herself possessed. This shows that Uterine Myoma and Hypertension

are evident in their family and are hereditary.

GENOGRAM

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HISTORY OF PAST AND PRESENT ILLNESS

Besides being hospitalized for her surgery, Ms. Myoma did not have any previous

hospital stays. She had only consulted a doctor two years ago, because she noticed that she often

had headaches. Upon the assessment with her doctor in Davao, they found that Ms. Myoma had

hypertension. To treat this, Ms. Myoma took aspirin and an anti-hyper medication to which she

could not recall the name of.

In regards to her current illness, Ms. Myoma had noticed that she had begun having

vaginal bleeding for about a year. She asked neighbors and friends about this, and because they

had told her it was a normal occurrence which may happen as a result of menopause, she sought

no further treatment. The bleeding, she explained to student nurses, was not painful, so she

believed that it was not really a concern. After telling her children about her condition, her

daughter kept insisting that she seek medical advice, however, she refused because of the high

costs which comes from hospitalization. After sometime, the bleeding began to increase, and the

patient finally listened to the advice of her children. She left for Mabalacat from Davao about a

week prior to her hospitalization, in which he doctor referred her to Dr. Flores of St. Raphael

Medical Center. After obtaining a necessary cardiopulmonary clearance as well as a pelvic

ultrasound (September 9, 2010), the patient was immediately booked for a total hysterectomy

which was done on September 11, 2010.

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DIAGNOSTIC & LABRATORY PROCEDURES

COMPLETE BLOOD COUNT

Analysis and
Diagnostic Indications or Date Ordered Normal
Results interpretatio
Procedure Purpose & Released Values
n

HGB (g/dL) To measure the Sept 10, 2010 140 120-160 Normal.
hemoglobin g/dl Patient was
able to
compensate
with
decreased of
oxygen
carrying
capacity and
availability of
oxygen
increased.

HCT (%) To aid Sept 10, 2010 43.1 36.0 – Normal. The
diagnosis of 47.0 ratio of solid
abnormal states particles in
the blood of
of hydration,
the patient is
polycythemia in proportion
and anemia and to the liquid
aids in part of the
calculation of blood
erythrocyte signifying
indices that the blood
is neither too
diluted nor
too
concentrated.

Platelet Count To evaluate Sept 10, 2010 246 150 – 400 Normal. It
platelet means that
(x10 9/L) production the
coagulation
capacity and
clotting factor
of the patient
is functioning

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well.

WBC (x10 To determine Sept 10, 2010 9.1 4.8 – 10.8 Normal
9/L) for presence of count. It
for further tests means the
patient’s
such as WBC
immune
differential function is
infection and intact and
also for functioning in
determination its optimum.
count Proximity of
the WBC
count to the
high limit
score means
the body is
trying to fight
present
developing
infection or
there is
presence of
bleeding in
some parts of
the body.

Differential To provide a Sept 10, 2010 40 55-65% The result is


Count: numeric below normal
estimate of the range
Segmenters (%) client’s immune indicating the
possible
status. presence of a
viral
infection.

Lymphocytes To check for Sept 10, 2010 48 25-35% The result is


(%) immune above normal
responses range
indicating
infection.

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Eosinophils To determine Sept 10, 2010 05 2-4% The result is


(%) presence of above normal
multicellular range
indicating the
parasites and
presence of a
certain parasitic
infections infection.

Monocytes (%) To determine Sept 10, 2010 07 2-6% The result is


presence of above normal
Chronic range. It
means
inflammatory
macrophages
disease, are activated.
Parasitic
infection, Viral
infection

COMPLETE BLOOD COUNT

NURSING RESPONSIBILITIES BEFORE, DURING, AND AFTER PROCEDURE

Before the Procedure

 Explain the procedure to the pt. and why it is indicated


 Inform the patient that fluid and food restriction is not required
 Inform the patient that a blood sample will be taken.
 Tell the patient that he may experience transient discomfort from the needle puncture
 Fill up laboratory request form properly and send it to the laboratory technician during
the collection of sample/specimen.
During the Procedure

 Inform the patient that pain may be felt through prick in the needle
 Instruct the patient to calm down to avoid uneasiness.
After the Procedure

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 Apply brief pressure to prevent bleeding


 Apply warm compress if Hematoma will develop at the venipuncture site.
PELVIC ULTRASOUND

Diagnostic Indications or Date Ordered Analysis and


Results
Procedure Purpose & Released interpretation

Pelvic Visualization of September 9, Uterus: Size 6.1 x 4.9 Central mass


Ultrasound the organs of 2010 x 5.9 cm, Anteverted, (3.2 x 3.8 x 3.9
homogenous, No
the pelvis, intermual/ subserous
cm) suggestive
including the myomatous growth of endometrial
uterus, polyp v.
fallopian tubes, Cervix: Size: 2.6 cm Submucous
x 2.5 cm.
and ovaries. myoma.
Abnormalities: No
This study is Focal lesions
done to detect
any masses or Endometrium:
obstructions in Endometrium is not
delineated. There is a
the region of round hyperechoic
the pelvis. mass noted measuring
3.2 x 3.8 3.9 cm
suggesting endo
metrial polyp vs.
Submucous myoma

Ovaries (Right) 1.7 x


2.4 x 2.4 cm lateral
(Left) 2.1 x 2.0 x 2.6
cm
Abnormalities: No
pathologic ovarian
lesion noted

PELVIC ULTRASOUND

NURSING RESPONSIBILITIES BEFORE, DURING, AND AFTER PROCEDURE


Before the Procedure

 Explain the procedure to the pt. and why it is indicated


 Instruct the patient to be placed on NPO for 8-12 hours post midnight
 Acquire a confirmed and informed consent prior to the procedure.
 Inform patient that the gel and the apparatus to be used may feel cold and uncomfortable
as it will be placed on the skin to visualize the organs.
During the Procedure

 Provide privacy
 Advise patient to remain still while the procedure is being informed

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After the Procedure

 Document that the procedure has been performed


 Inform physician when findings are available.

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BLOOD CHEMISTRY

Diagnostic Indications or Date Ordered Normal Analysis and


Results
Procedure Purpose & Released Values interpretation

Glucose ; RBS To measure the Sept 10, 2010 101 <140 Normal count.
amount of mg/dl It means the
glucose in the amount of
glucose in the
blood right at
blood is
the time of sufficient for
sample energy
collection production and
also not
excessive to
cause
hyperglycemia.
Indicated
insulin
(pancreatic)
function is
functioning to
its optimum.
Creatinine To evaluate Sept 10, 2010 0.8 0.4-1.4 Normal. It
kidney mg/dl means toxic
function. substances in
the body are
maintained in
normal amount
and signifies
the kidneys are
functioning
normally with
accordance to
its filtration
and excretion
of toxic
substances.
Result also
indicate
normal pH of
blood is
maintained.

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Potassium To detect Sept 10, 2010 3.82 3.4 - 5.3 Normal /


concentrations mmol/l within normal
that are too range. It means
electrolyte
high
supply in the
(hyperkalemia) body is
or too low sufficient to
(hypokalemia). meet hydration
needs.

BLOOD CHEMISTRY

NURSING RESPONSIBILITIES BEFORE, DURING, AND AFTER PROCEDURE

Before the Procedure

 Explain the procedure to the pt. and why it is indicated


 Inform the patient that fluid and food restriction is not required
 Inform the patient that a blood sample will be taken.
 Tell the patient that he may experience transient discomfort from the needle puncture
 Fill up laboratory request form properly and send it to the laboratory technician during
the collection of sample/specimen.
During the Procedure

 Inform the patient that pain may be felt through prick in the needle
 Instruct the patient to calm down to avoid uneasiness.
After the Procedure

 Apply brief pressure to prevent bleeding


 Apply warm compress if Hematoma will develop at the venipuncture site.

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PHYSICAL EXAMINATION & ASSESSMENT


Upon Admission, Lifted From the Chart: Assessed on September 9, 2010 8:15AM

Chief Complaint: Vaginal Bleeding


Complete History:
1 wk PTA (+)Vaginal bleeding
•Consulted physician and advised for surgery, hence admitted.
Past History

 (-) HPN

 (-) DM

 (-) Heart Disease

 (-) Asthma

 (-) Allergies

 Non-Smoker, Non-Alcoholic Beverage Drinker

 G6P6
Family History

 (-) HPN

 (-) DM
Present History

 Menopause at 53 years.

 Start of Menses age 12.


Physical Examination:

 VS: BP- 110/70, PR – 76, BR – 26, Temp – 36

 Pink Conjunctiva, Anicteric Sclerae

 NRRR, (-) Murmurs, CBS, (-) Rales, (-) Wheezes

 Globular, NABS, (-) Non Tender


Impression: G6P6 Submucous Myoma

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PHYSICAL EXAMINATION & ASSESSMENT (Cephalocaudal Assessment)

The patient was first met lying in bed with no contraptions such as IV or foley catheter.

She is a 57 year old woman, wearing a set of white pajamas and was watching TV with her

daughter and her husband. The patient is alert, and coherent, giving full and detailed responses to

all of the questions asked. She is 5’4 with black hair slightly turning grey at the roots. She

informed the student nurses that she would be discharged either by today or tomorrow depending

upon the doctor’s next visit and orders. Vital Signs were taken and Recorded as follows:

Vital Signs for 6:00pm


T- 36.1 ‘C
P- 80 bpm
R- 16 cpm
BP – 140/90 mmHg

First Nurse Patient Interaction: September 13, 2010 6:30PM

 Skin, Hair, and Nails


o Inspection
Skin

 Skin is dark brown in color and even in distribution.


