Case Study 2:

“Case Study of a 49-Years-Old Female with Myoma”

A Paper
Presented to the Faculty
of the College Department
Chinese General Hospital Colleges

In Partial Fulfillment
Of the Requirements for
Care of Mother and Child at Risks or with Problems (Acute and Chronic) Lec
N-109 MCN 2 LEC

Submitted by:
BSN – 2D | GROUP 3

MESINA, Krizelle Bea S. PUA, Marius Ashley

MONTECILLO, Jhon Brix E. PULPULAAN, Jaelo S.
NOLASCO, Ashley Jewell M. ROMBINES, Atasha Yzabelle L.
ONG, Jean Andre L. ROSALES, Eliza Joy J.
PANTOJA, Mary Grace B. SABADO, Thrisha Mae
PINEDA, Camille Joy C.

Submitted to:
Mrs. Geraldine Rowena S. Galang-Gatbonton, MAN, RN

April 25, 2023

 I. Background of the Study
A. Introduction

Myoma, also known as uterine fibroids, are common benign tumors that develop in the
muscular layer of the uterus. They affect up to 70% of women during their reproductive years
and can cause a range of symptoms, including heavy menstrual bleeding, pelvic pain, and
infertility. While myomas are generally not life-threatening, they can significantly impact a
woman's quality of life and may require medical or surgical intervention.

According to Gofur and Myoma (2021), the prevalence of myomas is estimated to be

20-40% in women of reproductive age, and they are the leading cause of hysterectomy
worldwide. The risk factors for myoma include age, obesity, African-American race, nulliparity,
and family history of myomas. The pathogenesis of myomas is not well understood, but it is
thought to involve abnormal smooth muscle cell proliferation and extracellular matrix
remodeling. Symptoms associated with myomas include abnormal uterine bleeding, pelvic pain,
and infertility.

In recent years, there has been an increasing interest in the management of myomas, with
a growing body of research focused on developing more effective treatments. This case study
will examine the case of a woman with symptomatic myomas, exploring the various treatment
options available and their outcomes. Several studies have examined the effectiveness of
different treatment options for myomas, including medical management, minimally invasive
procedures, and surgical interventions. For instance, a study by Sujatha et al. (2021) reported the
efficacy of uterine artery embolization in reducing myoma size and improving symptoms.
Similarly, a study by Rahman et al. (2018) found that laparoscopic myomectomy was associated
with lower rates of postoperative complications compared to open surgery. A study by Gingold et
al. (2018) discusses minimally invasive approaches to myoma management, which have become
increasingly popular in recent years. These techniques include laparoscopic and robotic
myomectomy, uterine artery embolization, and magnetic resonance-guided focused ultrasound.
These procedures have the advantage of shorter recovery times, decreased blood loss, and
decreased need for pain medication compared to traditional open surgery. The authors note that
appropriate patient selection is critical to achieve successful outcomes with these techniques.
Myoma is a common gynecologic condition affecting women during their reproductive years,
with a reported incidence of up to 77% in some populations. The exact cause of myoma
development is unknown, but various risk factors, such as age, genetics, hormonal imbalances,
and obesity, have been identified. The clinical presentation of myoma varies widely, with some
women being asymptomatic while others experience heavy menstrual bleeding, pelvic pain,
pressure, and infertility. In a retrospective evaluation of 1548 myoma patients, in the study of
David et al. (2016) found that pain associated with myoma was a common symptom, with 53.9%
of patients reporting pain in their lower abdomen or pelvis. Treatment options for myoma range
from conservative management to surgical intervention, with minimally invasive approaches

2
being increasingly used in recent years (Gingold et al., 2018). However, laparoscopic
morcellation, a technique used in minimally invasive surgeries, has been associated with the
development of parasitic myoma, a rare but potentially serious complication.

This case study aims to contribute to the existing body of research on myoma
management and to provide insight into the factors that may influence treatment decisions and
outcomes. By exploring the experiences of this particular patient and the outcomes of different
treatment options, this study aims to inform clinical decision-making and improve patient care.

Nurses are responsible for providing compassionate care that addresses both the physical
and emotional needs of patients. In this case, the nursing care plan would involve monitoring the
patient's vital signs, administering medications to manage pain and bleeding, and providing
emotional support and education to help her cope with her diagnosis. Nurses can also work
collaboratively with other healthcare professionals to ensure that the patient receives the most
appropriate treatment options.

Furthermore, nurses can play a crucial role in patient education and advocacy, providing
information about the disease process, available treatments, and resources. They can also
advocate for the patient's rights and preferences, ensuring that her wishes are respected
throughout the healthcare journey. Ultimately, nurses can make a significant impact on the
patient's overall health outcomes by providing comprehensive and compassionate care that
addresses her physical, emotional, and psychosocial needs.

3
B. Profile of Client
Clients initials: J.R.C.
Age now: 49 years old
When you had myoma: 47-48 years old (including onset of symptoms)
June 06, 1074
Birth date: Female
Sex: Filipino
Ethnicity: Roman Catholic
Religion: Married
Marital status: Cashier (started: October 2022)
Occupation: June 20, 2022
Date of Admission: N/A
Hospital/institution: N/A
Ward/area and bed number: R.D.C.
Spouse’s initials: 50 years old
Age: Painter
Occupation: G3P3 (3003)
OB score: J.R.C. II
Child’s initials: July 16, 1996
Birth date: N/A
Birth place: 26 years old
Age: Normal spontaneous delivery (NSD)
Manner of delivery: Single (with live-in partner)
Status: J.R.C III
Child’s initials: February 11, 1998
Birth date: N/A
Birth place: 25 years old
Age: Normal spontaneous delivery (NSD)
Manner of delivery: Single (with live-in partner)
Status: R.R.C
Child’s initials: May 31, 2001
Birth date: N/A
Birth place: 22 years old
Age: Normal spontaneous delivery (NSD)
Manner of delivery: Single
Status:

4
 II. Review of Related Literature

Uterine myoma known as leiomyomas or myomas is a benign tumor that appears in the
uterine muscle. According to David et al. (2016), myomas never develop prior to menarche, and
only 10% of myomas continue to grow after menopause. It was reported to be located in the
cervical (1-3%) and corporal regions. The diameter of uterine fibroids can range from 1mm to
20mm. Regarding size, it is comparable to a grapefruit. As studies have shown, the size of
fibroids varies, with small fibroids measuring between 1 and 5 centimeters in length, comparable
to a pea, and larger fibroids measuring between 5 and 10 centimeters, comparable to an orange.
The morphology of uterine myomas can also vary; they are often composed of a mass of several,
spherical or irregularly lobulated tumors. Despite the presence of a pseudocapsule, myomas can
be easily distinguished from normal myometrium and enucleated (David et al., 2016).

According to a study by Gofur (2021), the reproductive system was predominantly

impacted among 35-year-old females. Typically, the incidence is closer to 40 percent. The
increased occurrence of uterine myomas between the ages of 35 and 50 suggests a correlation
between uterine myoma incidence and estrogen. At menopause, the regression of uterine myoma
occurs. Up to 80% of women over 30 years old have uterine myomas, according to statistics.
Usually, fibroids are asymptomatic. Numerous symptoms induced by uterine myomas have a
negative impact on the quality of life of women with uterine myomas. Myomas generally result
in the following symptoms: heavy and extended menstrual flow, dysmenorrhea, dyspareunia,
feelings of pressure or foreign entities in the abdomen, and bladder pressure. Almost 43% of
women who had uterine fibroids reported that the condition altered the symptoms they
experienced on a daily basis (David et al., 2016).

According to Gofur et al. (2021), the most widespread benign tumor of the female
reproductive system is myoma or fibroids, and conventional hysterectomy is the third most
common surgical surgery globally. Uterine myomas are the most prevalent benign pelvic tumors,
affecting 25-30% of women throughout their menstrual cycle. Age, family history, and ethnicity
are all risk factors. Smoking, multiparity, and advanced pregnancy age appear to be protective
factors. Myomas can cause a variety of functional problems or be the cause of infertility.
Myomas can be surgically managed via operational hysteroscopy, myomectomy, or
hysterectomy, depending on the number, size, and location of myomas. Surgical myomectomy,
on the other hand, has been an alternative therapeutic option for over 100 years, originally by
laparotomy and more recently using less invasive procedures such as laparoscopy or
hysteroscopy. Because each surgical intervention has a modest but actual risk of problems,
conservative alternatives to surgery have.