 Skin is smooth without lesions or scars; no visible masses or evidence of
ecchymosis.
 Fine scaling of dry skin on lower inferior portion of legs and on outer
portion of arms.
 Presence of fissuring of skin on inferior portion of the feet
Hair and Scalp

 Hair is black, fine, and even in distribution


 Scalp is clean and dry

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Nails

 Nails are pale pink in color


 No presence of nail clubbing
o Palpation
Skin

 Skin is smooth and even, except for at the base of the feet
 Presence of calluses on the base of feet
 With a Skin turgor of 3 seconds
 Skin is dry and cool to touch.
 Skin is wrinkled and mobile in most areas except in areas of skin folds

Hair and scalp

 Smooth with no presence of masses or lesions


 Scalp is dry to touch.
 Hair is thin and fine; Black and grey in color
Nails

 Nails are smooth and firm. Nail plate is firmly attached to nail bed.
 With a capillary refill of 3 seconds.
 Head and Neck
o Inspection
Head

 Head is round, symmetric, erect, proportional, and midline to the client’s


body; no presence of visible lesions
 Head is held still and upright
 Face is symmetric with an oval appearance.
Neck

 Neck is symmetric with head centered and without bulging masses.

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Uterine Leiomyoma: A Case Study 20

 Thyroid cartilages move symmetrically as the client swallows.


 Neck movement is smooth and controlled
o Palpation
Head

 No swelling, tenderness or crepitations with movement of the jaw.


 Jaw can move laterally 1 to 2 cm in each direction.
Neck

 Trachea is midline
 Thyroid gland is not palpable
 No swelling or tenderness of the lymph nodes; lymph nodes are not
enlarged.
 Eyes and Ears
o Inspection
Eyes

 White sclera is seen around the iris


 Cornea is transparent with no opacities. Oblique view shows a moist
overall surface.
 With a thin arcus senilis around the iris.
 Pupils are equally rounded and respond to light and accommodation.
 The upper and lower eyelids close easily and meet completely when
closed.
 Eyes are able to move smoothly in an asterisk shape.
 The lower eyelids are upright
 No inward or outward turning eyes
 No presence of swelling, redness, or lesions of the eye.
 Upper and lower palpebral conjunctiva are free of swelling or lesions.
 Eyes have a sunken appearance.
 Iris is round, flat, and evenly colored.
Ears

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 Ears are equal in size bilaterally. The auricle aligns with the corner of each
eye.
 Earlobes are attached.
 Skin is smooth with no lesions; color is evenly distributed and consistent
with facial color.
 Small amount of brown flaky cerumen present.
 Canal walls are pink and smooth and without nodules.
o Palpation
Eyes

 No drainage noted from the puncta upon palpation of the nasolacrimal


duct.
 No palpable masses
Ears

 No tenderness upon palpation of the auricle and mastoid process.


 No palpable masses along the pinna
 Mouth, Nose, and Sinuses
o Inspection
Mouth

 Lips are cracked and dark brown in color.


 Teeth have a yellowish discoloration
 No presence of dental carries
 Presence of cracking of the crowns of the wisdom teeth
 Gums are pink in color
 With moist pale-pink buccal mucosa.
 Frenulum is midline
 Tonsils and uvula show no presence of swelling.
 Throat is pink in color
Nose

 Color is the same as the rest of the face

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 Nasal structure is both smooth and symmetric


 Client is able to sniff through each nostril while the other is occluded
 Nasal mucosa is pink, moist, and free of exudates
Sinuses

 Sinuses do not appear enlarged or swollen


o Palpation
Mouth

 No lesions, ulcerations, or nodules upon palpation


Sinuses

 Frontal and maxillary sinuses are non tender to palpation and no crepition
is evident.
o Percussion
Sinuses

 Sinuses are not tender upon percussion.


 Thoracic and Lung
o Inspection
 Skin is even in color
 Chest moves symmetrically with breathing
 with a respiratory rate of 16 breaths per minute
o Palpation
 Skin surface and lesions are free of masses
 Equal tactile fremitus noted
o Percussion
 Resonance is heard throughout all lung fields.
o Auscultation
 Clear breath sounds noted

 Heart and Neck Vessels

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Uterine Leiomyoma: A Case Study 23

o Inspection
 Jugular venous pulse is not normally visible when the client sits upright,
 Apical impulses are not visible.
o Palpation
 Carotid artery pulses are equally strong.
 Radial and apical pulses are identical.
 No pulsations or vibrations are palpated at the apex and the base of the
heart.
o Auscultation
 With a BP of 140/90 mmHg
 With a pulse rate of 80 beats per minute.
 No murmurs or extra heart sounds are heard.
 S1 and S2 sounds are clearly heard.
 Peripheral and Vascular
o Inspection
 Arms are bilaterally symmetric with minimal variation in size and shape.
 No edema of the hands or prominent venous patterning throughout all
extremities
 Veins are flat and barely seen under the surface of the skin.
 Consistent with skin color on the rest of the body.
 Legs have equal distribution of hair
 The skin tone of the legs are consistent with those of the rest of the body
 Legs are free of lesions and ulcerations
 Presence of bipedal edema
o Palpation
 Skin is cool to touch
 With a skin turgor of 3 seconds
 With a capillary refill of 3 seconds.
 Radial pulses have equal strength bilaterally
 Brachial pulses have equal strength bilaterally

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Uterine Leiomyoma: A Case Study 24

 Skin of the feet and toes are cold to touch.


 No presence of enlarged lymph nodes upon palpation
 Negative Homan’s sign
 Abdominal
o Inspection
 With the presence of bandage below umbilicus
 Bandage is clean and free of drainage
 Color is consistent with the color of the rest of the body
 No visible veins of the abdomen are present upon inspection
 No presence of ulcerations
 No presence of rashes
 Skin tone of umbilicus is similar with that of abdominal skin tone.
 Umbilicus is located on midline of the abdomen
 Abdomen has a protruded contour and is round in shape.
 Abdomen is symmetric
o Auscultation
 Soft gurgles are heard at a rate of five seconds per sound.
o Percussion
 Tympany is percussed over the abdomen.
o Palpation
 No palpable masses
 No signs of swelling of the umbilicus; no bulges, or masses.
 Musculoskeletal
o Inspection
 Client is able to stand on heals and toes
 Toes point straight point forward and lie flat, aligned with the lower leg.
 Client is able to move without limitation
 Cervical and lumbar spines are concave; thoracic spine is convex. The
spine is straight when observed from behind
 Joints are symmetric without signs of redness.

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Uterine Leiomyoma: A Case Study 25

 Client has full range of motion without limitation.


 Hands are symmetric in size; fingers lie in a straight line.
 Iliac crests are symmetric in height
o Palpation
 Presence of bipedal edema on lower extremities (ankles)
 No presence of joint swelling or tenderness on other areas of the body
 Hands and fingers are symmetric, non-tender, and without nodules.
 Hips are non tender.
 No heat, swelling or nodules noted on the fingers and toes.
REVIEW OF SYSTEMS

 Integumentary
o For her hair, the client takes baths at least once or twice a day. She uses any
available shampoo her daughter at home also uses, and this typically includes
Sunsilk, Vaseline, or Palmolive.
o Cleans nails at least once a week using cuticle remover.
o Client does not make use of styling products for the hair.
o Client says she has no history of other skin problems such as lesions, drainage or
swelling.
o Does not feel pain upon light or deep palpation.
o The client and his family have no history of skin allergies or skin cancer.
o Does not have any birthmarks or tattoos.
o No problems with perspiration or odor.
o Has not current history of excessive hair loss, infestations, or change and
appearance in the hair (such as excessive dryness or brittleness).
o Client does not sunbathe, and is not constantly exposed to chemicals which may
harm the skin such as paint, weed killers, insect repellents, and bleach.
 Musculoskeletal
o No previous history of problems with joints, muscles, and bones.
o No family history of gout, arthritis, or osteoporosis.

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Uterine Leiomyoma: A Case Study 26

o Does not experience back pain or pain in the joints during movement.
o On a typical day, she usually spends 4-6 hours in the sunlight.
o Client does not experience neck pain.
o Client experiences headaches every once in a while. The headache usually begins
on the nape of the neck and she describes it as an aching pain. The headache
usually lasts no more than 5-10 minutes and subsides when the client becomes
busy (he forgets the pain) or when he rests.
o Client does not feel any facial pain.
o No difficulty with moving the head and the neck.
o No history of lumps or lesions of the neck.
o Has not experienced dizziness, light-headedness, or a spinning sensation.
o Has not experienced loss of consciousness.
o No history of head or neck problems such as trauma, injury or falls.
 Hearing, Vision, Sinuses
o The client has no problems with vision.
o The client has no problems with hearing.
o No past history of ear infection, ringing of the ears (tinnitus), or drainage from
ears.
o Cleans ears regularly once every two days, usually after he bathes.
o No problems with sinuses
o At times, experiences colds, especially during the rainy season.
 Respiratory
o The client has no history of smoking
o No past history of PTB or other lung related problems.
o She has no history of lung cancer and has no family history of lung cancer,
asthma, or PTB.
 Lymphatic
o No familial history of breast cancer.
o No history of problems concerning the lymphatic system.

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Uterine Leiomyoma: A Case Study 27

 Circulatory
o Does not have any past history of heart problems.
o Has been taking anti-hypertensive medication (which she cannot recall the name
of) and aspirin for two years.
o Skin is often dry, however, she does not use any forms of moisturizer as it further
irritates the skin.
o Does not experience any pain or cramping in the legs.
o She does not have any sores or open wounds on his leg and foot.
o Household chores and working in the “bukid” are her daily forms of exercise.
 Gastrointestinal
o Does not currently experience nausea and vomiting.
o Diet includes “ulam” and about one cup of rice. Usually the main dish includes
mainly vegetables and fish. The client does not like to eat meats because they are
“difficult to chew.”
o Drinks an average of three coffee tall coffee glasses a day, made from pure freshly
grounded coffee.
 Genitourinary
o Had menarch at age twelve
o Client’s mother was also believed to have a myoma, because she had also been
experiencing the same symptoms of hypermenorrhagia.
o Menopause at 53 years old.
o Client states that he has no recent changes in urinary elimination pattern.
o Urinates every one or two hours at least once.
o Has no history of difficulty of urination.
 Neurological
o Does not experience numbness or tingling.
o No history of seizures.
o Patient, at times, has may experience a headache, but it is usually relieved with
diversional activities, rest, or medication such as paracetamol.

Group 3 N­404
Uterine Leiomyoma: A Case Study 28

o Has no current problem with the sense of smell.


o No difficulty in speaking or swallowing.
o Does not experience muscle weakness or tremors.
o No problems with memory loss.