According to the study of El-Balat et al. (2018), the impact of uterine illnesses such as
myomas has received little attention. Moreover, the many forms of symptoms are sometimes
poorly distinguished in research, leaving the precise prevalence uncertain. Most myomas are
asymptomatic and do not require treatment, however 20-50% of women with myomas have
problems that impair their quality of life and necessitate therapy. Myomas are commonly
responsible for symptoms such as heavy and extended menstrual flow, dysmenorrhea,
dyspareunia, sensations of pressure or foreign entities in the abdomen, and bladder pressure.
Myomas are the most common benign neoplasias of the female reproductive system, affecting

5
20-40% of all reproductive-age women. Most myomas are asymptomatic and do not require
treatment, however 20-50% of women with myomas have problems that impair their quality of
life and necessitate therapy. Myomas are commonly responsible for symptoms such as heavy and
extended menstrual flow, dysmenorrhea, dyspareunia, sensations of pressure or foreign entities in
the abdomen, and bladder pressure.

Heavy bleeding was the most often reported symptom (with over 90% of all patients),
followed by menstruation pain and then premenstrual discomfort (both in the 70-80% range) in
this research of over 1,500 myoma patients (David et al., 2016). The number, size, or location of
myomas in the research had no effect on the degree of premenstrual symptoms or discomfort
during sexual intercourse. Earlier research revealed that the size and position of myomas had no
influence on the occurrence and intensity of dyspareunia, however another study discovered that
the size but not the location of myomas was important to dyspareunia, which was more
commonly connected with intramural fundal myomas.

According to the study of Davis et al. (2016), along with his research discovered a high
level of dysmenorrhea in women with submucosal myomas and myomas with diameters smaller
than 5 cm, which is consistent with a prior population-based study. Nonetheless, the huge sample
size and lack of a comparison group of identical women without myomas make the data a
relevant point of reference for doctors looking to contextualize their own patients' symptom
concerns. The study also discovered that discomfort and hypermenorrhea are the most common
issues among myoma patients seeking specialist medical therapy. Further study is needed to
determine if the pain and other symptoms experienced by myoma patients are caused by the
myomas themselves, particular characteristics of the myomas, or other factors unrelated to the
myomas.

Several risk variables were connected with uterine myomas. First, the patient's age. It
typically manifests in those aged 35 and older. It was related to the patient's early family history.
Based on the data, the expression of VEGF (vascular endothelial growth factor)- was twice as
potent (a myoma-related growth factor). There were significant disparities between individuals
with and without a myoma family history. Moreover, the ethnicity of a patient impacts myomas.
According to Gofur (2021), uterine myoma affects Black women in the United States three to
nine times more frequently than African women. Finally, the diet and other undesirable
behaviors such as smoking—there has been research indicating that eating beef or red meat can
enhance the incidence of uterine myomas if the client consumes these foods. Thus, various risk
variables, including obesity, family history, smoking and other poor habits, ethnicity, and
maternal age, were related with uterine myomas.

In the study authored by Mendez et al. (2020), it is uncommon for pregnant women to
have prolapsed submucosal myomas. A diagnosis may be made using magnetic resonance
imaging (MRI). It seems to be more accurate than the ultrasonography of the vagina. Vaginal
myomectomy during pregnancy has been done in a few rare and common cases. Less than 1% of
cervical leiomyomas are uterine leiomyomas, which means that the possibility of seeing these
uncommon clinical entities is less than 1 in 1000 pregnancies. While uterine leiomyomas are
common during pregnancy, with a prevalence of about 10%. This condition during pregnancy is
linked to several complications like threatened abortion wherein there is vaginal bleeding before

6
20 weeks of AOG, IGR is when the baby in the womb does not develop normally; it may be
smaller or bigger than expected, abruptio placentae is when the placenta separates from the
uterus of the mother, mothers can also experience fetal pelvic pain, malpresentation or the baby
is not facing down the birth canal head first as labor progresses, and lastly premature labor
occurs when the mother's body begins preparing for delivery too early in pregnancy. The uterus
naturally tries to eliminate submucous myomas that develop pedunculated within the uterine
cavity through the endocervical canal. This happens when the cervix dilates. Submucosal
pedunculated myomas, regardless of their size, including the enormous ones, can still be
progressively delivered through a slightly dilated cervix. If complications have not occurred or
labor obstruction is not a cause for concern, pedunculated cervical leiomyomas can be removed
after vaginal delivery.

However, according to Moreta et al. (2020) there are few instances where a myomectomy
is performed while pregnant, it is when there is a possible labor problem. Myomectomy is a
surgical procedure done to remove myoma while protecting the uterus. Treatment of myoma is
necessary because there is a possibility of malignancy in the rapidly developing leiomyoma.
According to the study, two antepartum vaginal myomectomy patients were treated in the first
trimester, while three other instances were given treatment in the second trimester. While the
other patients, three individuals were able to carry their pregnancies to full term or close to term.
However, the remaining patients experienced early membrane rupture and acquired intra
amniotic infections. Wherein the amniotic membrane that surrounds the baby breaks before 37
weeks of pregnancy and the other is the inflammation of amniotic fluid, fetus, fetal membranes.
Both of two complications resulted in the death of the fetus. Effective management is really
important until the postpartum period or the final stage of delivery. If pregnancy-related issues
develop, a surgical treatment be taken into consideration, which is technically easier if the
leiomyoma has peduncles.

As claimed by El-Balat et al. (2018), over the years, myoma treatment has improved
significantly. Traditional surgical techniques have been improved by recent technological
developments that are minimally invasive treatments like laparoscopic myomectomy and
ultrasound treatments. These new medical procedures are an indication of our increasing
knowledge about the genetics and physiologic of fibroids. Many factors including symptoms,
fertility, general attitude, expectations, and age need to be examined at a very personal level in
order to create a multifactorial decision-matrix. The information available at hand will be a guide
to know what type of treatment will be done to the patients while considering the efficacy, side
effects, long-term effects, and potential problems. When there are more than five fibroids
present, the majority of surgeons will consider laparotomy. In a laparotomy, the patient's uterus is
accessed and fibroids are removed by the surgeon through an open abdominal incision. However,
the ultimate choice will depend on the surgeon's preference, the location of the myomas, and the
patient's desire to avoid laparotomy.

7
 According to Milazzo et al. (2017), with the delay in childbearing, the prevalence of
fibroids during pregnancy is projected to rise in the upcoming years. The prevalence is around
2%, varying by ethnicity (18% in African-American women, 8% in white), and ranges from
0.1% to 12.5%. 10% of Hispanic women). The incidence increases (25%) in older women having
in vitro fertilization (IVF) with an ovum donor recipient. Ten to thirty percent of pregnant
women with uterine myomas encounter difficulties throughout pregnancy, birth, and the
puerperium, although the majority have no symptoms.

The quantity, size, location, and connection to placenta implantation of fibroid lesions are
crucial elements in determining pregnancy morbidity. Most studies either lacked adequate
confounding variable control, were retrospective, or both. Only two meta-analyses on the
dangers of myoma during pregnancy have been done, and there have been no randomized
controlled trials on the topic. There have been very few population-based studies discovered in
the literature. The cumulative obstetric outcomes were only computed by one systematic study in
2008,4 and despite the dangers associated with myomectomy during pregnancy, no guidelines
have yet been proposed. A significant number of women with prior myomectomy will present to
the obstetric care unit as a result of the rise in the number of women having myomectomy in
recent years, first as a treatment for infertility. The doctor should inform the patient about the
risks and problems. It is widely believed that enhanced blood flow and hormone stimulation
during pregnancy cause myomas to grow quickly. The previous studies may have been biased
due to methodological aspects of data collection (retrospective analysis, different gestational
ages at enrollment, and use of ultrasound [US] equipment). More recent studies, however,
reported a non-linear increase in size, particularly in the first half of pregnancy. However, the
growth pattern in pregnancy for myomas differs from the trend for the concentration of the two
most well-known growth agents for fibroids: estrogen and progesterone (Milazzo et al., 2017).

It is widely believed that enhanced blood flow and hormone stimulation during
pregnancy cause myomas to grow quickly. The previous studies may have been biased due to
methodological aspects of data collection (retrospective analysis, different gestational ages at
enrollment, and use of ultrasound [US] equipment). More recent studies, however, reported a
non-linear increase in size, particularly in the first half of pregnancy. However, the growth
pattern in pregnancy for myomas differs from the trend for the concentration of the two most
well-known growth agents for fibroids: estrogen and progesterone.