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Uterine Leiomyoma: A Case Study 29

PHYSICAL EXAMINATION & ASSESSMENT (Cephalocaudal Assessment)


Second Nurse Patient Interaction: September 14, 2010 4:00PM

Received patient sitting on bed, awake, alert, and coherent with no current IV or
contraptions. Patient’s wound has been cleaned by the doctor earlier during the day and is free
from discharge or purulent drainage. The patient was wearing wearing a plain white t-shirt and
light blue pajamas. Vital Signs were taken and recorded as follows: (at 4:00pm)

T – 36.1 ‘C
P – 80 bpm
R – 20 cpm
BP – 120/80 mmHg

 Skin, Hair, and Nails


o Inspection
Skin

 Skin is dark brown in color and even in distribution.


 Skin is smooth without lesions or scars; no visible masses or evidence of
ecchymosis.
 Fine scaling of dry skin on lower inferior portion of legs and on outer
portion of arms.
 Presence of fissuring of skin on inferior portion of the feet
Hair and Scalp

 Hair is black, fine, and even in distribution


 Scalp is clean and dry
Nails

 Nails are pale pink in color


 No presence of nail clubbing
o Palpation
Skin

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Uterine Leiomyoma: A Case Study 30

 Skin is smooth and even, except for at the base of the feet
 Presence of calluses on the base of feet
 With a Skin turgor of 2 seconds
 Skin is dry and cool to touch.
 Skin is wrinkled and mobile in most areas except in areas of skin folds
Hair and scalp

 Smooth with no presence of masses or lesions


 Scalp is dry to touch.
 Hair is thin and fine; Black and grey in color
Nails

 Nails are smooth and firm. Nail plate is firmly attached to nail bed.
 With a capillary refill of 3 seconds.
 Head and Neck
o Inspection
Head

 Head is round, symmetric, erect, proportional, and midline to the client’s


body; no presence of visible lesions
 Head is held still and upright
 Face is symmetric with an oval appearance.
Neck

 Neck is symmetric with head centered and without bulging masses.


 Thyroid cartilages move symmetrically as the client swallows.
 Neck movement is smooth and controlled
o Palpation
Head

 No swelling, tenderness or crepitations with movement of the jaw.


 Jaw can move laterally 1 to 2 cm in each direction.
Neck

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Uterine Leiomyoma: A Case Study 31

 Trachea is midline
 Thyroid gland is not palpable
 No swelling or tenderness of the lymph nodes; lymph nodes are not
enlarged.

 Eyes and Ears


o Inspection
Eyes

 White sclera is seen around the iris


 Cornea is transparent with no opacities. Oblique view shows a moist
overall surface.
 With a thin arcus senilis around the iris.
 Pupils are equally rounded and respond to light and accommodation.
 The upper and lower eyelids close easily and meet completely when
closed.
 Eyes are able to move smoothly in an asterisk shape.
 The lower eyelids are upright
 No inward or outward turning eyes
 No presence of swelling, redness, or lesions of the eye.
 Upper and lower palpebral conjunctiva are free of swelling or lesions.
 Eyes have a sunken appearance.
 Iris is round, flat, and evenly colored.
Ears

 Ears are equal in size bilaterally. The auricle aligns with the corner of each
eye.
 Earlobes are attached.
 Skin is smooth with no lesions; color is evenly distributed and consistent
with facial color.
 Small amount of brown flaky cerumen present.
 Canal walls are pink and smooth and without nodules.

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Uterine Leiomyoma: A Case Study 32

o Palpation
Eyes

 No drainage noted from the puncta upon palpation of the nasolacrimal


duct.
 No palpable masses
Ears

 No tenderness upon palpation of the auricle and mastoid process.


 No palpable masses along the pinna
 Mouth, Nose, and Sinuses
o Inspection
Mouth

 Lips are cracked and dark brown in color.


 Teeth have a yellowish discoloration
 No presence of dental carries
 Presence of cracking of the crowns of the wisdom teeth
 Gums are pink in color
 With moist pale-pink buccal mucosa.
 Frenulum is midline
 Tonsils and uvula show no presence of swelling.
 Throat is pink in color
Nose

 Color is the same as the rest of the face


 Nasal structure is both smooth and symmetric
 Client is able to sniff through each nostril while the other is occluded
 Nasal mucosa is pink, moist, and free of exudates
Sinuses

 Sinuses do not appear enlarged or swollen


o Palpation

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Uterine Leiomyoma: A Case Study 33

Mouth

 No lesions, ulcerations, or nodules upon palpation


Sinuses

 Frontal and maxillary sinuses are non tender to palpation and no crepition
is evident.
o Percussion
Sinuses

 Sinuses are not tender upon percussion.


 Thoracic and Lung
o Inspection
 Skin is even in color
 Chest moves symmetrically with breathing
 with a respiratory rate of 20 breaths per minute
o Palpation
 Skin surface and lesions are free of masses
 Equal tactile fremitus noted
o Percussion
 Resonance is heard throughout all lung fields.
o Auscultation
 Clear breath sounds noted

 Heart and Neck Vessels


o Inspection
 Jugular venous pulse is not normally visible when the client sits upright,
 Apical impulses are not visible.
o Palpation
 Carotid artery pulses are equally strong.
 Radial and apical pulses are identical.

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Uterine Leiomyoma: A Case Study 34

 No pulsations or vibrations are palpated at the apex and the base of the
heart.
o Auscultation
 With a BP of 120/80 mmHg
 With a pulse rate of 80 beats per minute.
 No murmurs or extra heart sounds are heard.
 S1 and S2 sounds are clearly heard.
 Peripheral and Vascular
o Inspection
 Arms are bilaterally symmetric with minimal variation in size and shape.
 No edema of the hands or prominent venous patterning throughout all
extremities
 Veins are flat and barely seen under the surface of the skin.
 Consistent with skin color on the rest of the body.
 Legs have equal distribution of hair
 The skin tone of the legs are consistent with those of the rest of the body
 Legs are free of lesions and ulcerations
 Presence of bipedal edema
o Palpation
 Skin is cool to touch
 With a skin turgor of 2 seconds
 With a capillary refill of 3 seconds.
 Radial pulses have equal strength bilaterally
 Brachial pulses have equal strength bilaterally
 Skin of the feet and toes are cold to touch.
 No presence of enlarged lymph nodes upon palpation
 Negative Homan’s sign
 Abdominal
o Inspection
 With the presence of bandage below umbilicus

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Uterine Leiomyoma: A Case Study 35

 Bandage is clean and free of drainage


 Color is consistent with the color of the rest of the body
 No visible veins of the abdomen are present upon inspection
 No presence of ulcerations
 No presence of rashes
 Skin tone of umbilicus is similar with that of abdominal skin tone.
 Umbilicus is located on midline of the abdomen
 Abdomen has a protruded contour and is round in shape.
 Abdomen is symmetric
o Auscultation
 Soft gurgles are heard at a rate of five seconds per sound.
o Percussion
 Tympany is percussed over the abdomen.
o Palpation
 No palpable masses
 No signs of swelling of the umbilicus; no bulges, or masses.
 Musculoskeletal
o Inspection
 Client is able to stand on heals and toes
 Toes point straight point forward and lie flat, aligned with the lower leg.
 Client is able to move without limitation
 Cervical and lumbar spines are concave; thoracic spine is convex. The
spine is straight when observed from behind
 Joints are symmetric without signs of redness.
 Client has full range of motion without limitation.
 Hands are symmetric in size; fingers lie in a straight line.
 Iliac crests are symmetric in height
o Palpation
 Presence of bipedal edema on lower extremities (ankles)
 No heat, swelling or nodules noted on the fingers and toes.

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Uterine Leiomyoma: A Case Study 36

Group 3 N­404
Uterine Leiomyoma: A Case Study 37

ANATOMY & PHYSIOLOGY

The female reproductive system

consists of the ovaries, uterine

tubes (or fallopian tubes), uterus,

vagina, external genitalia, and

mammary glands. The internal

reproductive organs of the

female are located within the

pelvis, between the urinary

bladder and the rectum. The

uterus and the vagina are in the midline , with an ovary to each side of the organ. The internal

reproductive organs are held in place within the pelvis with ligaments. The most conspicuous is

the brad ligament, which spreads out on both sides of the uterus and to which the ovaries and the

uterine tubes attach.

Ovaries

The two ovaries are small organs suspended in the pelvic

cavity by ligaments. The suspensory ligament extends

from each ovary to the lateral body wall, and the ovarian

ligament attaches the ovary to the superior margin of the

uterus. In addition, the ovaries are attached to the posterior

surface of the broad ligament by folds of the peritoneum called the mesovarium. The ovarian

arteries, veins, and nerves transverse the suspensory ligament and enter the ovary through the

mesovarium.

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Uterine Leiomyoma: A Case Study 38

A layer of visceral peritoneum covers the surface of the ovary. The outer part of the ovary is

made up of dense connective tissue and contains the ovarian follicles. Each of the ovarian

follicles contains an oocyte, the female sex cell. Loose connective tissue makes up the inner part

of the ovary, where blood vessels, lymphatic vessels, and nerves are located.

Uterine Tubes

A uterine tube, fallopian tube, or oviduct (named after the italian anatomist, Gabriele Fallopio) is

associated with each ovary. The uterine tubes extend from the area of the ovaries to the uterus.

The open directly into the peritoneal cavity near each ovary and receive an oocyte. The opening

of each uterine tube is surrounded by long, thin processes called fimbriae.

The fimbriae nearly surround the surface of the ovary. As a result, as soon as the oocyte is

ovulated, it comes into contact with the surface of the fimbriae. Cilia on the fimbriae surface

sweep the oocyte into the uterine tube. Fertilization usually occurs in the part of the uterine tube

near the ovary known as the ampulla.

Uterus

The uterus is as big as the size of a medium-sized pear. It is oriented in the pelvic cavity with the

larger, rounded portion directed superiorly. The part of the uterus superior to the entrance of the

fallopian tubes is called the fundus. The main part of the uterus is called the body, and the

narrower part is termed the cervix and is directed inferiorly. Internally, the uterine cavity in the

fundus and uterine body continues through the cervix as the cervical canal, which opens into the

vagina. The cervical canal is lined by mucous glands.