According to the current evidence, the same rapid growth pattern of fibroids may be
explained by the rapid exponential increase of serum human chorionic gonadotropin (hCG) from
the early weeks of pregnancy until 12 weeks and the unique kinetics of its receptor. In vitro tests
substantiate this. The average fibroid volume increases by 12% during pregnancy, while very
few fibroid volumes rise by more than 25%. According to Strobelt et al., fibroids that are larger
than 5 cm in diameter are more prone to enlarge. There is conflicting information regarding the
clinical factors (age, parity, and BMI) that affect volumetric change in myomas. The growth of
myomas appears to be affected by controlled ovarian hyperstimulation for IVF, but only if a
pregnancy takes place (Milazzo et al., 2017).

8
 According to Gofur’s study in 2021, the position of the myoma to the uterine lining is
divided into 3 types: submucosal myomas, intramural/interstitial myomas, and
subserous/subperitoneal myomas. Submucosal myomas develop beneath the endometrium and
juts out into the uterus cavity. Additionally, developing stems that are lengthy and protrude
through the cervix into the vagina so that it may be observed under a microscope, are known as
Myom Geburt. Cervical myoma may extend into the cervical canal waterway in order to create a
crescent-shaped OUE. This submucosal myoma most frequently results in profuse and irregular
uterine bleeding because uterine bleeding is the most plentiful because it grows under the
endometrium and in the endometrium (menometrorrhagia). This kind of myoma submucosa is
also more likely to develop sarcomas. As a "curet bump," submucosal myoma can be felt to be
present (lump curettage time).; Intramural/interstitial myoma, it develops between the
myometrial fibers on the uterine wall; subserous/subperitoneal myoma develops outside the
uterine wall (under the tunica serosa) and protrudes outward on the surface of the uterus, which
is coated in serosa. It is also possible to stem this kind of myoma. The stalk of the myoma
subserosa with this stem may atrophy and be absorbed so that it is discharged, leading to the
development of a "parasitic myoma," if the extrauterine hemorrhage from the omentum's blood
vessels occurs.

III. Clinical Findings

A. Medical Diagnosis
A female client who is 49 years old with an obstetric score of G3P3 (3003)
is diagnosed with Abnormal Uterine Bleeding (AUB) probably sec to polyp,
Prolapsed Submucous Myoma, Anemia Mild.

B. History of Condition
Patient J.R.C. is a 47 years old patient who was diagnosed with myoma.
According to the patient J.R.C., she normally experiences regular menstruation,
but in November 2021, she missed period. She suspected she was in the
menopause phase at that time because it was uncommon for her to experience it
and she was also getting older. It was December of the same year when she began
bleeding again, she initially believed it was just a normal monthly period not until
she experienced extreme pain “Sobrang sakit ng balakang ko, tapos sobra akong
dinudugo” as verbalized by the patient. In order to reduce the discomfort, patient
J.R.C. took 500 mg of mefenamic acid.

Three weeks have passed and it is already January 2022 but there is still
bleeding and so much pain in her hips and abdomen. She got afraid that she might
run out of blood, which is why she decided to go to hospital for a check-up.
According to J.R.C., her OB performed some examinations in order to identify the
complication, this includes an internal exam (IE) every two weeks from January
to February, CBC platelet, urinalysis, and X-ray. It was March 2022 when she was
diagnosed with myoma. The doctor explained to her that the polyp is already 4 cm
and it needs to be removed as soon as possible. Starting from the week that she
was diagnosed, she would go to the hospital to have an IE every week until her
body became ready to undergo surgery. It was June when they were able to make

9
 a schedule for the total abdominal hysterectomy bilateral salpingo-oophorectomy
(TAHBSO) surgery. It took 4 months because of the weight and the blood sugar of
patient J.R.C. that had to be corrected because it is necessary to follow the
requirements before allowing the patient to undergo the surgery. Also, it is
difficult to get a slot for operation in the public hospital, causing the delay of the
surgery.

After the surgery, she was so hungry she ate the whole bowl of macaroni
soup but it triggered her stomach and she vomited. The nurse in charge forgot to
tell her that only a small amount of food is allowed after surgery. After what
happened, the doctor explained to her that the reason why she vomited after eating
the macaroni soup is that the patient must eat only a light meal after surgery.
“Masakit din, pati yung balat ko natuklap” as verbalized by the patient as the
nurse removed the micropore near the surgery site before removing the sutures.
The patient also experienced constipation for a few days after the surgery. The
doctor advised her to have a soft diet like oats and rich in fiber foods like papaya,
pineapple, etc. She followed her doctor and did not take any laxatives.

C. Nursing History
I. Health Perception and Health Management Pattern
Client J.R.C. stated “okay naman” when asked how her general health has
been in the present. When asked about her ancestors’ health history she said that
they do not have a history of illness. But her sister has the same condition as hers,
myoma. In the past six months, she experienced having a cough but she asserted
that it was relieved once she took Robitussin or Solmux, a medication used to
relieve coughs. According to patient J.R.C., taking vitamins, exercising by
walking, going to Luneta Park for fun, and going to work are the most crucial
things she does to maintain her health. Additionally, she received the CoVid-19
vaccination, Sinovac. She added that her mother had informed her that she had
received a measles vaccination when she was just a child. She also denied use of
cigarettes, alcohol, or drugs. When questioned about if it has been easy for her to
follow the doctor's or nurse’s suggestion, she answered yes easily. No beliefs or
traditional concepts that hindered client J.R.C. following the doctors’ or nurses’
advice. She also stated that she does not believe in “usog”, “suob”, and even faith
healers.

10
 II. Nutritional and Metabolic Pattern
Client J.R.C.’s daily food intake is composed of: In the morning, she was
used to just having a light meal opposite when having lunch where she was used
to eating a heavy meal. For a PM snack, she prefers having sweets such as banana
cue. At night, for dinner she likes to have a light meal also. The patient asserted
that she avoids eating excessive rice and meat and that she prefers having fish and
vegetables. She added that she cannot avoid drinking soft drinks because she and
her family drink carbonated drinks everyday.
When questioned about her 24-hour diet, she revealed that she consumed
bread and milk in the morning, 1 cup of rice with veggies and fish for lunch, a
banana cue for an afternoon snack, and 1/2 cup of rice and 1 piece of pork for
evening. Patient J.R.C. takes Centrum for her supplements. Her favorite food
which she described as the “hindi mahindian” food is cake and she also likes
coke sakto which contains 200 ml of carbonated drink. For her daily fluid intake,
she said that she consumes 8 and more glasses of water as a “pambawi” because
she likes to drink soft drinks as stated in the former paragraph. She often drinks
coffee in the morning and in the afternoon she alternates drinking coffee with
milk. She palpitates when she drinks coffee. Despite her desire to stop drinking it,
she claimed that her need for the effects of coffee is due to her job.
When asked to describe her general appetite she said that she is “magana
naman” and highlighted that she is not a picky eater. Client also denied having
any food allergies and dental problems because she immediately solves it by
going to the dentist once she feels she has a toothache and gets the tooth extracted
right away. Patient J.R.C. also gained weight; when she first developed myoma,
she weighed 49 kilos; after being diagnosed with myoma, her weight increased to
60 kilograms; and after myoma has been ruled out, she weighs 50 kilograms. As
of right now, her weight is 54 kilograms and her height is 5 feet flat making her
BMI 23. 2 which is classified as normal.

III. Elimination Pattern

Patient J.R.C.’s bowel elimination pattern: Client J.R.C. defecates once
per day and usually in the morning. She described her stool’s consistency as firm
and the color is light brown. She did have defecation problems post-operatively
but now she denied having any problems and discomfort. Before hospitalization
she described her bowel movement as “okay pa” but after hospitalization she said
that she experienced difficulties and pain while defecating. When asked if she
used laxatives, she stated that she did not, but that she was prescribed and enjoys
eating fiber-rich meals.
Patient J.R.C.’s urinary elimination pattern: Client J.R.C. indicated that
she urinates 4 to 5 times per day, with an estimated volume of 100 cc/mL per

11
urine. Its tint is yellowish since she consumes Centrum vitamins, as she stated.
She also added that her urine (based on her experience) smells like medicine
because of taking Centrum. She explained that her difficulty with urinating is that
she gets up in the middle of the night to urinate, but she denied feeling any
discomfort. She further reported that there is no discernible difference in her urine
elimination prior to and following hospitalization. Excessive perspiration, any
odor problems and discharge are also denied by the client.

IV. Activity and Exercise Pattern

Patient J.R.C. stated that she does not have any breathing problems. Prior
to her hospitalization, she stated that she could still do lifting of heavy objects, as
compared to her current predicament, in which she is unable to carry heavy
objects after hospitalization. Walking is the only type of exercise she does and
does not feel pale while doing it. Due to her work, she did not have any spare time
for activities and highlighted that she just wants to sleep after her work. When
patient J.R.C. was asked if she thinks she has the sufficient energy required for
completing daily activities, J.R.C. stated that yes, she has the energy needed for
her daily activities like work, and that during day offs, she tries to sleep as much
as she can.