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Uterine Leiomyoma: A Case Study 39

The Uterine wall is composed of three layers: a serous layer or perimetrium of the uterus,

consists of smooth muscle is quite thick and accounts for the bulk of the uterine wall. The inner

most layer of the uterus is called the endometrium. The endometrium consists of simple

columnar epithelium tissues with an underlying connective tissue layer. Simple tubular glands,

called enometrial glands, are formed by folds of the endometrium. The superficial part os the

endometrium is sloughed off during menstruation.

The uterus is supported by the broad ligament and the round ligament. In addition to these

ligaments that support the uterus, much support is provided inferiourly to the uterus by skeletal

muscles of the pelvic floor. If ligaments that suppor the uterus or the muscles of the pelvic floor

are weakened such as in childbirth, the uterus can extend inferiorly into the vagina, a condition

termed as a prolapsed uterus. Severe cases require surgical correction.

Vagina

The vagina is the female organ of copulation and functions to receive the penis during

intercourse. It also allows menstrual flow and childbirth. The vagina extends from the uterus to

outside the body. The superior portion of the vagina is attached to the sides of the cervix so that a

part of the cervix extends into the vagina.

The wall of the vagina consists of an outer muscular layer and an inner mucous layer. The

muscular layer is smooth muscle and contains many elastic fibers. Thus the vagina can increase

in size to accommodate the penis during intercourse, and it can stretch greatly during childbirth.

The mucous membrane is moist stratified squamous epitheliam that forms a protective surface

layer. Lubricating fluid passes through the vaginal epithelium into the vagina.

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Uterine Leiomyoma: A Case Study 40

In young females, the vaginal opening is covered by a thin mucous membrane known as the

hymen. The hymen can completely close the vaginal oriface in which case it must be removed to

allow menstrual flow. More commonly, the hymen is perforated by one or several holes. The

openings of the hymen are usually greatly enlarged during the first sexual intercourse. The

hymen can also be perforated during a variety of activities including strenuous exercise. The

condition of the hymen is therefore not a reliable indicator of virginity.

The External Genitalia

The external female genitalia, also called the vulva, or pudendum, consists of the vestibule and

its surrounding structures. The vestibule is the space into which the vagina and urethra open. The

urethra opens just anterior to the vagina. The vestibule is bordered by a pair of thin, longitudinal

skin folds called the labia minora. A small erectile structure called the clitoris is located in the

anterior margin of the vestibule. The two labia minora unite over the clitoris to form a fold of

skin known as the prepuce.

The clitoris consists of a shaft and a distal glans. Like the glans penis, the clitoris is well supplied

with sensory receptors, and it is made up of erectile tissue. An additional erectile tissue is

located on either side of the vaginal opening.

On each side of the vestibule, between the vaginal opening and the labia minora, are openings of

the greater vestibular glands. These glands produce a lubricating fluid that helps maintin the

moistness of the vestibule.

Lateral to the labia minor are two prominent rounded folds of skin called the labia majora. The

two labia majora unite anteriorly at the elevation of tissue over thepubic symphysis calle dthe

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Uterine Leiomyoma: A Case Study 41

mons pubis. The lateral surfaces of the labia majora and the surface of the mons pubis are

covered with coarse hair. The medial surfaces of the labia minora are covered with numerous

sebaceous and sweat glands. The space between the labia minor is called the pudendal cleft.

Most of the time, the labia minora are in contact with each other across the midline , closing the

pudendal cleft and covering the deeper structures within the vestibule.

The region between the vagina and the anus is the clinical perineum. The skin and muscle of this

region can tear during childbirth. To preven such tearing, an incision called an episiotomy is

sometimes made in the clinical perineum. Traditionally, this clean, straight incision is thought to

result in less injury, and less trouble in healing, and less pain. However, many studies indicate

that there is less injury and pain when no episiotomy is performed.

Mammary Glands

Mammary glands are located inside the breasts of sexually mature female body. They are in

actuality modified sweat glands which are in fact comprised of secretory mammary alveoli and

the appropriate ducts. Mammary glands are considered to be part of the integumentary system

rather than the reproductive system. The glands are associated with the female reproductive

system in part due to their assistance in attracting a mate as well as their role in nourishing a

baby. Size and shape of the female breast are different for every human body and factors such as

race, age, body fat, and pregnancy can make a large difference in these variations.

The release of estrogen during puberty releases hormones that stimulate the growth of the breasts

and the functions of the mammary glands. Pregnant women as well as nursing women

experience hypotrophy of the breasts while it is not uncommon for atrophy of the breasts to

occur after menopause.

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Uterine Leiomyoma: A Case Study 42

Breasts are situated over ribs 2 through 6 and overlap the pectoral muscle as well as some

portions of the oblique muscles. The lateral margin of the sternum creates an unintentional

margin for the edge of each breast. Each breast also follows the anterior margin of the respective

axilla. Coming within very close proximity to the Axillary vessels, the breasts upward and

laterally toward the axilla, which contributes to the high incidence of breast cancer due to the

axillary process’ lymphatic drainage.

15 to 20 lobes compose the mammary gland, and each lobe is equipped with its own duct to the

outside of the body. Adipose tissue in varying amounts segregates each lobe. While this tissue

controls the size and shape that the breast takes, there is no determination by this tissue when it

comes to the woman’s ability to suckle her young. Lobules are subdivisions of each lobe. These

subdivisions contain mammary alveoli. The milk of a lactating female are produced within the

mammary alveoli. Suspensory ligaments support the breasts which are attached between the

lobules and run deep into the fascia which overlap the pectoral muscles. Breast milk is secreted

into a network of mammary ducts which receive the milk from the clusters of mammary alveoli.

These mammary ducts converge to form lactiferous ducts. Near the nipple, each lactiferous duct

expands into the lumen to allow for outward flow of milk. The lactiferous sinuses store the milk

before the suckling action, or additional pressure, releases it from the body. The milk leaves the

body from the tip of the nipple.

The nipple contains some erectile tissue that protrudes into a cylindrical projection. The circular

area around the nipple that contrasts in color is the areola. Sebaceous areola glands create a

bumpy surface around the areola which reside just under the surface of the areola’s skin. These

glands secrete fluids during lactation as well as when a woman is not lactating, which keep the

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Uterine Leiomyoma: A Case Study 43

nipple supple. The complexion of the areola is based on the complexion of the skin that covers

the rest of the body, varying in pigments and tints. During gestation most areola surfaces darken.

It also becomes larger in most cases. This is thought to be more obvious for a nursing infant to

find.

Branches of the internal thoracic artery are responsible for supplying blood flow to the nipple as

well as the rest of the breast and mammary glands. Between the second, third, and forth

intercoastal spaces these braches of the thoracic artery enter the mammary glands. These spaces

are positioned laterally to the sternum and offer entry to the mammary artery, which only

supplies supportive blood. The return veins run alongside the initial arteries which supply the

blood. During pregnancy and lactation, and sometimes during other periods, a superficial venous

plexus can be seen through the surface of the skin.

The fourth, fifth, and sixth thoracic nerves innervate the breast principally through sensory

somatic neurons. These neurons are derivative of the anterior and lateral branches of the thoracic

nerves. The release of milk is dependant upon the sensory innervations as stimulus is the only

natural release an infant can provide to be nourished.

Menstrual Cycle

Menstruation is the shedding of the lining of the uterus (endometrium) accompanied by bleeding.

It occurs in approximately monthly cycles throughout a woman's reproductive life, except during

pregnancy. Menstruation starts during puberty (at menarche) and stops permanently at

menopause.

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Uterine Leiomyoma: A Case Study 44

By definition, the menstrual cycle begins with the first day of bleeding, which is counted as day

1. The cycle ends just before the next menstrual period. Menstrual cycles normally range from

about 25 to 36 days. Only 10 to 15% of women have cycles that are exactly 28 days. Usually, the

cycles vary the most and the intervals between periods are longest in the years immediately after

menarche and before menopause.

Menstrual bleeding lasts 3 to 7 days, averaging 5 days. Blood loss during a cycle usually ranges

from ½ to 2½ ounces. A sanitary pad or tampon, depending on the type, can hold up to an ounce

of blood. Menstrual blood, unlike blood resulting from an injury, usually does not clot unless the

bleeding is very heavy.

The menstrual cycle is regulated by hormones. Luteinizing hormone and follicle-stimulating

hormone, which are produced by the pituitary gland, promote ovulation and stimulate the ovaries

to produce estrogen and progesterone stimulate the uterus and breasts to prepare for possible

fertilization. The cycle has three phases: follicular (before release of the egg), ovulatory (egg

release), and luteal (after egg release).

Menopause

When a woman is 40-50 years old, the menstrual cycles become less regular and ovulation does

not consistently occur during each cycle. Eventually, the cycles stop completely. The cessation of

menstrual cycles is called menopause, and the whole time period from the onset of irregular

cycles to their complete cessation is called the female climacteric.

The major cause of menopause is age-related changes in the ovaries. The number of follicles

remaining in the ovaries of menopausal women is small. In addition to this, the follicles that

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Uterine Leiomyoma: A Case Study 45

remain become less sensitive to the stimulation of FSH and LH. As the ovaries become less

responsive to stimulation by FSH and LH, fewer mature follicles and copora lutea are produced.

Gradual changes occur in women in response to the reduced amount of estrogen and

progesterone produced by ovaries.

During the climacteric, some women experience “hot flashes,” irritability, fatigue, anxiety,

temporary decrease in libido, and occasionally severe emotional disturbances. Many of these

symptoms can be treated successfully with hormone replacement therapy, which usually consists

of small amounts of estrogen or progesterone. A potential side effect of HRT is a slightly

increased possibility of the development of breast cancer, uterine cancer, heart attacks, strokes,

and blood clots. HRT does slow the decrease in bone density that can become sever in some

women after menopause, and decreases the risk of developing colorectal cancer.

HORMONES AND FEMALE CYCLES

The ovarian cycle is

hormonally regulated in two phases.

The follicle secretes estrogen before

the ovulation; the corpus luteum

secretes both estrogen and

progesterone after ovulation.

Hormones from the hypothalamus and

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Uterine Leiomyoma: A Case Study 46

anterior pituitary control the ovarian cycle. The ovarian cycle covers events in the ovary; the

menstrual cycle occurs in the uterus.

Menstrual cycles vary from between 15 and 31 days. The first day of the cycle is the

first day of blood flow (day 0) known as menstruation. During menstruation, the uterine lining is

broken down and shed as menstrual flow. FSH and LH are secreted on day 0, beginning both the

menstrual cycle and the ovarian cycle. Both FSH and LH stimulate the maturation of a single

follicle in one of the ovaries and the secretion of estrogen. Rising levels of estrogen in the blood

trigger secretion of LH, which stimulates follicle maturation and ovulation (day 14, or mid

cycle). LH stimulates the remaining follicle cells to form the corpus luteum, which produces both

estrogen and progesterone.

Estrogen and progesterone stimulate the development of the endometrium and

preparation of the uterine lining for implantation of a zygote. If pregnancy does not occur, the

drop in FSH and LH causes the corpus luteum to disintegrate. The drop in hormones also causes

the sloughing off of the inner lining of the uterus by a series of muscle contractions of the uterus.

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Uterine Leiomyoma: A Case Study 47

BOOK-BASED PATHOPHYSIOLOGY

Schematic Diagram

Predisposing Precipitating Factors:


Factors:
-High fat diet
-Age
-Obesity
Etiology:
-Race
Unknown
-Anxiety/Stress
-Heredity
-Oral Contraceptives or
-Early Menarche Estrogen
Estrogen Dominance
Dominance or
or
increase
-Hormone replacement therapy
increase in Estrogen
in Estrogen
-Nulliparity production
production
-Luteal Insufficiency

-Coffee/ Caffeine intake


Proliferation of cells
in uterus* S/sx:
* Classified
according to area -Swelling of breasts
of growth: Overgrowth the -Depression
intramural, endometrial lining
submucous, & -Loss of sex Drive
subserous
Myoma: -Dysmenorrhea
Development of
uterine fibroid

Uterine Cavity S/sx:


begins to stretch or -Pain
increase in size
-Increased pelvic Pressure

Interference in the
vascular supply

Degeneration of the S/sx:


interior part of
fibroid -hypermenorrhea

-Abnormal bleeding

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Uterine Leiomyoma: A Case Study 48

B O O K - B A S E D :
S Y N T H E S I S O F T H E D I S E A S E

Definition of the Disease

Uterine Leiomyomas are the


most common pelvic tumors of
reproductive-age women (Ling
& Duff, 2009). They occur in
up to 50 % of patients in
autopsy series, and are more
common in African-American
women. They are composed of
smooth muscle cells within a
fibrous tissue matrix and are
unicellular in origin. The
growth of these benign tumor
tends to be promoted by estrogen and other growth factors.

Uterine fibroids are leiomyomata of the uterine smooth muscle. They may vary in size and
location. Leiomyomas may be submucous, subserous, intraligamentous, peduncultated or
parasitic (Ling & Duff, 2009) As other leiomyomata, they are benign, but may lead to excessive
menstrual bleeding (menorrhagia), often cause anemia and may lead to infertility. Enucleation is
removal of fibroids without removing the uterus (hysterectomy), which is also commonly
performed. Laser surgery (called myolysis) is increasingly used, and provides a viable alternative
to traditional surgeries. Oral contraceptive pills can be used to decrease excessive menstrual
bleeding and pain associated with uterine fibroids.

Uterine leiomyomas originate in the myometrium and are classified by location:

 Submucosal – lie just beneath the endometrium.


 Intramural – lie within the uterine wall.

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Uterine Leiomyoma: A Case Study 49

 Subserosal – lie at the serosal surface of the uterus or may bulge out from the
myometrium and can become pedunculated.

The tumors become malignant in less that 0.1 % of patients, which should serve as comfort to
women concerned with the possibility of uterine malignancy in association with a fibroid.
(McCann & Holmes, 2003)

The actual cause of uterine myomas/ leiomyomas are unknown, however, they are seen to be
increased with the presence of the following factors.

The incidence is higher on women during the reproductive years where estrogens and other
hormones are actively produced by the body. Many women opt to use oral contraceptives as a
birth control method. Oral contraceptives promote estrogen dominance and eventually influence
the growth of the cells in the uterus. High-fat diet is also considered a source of estrogen where
as diets rich in fiber and low in fat decreases estrogen reabsorption. Leimyoma formation is also
possible because of hyperestrogenism due to progesterone deficiency that is caused by luteal
insufficiency. Apart from estrogen stimulation, heredity is a factor in the occurrence of
leimyomas. Fibroids formation is 4.2 times more common in first-degree relatives than with
fibroids without genetic influence.

Estrogen is vital in the regulation the menstrual cycle. Presence of this hormone during the first
phase influences the proliferation of smooth muscle cells in the uterine walls. Overstimulation
increases the size of the uterine lining and further develops into a fibroid. During menstruation,
the excessively thickened endometrium does not desquamate (shed its lining) easily (or even
completely) at the end of the cycle, resulting in prolonged and/or excessive menstrual bleedings.
Following the degeneration of the interior part of the fibroid, are the degenerative changes that
eventually replace smooth muscle cells by fibrous connective tissue. The fibroid continually
grows and its size puts pressure on the adjacent organs, the bladder and rectosigmoid. Urinary
frequency and constipation, respectively, are the results of the compression of these organs.

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Uterine Leiomyoma: A Case Study 50

Predisposing Factors

1. Age is a risk factor in the disease process of uterine leiomyoma. This is due to the differences
of estrogen and progesterone levels in females as they get older and undergo the processes of
menopause.
2. Race – Although an actual connection between the disease process and race have yet to been
validated and affirmed, many studies have shown that particular races such as American and
African Americans are more susceptible to tumor growth in the endometrial lining among
premenopausal women (Marshall, 1997).

3. Heredity – Women who’s mothers have had myoma themselves are more susceptible to
getting the disease than those who have no family history of the disease. (Faerstein, 1997)

4. Early Menarche and Nulliparity – Studies have suggested that an early start of menarche
(less than the average age of 13) and nulliparity contribute to the development of a uterine
leiomyoma, however, how this connection or relationship between the risk factor and the
disease processes are still unknown (Faerstein, 2001). It is believed that these factors are
precipitated because of the estrogen and progesterone levels in the body.

Precipitating Factors

1. High Fat Diet & Obesity – is also considered a source of estrogen where as diets rich in fiber 
and low in fat decreases estrogen reabsorption. Fat has an enzyme that converts adrenal 
steroids to estrogen. The higher the fat intake, the higher the conversion of fat to estrogen. 
Overeating is the norm in developed countries. A population from such countries, especially 
in the Western hemisphere where a large part of the dietary calorie is derived from fat, has a 
much higher incidence of menopausal symptoms. Studies have shown that estrogen and 
progesterone levels fell in women who switched from a typical high­fat, refined­carbohydrate
diet to a low­fat, high­fiber and plant­based diet even though they did not adjust their total 
calorie intake. Plants contain over 5,000 known sterols that have progestogenic effects.
2. Anxiety/ Stress – The stress levels of the individuals can influence the production of estrogen 
and progesterone in the body. Stress causes adrenal gland exhaustion as well as reduced 

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Uterine Leiomyoma: A Case Study 51

progesterone levels. This tilts the estrogen to progesterone ratios in favor of estrogen. 
Excessive estrogen in turn causes insomnia and anxiety, which further taxes the adrenal 
glands. This leads to a further reduction in progesterone output and even more estrogen 
dominance. After a few years in this type of vicious cycle, the adrenal glands become 
exhausted. This dysfunction leads to blood sugar imbalance, hormonal imbalances, and 
chronic fatigue.

3. Oral Contraceptives or HRT ­ Oral contraceptives promote estrogen dominance and 
eventually influence the growth of the cells in the uterus. This increases the level of estrogen 
in the body. Premarin, an estrogen­only drug commonly used in the past 40 years, is the 
mainstay of estrogen replacement therapy (ERT). It is a patented, chemicalized hormonal 
substitute that is different than the natural estrogen in your body. It contains 48% estrone and
only a small amount of progesterone, which is insufficient to have an opposing effect. The 
indiscriminate and over­prescription of Premarin to many who may not need it is the 
problem. Symptoms include water retention, breast swelling, and fibrocysts in the breast, 
depression, headache, gallbladder problems, and heavy periods. The excessive estrogen from 
ERT also lead to increased chances of DNA damage, setting a stage for endometrial and 
breast cancer

4. Luteal Insufficiency ­ Leimyoma formation is also possible because of hyperestrogenism due 
to progesterone deficiency that is caused by luteal insufficiency

5. Caffeine or Coffee intake  ­ Increase in coffee consumption. Caffeine intake from all sources 
is linked with higher estrogen levels regardless of age, body mass index (BMI), caloric 
intake, smoking, alcohol, and cholesterol intake. Studies have shown that women who 
consumed at least 500 milligrams of caffeine daily, the equivalent of four or five cups of 
coffee, had nearly 70% more estrogen during the early follicular phase than women who 
consume no more than 100 mg of caffeine daily, or less than one cup of coffee. Tea is not 
much better as it contains about half the amount of caffeine compared to coffee. The 
exception is herbal tea like chamomile, which contains no caffeine.

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Uterine Leiomyoma: A Case Study 52

Signs & Symptoms with Rationale

1. Swelling of breasts – Enlargement of the breast and tenderness results from a fluctuation of
the hormones progesterone and estrogen.

2. Depression –  Due to imbalanced levels of estrogen in the body.

3. Loss of Sex Drive – Due to imbalanced levels of estrogen in the body.

4. Dysmenorrhea –  Due to imbalanced levels of estrogen in the body.

5. Pain – Due to the stretching of the uterus and the proliferation of cells which damages the
endometrial wall. 

6. Increased pelvic pressure – Due to the growth of the tumor.

7. Hypremenorrhea and Abnormal Bleeding  – Due to the growth of the tumor as well as the
deterioration   of   the   surrounding   tissues   which   may   come   from   the   ischemia   due   to   the
tumor’s growth.

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Uterine Leiomyoma: A Case Study 53

CLIENT-CENTERED PATHOPHYSIOLOGY

Schematic Diagram

Predisposing Precipitating Factors:


Factors:
-High fat diet
-Age
-Obesity
Etiology:
-Race
Unknown -Anxiety/Stress (Working in the
-Early Menarche bukid)

Estrogen
Estrogen Dominance
Dominance or
or
-Coffee/ Caffeine intake
increase
increase in Estrogen
in Estrogen
production
production

Proliferation of cells in uterus*


(Sub mucous)

Overgrowth the
endometrial lining

Myoma:
Development of
uterine fibroid

Uterine Cavity
begins to stretch or
increase in size

Interference in the
vascular supply

Degeneration of the s/sx:


interior part of
-Abnormal bleeding
fibroid

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Uterine Leiomyoma: A Case Study 54

C L I E N T - B A S E D :
S
Y N T H E S I S O F T H E D I S E A S E

Predisposing Factors

5. Age is a risk factor in the disease process of uterine leiomyoma. The client is currently 57
years old. This is due to the differences of estrogen and progesterone levels in females as
they get older and undergo the processes of menopause.
6. Heredity – Women who’s mothers have had myoma themselves are more susceptible to
getting the disease than those who have no family history of the disease. (Faerstein, 1997).
The client’s mother was believed to also have a myoma, as the client recalls that she was
experiencing the same symptoms.

7. Early Menarche and Nulliparity – The client had her menarche at 12 years of age. Studies
have suggested that an early start of menarche (less than the average age of 13) and
nulliparity contribute to the development of a uterine leiomyoma, however, how this
connection or relationship between the risk factor and the disease processes are still unknown
(Faerstein, 2001). It is believed that these factors are precipitated because of the estrogen and
progesterone levels in the body.

Precipitating Factors

1. High Fat Diet & Obesity – is also considered a source of estrogen where as diets rich in fiber 
and low in fat decreases estrogen reabsorption. Fat has an enzyme that converts adrenal 
steroids to estrogen. The higher the fat intake, the higher the conversion of fat to estrogen. 
Overeating is the norm in developed countries. A population from such countries, especially 
in the Western hemisphere where a large part of the dietary calorie is derived from fat, has a 
much higher incidence of menopausal symptoms. Studies have shown that estrogen and 
progesterone levels fell in women who switched from a typical high­fat, refined­carbohydrate
diet to a low­fat, high­fiber and plant­based diet even though they did not adjust their total 
calorie intake. Plants contain over 5,000 known sterols that have progestogenic effects.

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Uterine Leiomyoma: A Case Study 55

2. Anxiety/ Stress – The stress levels of the individuals can influence the production of estrogen 
and progesterone in the body. Stress causes adrenal gland exhaustion as well as reduced 
progesterone levels. This tilts the estrogen to progesterone ratios in favor of estrogen. 
Excessive estrogen in turn causes insomnia and anxiety, which further taxes the adrenal 
glands. This leads to a further reduction in progesterone output and even more estrogen 
dominance. After a few years in this type of vicious cycle, the adrenal glands become 
exhausted. This dysfunction leads to blood sugar imbalance, hormonal imbalances, and 
chronic fatigue.

3. Caffeine or Coffee intake  ­ The client has an average consumption of at least three (tall) cups
of coffee a day. Increase in coffee consumption. Caffeine intake from all sources is linked 
with higher estrogen levels regardless of age, body mass index (BMI), caloric intake, 
smoking, alcohol, and cholesterol intake. Studies have shown that women who consumed at 
least 500 milligrams of caffeine daily, the equivalent of four or five cups of coffee, had 
nearly 70% more estrogen during the early follicular phase than women who consume no 
more than 100 mg of caffeine daily, or less than one cup of coffee. Tea is not much better as 
it contains about half the amount of caffeine compared to coffee. The exception is herbal tea 
like chamomile, which contains no caffeine.

Signs & Symptoms with Rationale

1. Hypremenorrhea and Abnormal Bleeding  – Due to the growth of the tumor as well as the
deterioration   of   the   surrounding   tissues   which   may   come   from   the   ischemia   due   to   the
tumor’s growth. This was only assessed upon admission of the client as the client was seen
by the student nurses after her surgery. (September 9, 2010)

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Uterine Leiomyoma: A Case Study 56

1. MEDICAL MANAGEMENT

I n t r a v e n o u s
Th e r a p y

INTRAVENOUS FLUID THERAPY

Medical Date Ordered General Indication or Clients Response


Management Description Purposes to Treatment

5% Dextrose in DO: Sept 10, Hypertonic  To replace No adverse


Lactated 2010 Solution fluids and reactions or IV
Ringer’s electrolytes complications
Solution DC: Sept 13, A solution loss noted
2010 containing  To increase
(30gtts/min) sodium chloride, vascular/
potassium plasma
volume
chloride, calcium
necessary
chloride and during
sodium lactated bleeding or
in distilled water, blood loss
referred to  To replenish
Lactated fluid loss of
Ringer’s solution the body,
maintain
calories from
nutritional
dextrose intake when
patient is
unable to
tolerate
feedings, also
serves as
medium for
administratio
n of
medications.

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Uterine Leiomyoma: A Case Study 57

INTRAVENOUS THERAPY

NURSING RESPONSIBILITIES BEFORE, DURING, AND AFTER


Before the Procedure

 Check the doctor’s order regarding to what type of IVF to be used and also its volume and rate.
 Explain the procedure to the patient.
 Gather all materials needed for the insertion of IVF to save time and not to waste time for looking for other
materials.
 Wash hands before and after the procedure to prevent contamination from insertion site.
During the Procedure

 Place patient in a comfortable position to facilitate easy insertion of IV line and to decrease patient’s fear
about the procedure.
 Make sure that we give the proper IV fluid and drop rate accurately because patient may experience fluid
overload or dehydration.
 Check for its patency by observing the backflow of blood upon insertion.
After the Procedure

 Press the site where the needle was inserted and secure it with micropore.
 Check the site of hand where the needle is inserted if bulging is not visible. If so, reinsertion is to be
undertaken.
 Advice patient to avoid scratching the site less movement of the hand where the needle was inserted to
keep it in place.
 Instruct patient and significant others to inform the nurse on duty if bulging of the site is visible, if there is
back flow of blood of if IVF is not infusing well.
 Observe the IV site at least every hour for signs of infiltration or other complications fluid or electrolyte
overload and air embolism.
 IVF regulation should be checked and monitored upon receiving patient.
 Always check the doctor’s order for new orders regarding the IVF supplement of the patient.
 Always check if the IVF is infusing well and intact.
 Monitor the patient’s skin integrity.
 Provide comfort for the patient.
 Remove and dispose used items.
 Report and record as appropriate.
 Place IV tag

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Uterine Leiomyoma: A Case Study 58

P h a r m a c o l o g i c a l ,
M a n a g e m e n t

Drug Name

Clients
Generic Name Indication or
General Action Dates Response to
(Brand Name) Purposes
Treatment

Brand Name: 1g/IV q 8 First generation The patient


cephalosporin verbalizes
Ancef Date ordered: ANST x 1 more anti-infective understanding of
dose drug that inhibits taking this
09/11/10
cell-wall medication
Generic Name: synthesis,
promoting
Cefazolin Date performed: osmotic
Sodium instability;
09/11/10 usually
bactericidal.

Brand Name: Date ordered: 10 mg / amp Opioid The patient


PRN analgesics. Binds
Nubain 09/11/10 with opiate verbalizes relief
from pain
Receptors in the
CNS, altering
Generic Name: Date performed:
perception of
Nalbuphine 09/11/10 and emotional
Hydrochloride response to pain.

Brand Name: Date ordered: Antianginals. The patient


Inhibits calcium verbalizes
Amlodipine 09/12/10 ion influx acriss understanding of
Besylate cardiac and taking this
smooth- muscle medication

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Uterine Leiomyoma: A Case Study 59

Date performed: 5 mg / tab OD cells, dilates


coronary arteries
09/12/10 and arterioles,
and decreases
Generic Name:
blood pressure
and myocardial
oxygen demand.
Norvasc

Brand Name: Date ordered: 75 mg/deep IM Nonsteroidal


ANST anti-
Voltaren 09/12/10 inflammatory The patient
(-) drug, may inhibit verbalizes
prostaglandin understanding of
synthesis, to taking this
Generic Name: Date performed:
produce anti- medication
Diclofenac 09/12/10 inflmmatory,
Sodium analgesic and
anti-pyretic
effects.

Nursing Responsibilities for All Drugs

Before the administration of drug:

 Verify Doctor’s order


 Remember the 10R’s of Drug administration
During the administration of drug:

 Verify patient’s identification


 Inform the patient with regards to drug administration
 Clean the IV port prior to administration of the drug
After the administration of drug:

 Monitor patient for adverse effects


 Inform patient that easy bruising may occur
 Caution patient not to stop taking drug abruptly without first consulting prescriber

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Uterine Leiomyoma: A Case Study 60

D i e t &
A c t i v i t y
M a n a g e m e n t

LOW SALT, LOW FAT DIET

General Indication or Clients Response


Type of Diet Date Ordered
Description Purposes to Treatment

Low Salt, Low Reduced sodium To prevent risk Sept 10, 2010 Client has been
Fat diet. and cholesterol for other complying with
content of food complications Upon admission the diet and was
which may arise able to maintain
from blood pressure
hypertension. within normal
limits for most
days.

LOW SALT, LOW FAT DIABETIC DIET

NURSING RESPONSIBILITIES BEFORE, DURING, AND AFTER

Before the Procedure

 Check the doctor’s order.


 Check the right client.
 Be sure that the diet is properly instructed.
During the Procedure

 Monitor if the client complies with the given diet.


 Be sure patient is taking or eating food he can tolerate
After the Procedure

 Assess for patient’s condition; how he responds to the diet

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Uterine Leiomyoma: A Case Study 61

Active and Passive Range of Motion Exercises

General Indication or Clients Response


Type of Activity Date Ordered
Description Purposes to Treatment

Active and Range of motion To prevent any Sept. 11, 2010 The client was
Passive Range of (ROM) exercises aggravations of able to comply
Motion Exercises are ones in which complications of After Surgery with the activity;
a nurse or patient immobility such therefore
move each joint as thrombus thrombus
through as full a formation. formation had
range as is been prevented.
possible without
causing pain.

ACTIVE AND PASSIVE RANGE OF MOTION EXERCISES

NURSING RESPONSIBILITIES BEFORE, DURING, AND AFTER

Before the Procedure

 Check the doctor’s order.


 Check the right client.
 Be sure that the activity is properly instructed.
 Ensure that the patient understands why this type of activity is being prescribed.
During the Procedure

 Monitor if the client complies with the given activity


 Be sure patient is taking or eating food he can tolerate
After the Procedure

 Assess for patient’s condition; how he responds to the activity

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Uterine Leiomyoma: A Case Study 62

Turning, Coughing, And Deep Breathing

General Indication or Clients Response


Type of Activity Date Ordered
Description Purposes to Treatment

Turning, A type of To assist in Sept. 11, 2010 The client was


Coughing, And exercise which is loosening and able to comply
Deep Breathing educated prior to expectoration of After Surgery with the activity
the surgery and mucous as evidenced by
implemented clear breath
soon after the sounds.
effects of
anesthesia have
worn off which
includes
activities such as
coughing and
deep breathing
with the use of a
splint.

TURNING, COUGHING, AND DEEP BREATHING

NURSING RESPONSIBILITIES BEFORE, DURING, AND AFTER

Before the Procedure

 Check the doctor’s order.


 Check the right client.
 Be sure that the activity is properly instructed.
 Ensure that the patient understands why this type of activity is being prescribed.
During the Procedure

 Monitor if the client complies with the given activity


 Be sure patient is taking or eating food he can tolerate
After the Procedure

 Assess for patient’s condition; how he responds to the activity

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Uterine Leiomyoma: A Case Study 63

S u r g i c a l
M a n a g e m e n t

TOTAL ABDOMINAL HYSTERECTOMY

Total abdominal hysterectomy is utilized for benign and malignant disease where removal of the internal
genitalia is indicated. The operation can be performed with the preservation or removal of the ovaries on one
or both sides. In benign disease, the possibility of bilateral and unilateral oophorectomy should be thoroughly
discussed with the patient. Frequently, in malignant disease, no choice exists but to remove the tubes and
ovaries, since they are frequent sites of micrometastases.

In general, the modified Richardson technique of intrafascial hysterectomy is used.

The purpose of the operation is to remove the uterus through the abdomen, with or without removing the tube
and ovaries.

Physiologic Changes. The predominant physiologic change from removal of the uterus is the elimination of
the uterine disease and the menstrual flow. If the ovaries are removed with the specimen, the predominant
physiologic change noted is loss of the ovarian steroid sex hormone production.

Points of Caution. The predominant point of caution in performing abdominal hysterectomy is to ensure that
there is no damage to the bladder, ureters, or rectosigmoid colon.

Mobilization of the bladder with a combination of sharp and blunt dissection frees the bladder from the lower
uterine segment and upper vagina. This reduces the incidence of damage to the bladder.

By exercising extreme care in management of the uterine artery pedicle, the surgeon may minimize the risk of
injury to the ureter. The same is true of the management of the cardinal and uetrosacral ligament pedicles.

If the vaginal cuff is left open with the edges sutured, the incidence of postoperative pelvic abscess is
dramatically reduced.

Instruments Used:
- Self-retaining retractors
- Moist Gauze packs
- 0 synthetic absorbable suture
- Clamps
-Straight Ochsner Clamp
-Curved Ochsner clamps
-Metzenbaum Scissors
-Scalpel

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Uterine Leiomyoma: A Case Study 64

The patient is placed in the dorsal lithotomy


position, and an adequate pelvic examination is Self-retaining retractors are placed in the
performed with the patient under general abdominal incision, and the bowel is packed off
anesthesia. This is extremely important because it with warm, moist gauze packs. A 0 synthetic
allows the surgeon to become acquainted with the absorbable suture is placed in the fundus of the
anatomy of the internal genitalia. This is frequently uterus and used for uterine traction. The uterus is
impossible when the patient is examined in the deviated to the patient's right. The left round
gynecologic clinic. The patient is then put in ligament is placed on stretch and incised between
approximately a 15° Trendelenburg position. A clamps.
Foley catheter is left in the bladder and connected
to straight drainage. In general, midline incisions are
preferred for malignant disease, since they allow
accurate staging and exposure to the upper
abdomen and aortic lymph nodes. If investigation of
the upper abdomen and aortic lymph nodes is
needed, the midline incision should be extended
around and above the umbilicus for appropriate
exposure.

For benign disease, the Pfannenstiel incision is an


adequate alternative to the midline incision.

After the abdomen is entered, it should be


thoroughly explored; including the liver, gallbladder,
stomach, kidneys, and aortic lymph nodes.

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Uterine Leiomyoma: A Case Study 65

The distal stump of the round ligament is ligated


with 0 synthetic absorbable suture. The proximal
stump is held with a straight Ochsner clamp. At this While retracting the uterus cephalad, the surgeon
point the leaves of the broad ligament are opened opens the anterior lead of the broad ligament to the
both anteriorly and posteriorly. This is performed by vesicouterine fold. Steps 2-4 are carried out on the
delicate dissection with the Metzenbaum scissors. opposite side.

The vesicoperitoneal fold is elevated, and the fine If the ovaries are to be preserved, the uterus is
filmy attachments of the bladder to the pubovesical retracted toward the pubic symphysis and deviated

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Uterine Leiomyoma: A Case Study 66

cervical fascia are visible. The bladder can be to one side with the infundibulopelvic ligament,
dissected off the lower uterine segment of the tube, and ovary on tension. A finger should be
uterus and cervix by either blunt or sharp dissection. inserted through the peritoneum of the posterior
If there has been extensive lower segment disease, leaf of the broad ligament under the suspensory
previous cesarean sections, or pelvic irradiation, ligament of the ovary and Fallopian tube. The tube
blunt dissection of the bladder off the cervix is and suspensory ligament are doubly clamped,
dangerous, and a sharp dissection technique should incised, and tied with 0 synthetic absorbable
be performed. suture. The distal stump of this structure is best
doubly tied, first with a single tie of 0 synthetic
absorbable suture and then with a ligature of 0
synthetic absorbable suture. The same procedure
is carried out on the opposite side.

The uterus is then retracted cephalad and deviated


to one side of the pelvis with the lower broad
ligament on stretch. The filmy tissue surrounding
the uterine vessels is skeletonized by elevating the The uterus is held in traction in the cephalad
round ligament and dissecting the tissue away from position, and the handle of the knife is used to
the uterine vessels. Three curved Ochsner clamps dissect the pubovesical cervical fascia inferiorly.
are placed at the junction of the lower uterine This step mobilizes the ureter laterally and
segment on the uterine vessels. This is best caudally.
performed by placing the tips of the curved Ochsner
clamps onto the uterus and allowing them to slide
off the body of the uterus, thus ensuring complete
clamping of the uterine vessels. An incision is made
between the upper Ochsner clamp and the two
lower Ochsner clamps. This is suture-ligated with
two 0 synthetic absorbable sutures, placing the first
suture at the tip of the lower Ochsner clamp and
tying the suture behind the base of the clamp. The
middle Ochsner clamp is left in place and is similarly

Group 3 N­404
Uterine Leiomyoma: A Case Study 67

suture-ligated by a second ligature placed at the tip


of the Ochsner clamp and tied behind the base of
the clamp. No attempt is made to place a suture in
the middle of the pedicle, since it contains blood
vessels and a pedicle hematoma can be created.

The same procedure is carried out on the opposite


side.

A delicate, transverse, curved incision is made in


the pubovesical cervical fascia overlying the lower
uterine segment. The separation of the pubovesical
cervical fascia from the underlying cervical stroma is
facilitated by placing traction on the uterus in the
cephalad position.

The posterior leaf of the broad ligament is incised


Two straight Ochsner clamps are applied to the down to the uterosacral ligaments and across the
cardinal ligament for a distance of approximately 2 posterior lower uterine segment between the
cm. The cardinal ligament is incised between the rectum and cervix.
two clamps, and the distal stump is ligated with 0
synthetic absorbable suture. The suture is tied at
the base of the clamp; no attempt is made to place
this suture within the body of the pedicle because
vessels can be torn and hematomas created.

The same procedure is carried out on the opposite

Group 3 N­404
Uterine Leiomyoma: A Case Study 68

cardinal ligament.

The uterosacral ligaments on both sides are


clamped between straight Ochsner clamps, incised, The uterus is placed on traction cephalad, and the
and ligated with 0 synthetic absorbable suture. lower uterine segment and upper vagina are
palpated between the thumb and first finger of the
surgeon's hand to ensure that the ligaments have
been completely incised. The vagina is entered by
a stab wound with a scalpel and is cut across with
either a scalpel or scissors. The uterus is removed.
The edges of the vagina are picked up with straight
Ochsner clamps in a north, south, east, and west
direction.

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Uterine Leiomyoma: A Case Study 69

The pelvis is reperitonealized with running 2-0


a. The vaginal cuff is never closed in our clinic. This synthetic absorbable suture from the anterior to the
alone has accounted for a radical decrease in posterior leaf of the broad ligament. The stumps of
postoperative febrile morbidity and abscess the tubo-ovarian round, suspensory ligament of the
formation. The edges of the vaginal mucosa are ovary, and the cardinal and uterosacral ligaments
sutured with a running locking 0 synthetic are buried retroperitoneally.
absorbable suture starting at the midpoint of the
vagina underneath the bladder and carried around
to the stumps of the cardinal and uterosacral
ligaments, which are sutured into the angle of the
vagina.

b. The running locking suture is carried around the


posterior wall of the vagina ensuring that the
rectovaginal space is obliterated.

c. The cardinal and uterosacral ligaments of the


opposite side have been included in the running
locking 0 synthetic absorbable suture, and the
reefing process has been completed to the midpoint
of the anterior vaginal wall. At this point, meticulous
care should be taken to ensure that the lateral angle
of the vagina is adequately secured and that
hemostasis is complete between the lateral angle of
the vagina and the stumps of the cardinal and
uterosacral ligaments. This can be a site of
hemorrhage.

At this point, the pelvis is thoroughly washed with


sterile saline solution. Meticulous care is taken to

Group 3 N­404
Uterine Leiomyoma: A Case Study 70

ensure that hemostasis is present throughout the


dissected area.

Drains are rarely needed. If they are indicated, they


are placed through the open vaginal cuff and carried
along the lateral pelvic wall retroperitoneally.

If the tube and ovary are to be removed, they are


removed at Step 6 in the operation. Instead of
placing a finger underneath the tube and
suspensory ligament of the ovary, a finger is placed
under the infundilbulopelvic ligament on that side.
Care is taken to ensure that the ureter is not
included. In various forms of pelvic disease
(endometriosis, pelvic inflammatory disease, etc.),
the ureter can be deviated close to the
infundibulopelvic ligament.

The infundibulopelvic ligament is doubly clamped


and incised, and the distal stump of the ligament is
doubly ligated with a tie of 0 synthetic absorbable
suture plus a ligature of 0 synthetic absorbable
suture.

For a bilateral salpingo-oophorectomy, the same


procedure is carried out on the opposite
infundibulopelvic ligament.

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Uterine Leiomyoma: A Case Study 71

The tube and ovary have been mobilized medially The peritoneum of the pelvis has been
with the uterine specimens. The remainder of the reestablished with the tube and ovary removed.
operation is carried out as described in Steps 7-13. The stump of the infundibulopelvic ligament is
buried retroperitoneally.

Postoperatively, no vaginal packing is left in the


vagina, and no Foley catheter drainage of the
bladder is indicated.

The open vaginal cuff closes without difficulty.


Rarely, a small bit of granulation tissue is noted in
the upper vagina and is adequately treated by
application of silver nitrate 4 weeks postoperatively
in the clinic or office. The patient is allowed to
resume sexual intercourse 4 weeks after
examination in the clinic and is allowed to resume
work 5 weeks postoperatively.

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Chronic Obstructive Pulmonary Disease: A Case Study 72

NURSING CARE PLAN

DECREASED CARDIAC OUTPUT

Nursing Scientific Nursing


Cues Objectives Rationale Evaluation
Diagnosis Explanation Interventions
Decreased A surgery is a type After 4 hours Monitored and - To establish a base line data After 4 hours of
Cardiac Output of stress upon the of nursing recorded vital signs nursing
S: - related to body. After a interventions, interventions, the
increased surgery, the patient is the patient BP Promote adequate - To promote healing of the BP of the patient
O: with a BP rest patient and to lower heart rate.
afterload as left with a scar from will decrease to lowered to
of 140/80
evidenced by a BP the incision, which less than 120/80
of 140/80 pay cause pain. This 140/80 but not
pain may cause an lower than -To lessen anxiety from pain
Encourage
which may cause an increase
increase in the blood 100/70 relaxation in BP
pressure of the techniques such as
client. This listening to music
prolonged increase
in blood pressure in Provide
time decreases the psychological -To lessen anxiety
tissue perfusion and support
the blood out put of
Encourage
the heart. -To promote proper perfusion
ambulation as of blood to tissues to promote
tolerated healing.

- To prevent orthostatic
hypotension which may result
Encourage changing from prolonged
position slowly immobilization.
Chronic Obstructive Pulmonary Disease: A Case Study 73

ACTIVITY INTOLERANCE

Nursing Scientific Nursing


Cues Objectives Rationale Evaluation
Diagnosis Explanation Interventions

S: “Di pa Activity Because stress After 2 hours Provide positive -To Enhance
masyadong intolerance and pain is an of nursing atmosphere learning
makagalaw,ang related to inevitable factor interventions, After 2 hours
hirap.” generalized post most surgical the patient -To promote a of NPI, the
weakness as procedures, the and SO will Promote comfort positive atmosphere patient and SO
measures like fixing conducive to identified
manifested by client avoids identify the bedside
discomforts, movement in order techniques to learning. techniques to
weakness and to lessen the enhance enhance
Provide adequate rest
-To promote healing. activity
O: with facial facial grimace. aggravation of this activity
periods tolerance
grimace, pain. They become tolerance of
appears weak, immobile, not the patient. Instructed SO to
with verbal reposition the patient -To promote adequate
wanting to move
reports of every 2 hours with tissue perfusion all
as a result of this
discomforts
proper assistance throughout the body.
pain. Because of
this, the
immobilization Instructed SO to use
can cause -To provide safety
side rails, overhead
complications, and pillows in
such as thrombus changing the position
formation. of the patient
Chronic Obstructive Pulmonary Disease: A Case Study 74

DISCHARGE PLANNING

Topic: Exercises, Medication, and Diet post Hysterectomy

Time allotment: 1 Hour

Venue: Room

Teaching
Objectives Content Time allotment Evaluation
Strategies

After 1 hour of The patient was


health teaching A. Demonstration Discussion- able to identify
the patient & and education of 15 minutes Demonstration and demonstrate
passive and active
significant others range of motion
the exercises
(SOs) should be exercises. which must be
able to: A.1 The Effects of implemented as
Mobilization well as the diet
A. Demonstrate she should
B. Demonstation of
and understand turning coughing
30 minutes Discussion- maintain to
the importance and deep breathing Demonstration manage her
of active and with the use of hypertension.
passive range of Splint.
motion exercises B.1 Prevention of
post operative
pneumonia.
B. Carry out B.2 Adequate
deep breathing oxygenation to
exercises and promote perfusion to
understand the tissues.
rationale for this
C. Samples of Low
Salt and Low fat
C. Adhere to a foods
low salt and Low C.1 Vegetables over
Fat diet as well red meats
C.2 Types of meats
as lessen the
which are healthier
intake of alternatives. 15 minutes Discussion-
caffeine. C.3 Avoidance of Demonstration
sauces
D. Following the C.4 Monitoring of
Medications BP
C.5 Effects of
ordered after caffeine.
discharge
D. Medications
given and their uses
Uterine Leiomyoma: A Case Study 75

LEARNING DERRIVED

For almost 2 weeks of duty, we have encountered several constraints with regards to the
implementation of interventions. It was not that easy especially we are dealing with people who
have different health problem, problem through which if jeopardized, can either put us in an
obnoxious situation or be blameworthy for any complications.

For almost three weeks of multi-tasking and time management, the SRFMC exposure has
taught us how to appropriately deal with people. The idea of caring for them is not too easy.
Slightly hard, because some of the patient’s has very serious illness which can put us to danger,
that is why we are there to care for them properly with tender loving care.

We have learned to thoroughly assess our patient to comply with the requisites. Also, we
have acquainted ourselves with regards to establishing rapport with our patient to have a trusting
relationship. We have learned how to be patient; to respect and accept their beliefs and values
without judging them; to communicate with them therapeutically. Basically, it’s the feeling of
confidence you have in yourself that will facilitate accomplishment and error-free
implementation of nursing care. The nurse has a lot of responsibilities to take in, thus, confidence
is a very important factor.

The exposure wasn’t centered mainly to rendering care. It was also focused to building
and developing intrapersonal and interpersonal relationships. To adjust and adapt with the
environment is a humongous task! It’s not that easy. But mingling with those patients helps you
identify your strength and weaknesses, and it aids in modifying what is somehow negative in our
attitudes. To sum this all up, it was a SUCCESS! Thanks be to GOD.

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Uterine Leiomyoma: A Case Study 76

REFERENCES

Black, J.M., Hawks, J. H. (2009). Medical­surgical nursing: clinical management for 
positive outcomes. Vol.2. New York. Saunders.

Blanchard, R., Loeb, S. (2004) Blanchard & Loeb publishers nurse’s drug handbook. 
Michigan. Blanchard & Loeb.

Fischbach, F.T., Dunning, M.B. (2008). A manual of laboratory and diagnostic tests. 
Springhouse, PA. Lippincott, Williams, & Wilkins.

Gutierrez, K. J., Peterson, P.G. (2007). Saunders sursing survival guide pathophysiology. 
2nd Edition. New Orleans Louisiana. Saunders & Elsevier.

Hole, J.W. (1993). Human anatomy and physiology. 6th edition. Dubuque, IA. Wm C. 
Brown Publishers, inc

Huether, S.E., McCance, K.L. (2000). Understanding pathophysiology.2nd edition. 
Singapore: Elsevier Science.

Karch, A. M. (2000). Lippincott’s nursing drug guide 2000. University of Michigan. 
Lippincott, Williams, & Wilkins.

Keogh, J. (2009). Nursing laboratory and diagnostic tests demystified. Boston. McGraw­
Hill Professional.

McCann, J. A., Holmes, H. N., Robinson, J.M., et al. (2003). Professional guide to 
pathophysiology. Springhouse, PA. Lippincott, Williams, & Wilkins.

Nicoll, D., McPhee, S.J., Pignone, M., Chuanyi, M.L. (2007). Pocket guide to diagnostic 
tests: Lange clinical science series. Springhouse, PA. McGraw­Hill.

Porth, Carol M., (2005). Pathophysiology:  Concepts of altered health states.  7th Edition. 
Boston: Lippincott, Williams, & Wilkins.

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Uterine Leiomyoma: A Case Study 77

Stockley, R. A. (2007). Chronic obstructive pulmonary disease. Chicago, IL. Wiley­ 
Blackwell.

Spratto, G.R., Woods, A.L. (2004). PDR nurse’s drug handbook. Springfield, IL. 
Cengage Learning, inc. 

Wallach, J.B. (2007). Interpretation of diagnostic tests: Doody’s all reviewed collection. 
Springhouse, PA. Lippincott, Williams, & Wilkins.

Weber, J., Kelley, J. (2007). Health assessment in nursing. 2nd edition. Boston. 
Lippincott, Williams & Wilkins.

Marshall, L., Spiegelman D., Barbieri R., Goldman M.B., Manson, J., Colditz, GA, 
Willet, W.C., Hunter, D. (1997) Variation in the incidence of uterine leiomyoma 
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Faerstein, E., Szklo, M., Rosenshein, N., (1997) Risk factors for uterine leiomyoma: a
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Lam, M., (2010) Estrogen Dominance: The silent epidemic. The Authority on Natural
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September 14, 2010

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