V. Sleep and Rest Pattern

The interviewers asked client J.R.C. about her general sleep rest pattern,
client J.R.C. answered that she is well rested, and when waking up she doesn’t
feel weak. Client J.R.C. mentioned that she had difficulty sleeping when she had
myoma. The client also mentioned that her noisy neighbor was a factor in her
waking up in the middle of the night. Client J.R.C. stated that 11 pm is the usual
time she sleeps and wakes up at around 6-7 am. The interviewers asked client
J.R.C. if she noticed any difference in her sleep-rest pattern before and after
hospitalization, client J.R.C. stated that before hospitalization, she had difficulty
in sleeping because of her heavy bleeding and pain. She mentioned that it is 10/10
on the pain scale and often drinks mefenamic for self-medication. Client J.R.C.
mentioned she got 7-8 hours of rest/relaxation. The interviewers also asked client
J.R.C. what she feels after waking, if she feels any headache, drowsiness, or if she
feels refreshed which client J.R.C. answered that she feels energized; refreshed.
Client J.R.C. doesn’t drink any medication for sleeping, even milk. She doesn’t
nap during the day, and lastly, she stated that she is getting enough rest.

12
 VI. Cognitive and Perceptual Pattern
In this part, the interviewers asked client J.R.C. about her
cognitive-perceptual pattern. Client J.R.C. stated that she doesn’t have any
hearing difficulty and does not wear a hearing aid. About her vision, client J.R.C.
mentioned that she wears glasses to help her see things, she has a grade of
100/125, and it was last checked in October 2022. Next, the client was asked if
she had had changes in her memory lately, she responded that she noticed that she
tends to forget things easily because of her medications and anesthesia. She
mentioned that she thinks about her decisions, but not struggling in making
decisions. Client J.R.C. also stated that she is an audiovisual learner and
sometimes, she has difficulty in learning because of her memory.

VII. Self-Perception and Self-Concept Pattern

Client J.R.C. was asked to describe herself before and after
hospitalization, she answered that she feels better because she doesn’t feel any
illness because of myoma. She feels good most of the time because she doesn’t
feel pain anymore. The interviewers asked if there are any changes in her body
and client J.R.C. responded that she noticed a change in her weight, she noticed
her complexion getting dark. Before, she had an impression that if a person gets
an operation, that person will have difficulty. But after surgery, she feels okay and
much better. Because the pain is no longer there as well as its complication. She
mentioned that she doesn’t lift anything heavy. The interviewers asked if there are
any changes in the way she feels about herself and her body since her illness
started. client J.R.C. responded that she feels irritable all the time, and feels pissed
off about her body because of the pain brought by her illness. But now, she
doesn’t feel that way. She mentioned that noisy neighbors and teens that are
hanging out the side of her house are what make her easily angry. Lastly, client
J.R.C. was asked if she ever feels like she’ll lose hope and not be able to control
things in life. Client J.R.C. stated, no! When she had her illness she wanted to get
better. She thinks about her child and what if her illness gets worse. She
mentioned that she wants to be strong and get operated on. She mentioned that
drinking meds, having rest, family, and eating cake are the things that had helped
her during this kind of situation.

VIII. Role and Relationship Pattern

In this part, the client was asked about her role-relationship pattern. She
stated that she lives with her husband and her youngest child and their family type
is nuclear. The interviewers asked about her role in the family in which she
answered that the two of them provide for the financial needs of their family. The
client mentioned that her family depends on her and her husband and work is

13
what helps them to manage it. She mentioned that during her stay in the hospital,
her husband was the one who performed her responsibilities and helped her. She
stated that her family was cooperative and there is no family problem that she had
difficulty handling. When it comes to handling their problems, client J.R.C. stated
that communication helps them to avoid making the issue big. When asked what
her family feels about her hospitalization, client J.R.C. answered that they are
worried and sad, but supportive or helpful to her during her stay in the hospital,
they bring food and give her emotional support. The interviewers also asked if she
belonged to any social groups, had any close friends, or if she felt lonely. Client
J.R.C. answered that she doesn’t have any social groups now, but before she
became a volunteer in the health center of their Barangay. She stated that she has
a limited circle of friends. Lastly, she feels a part of their neighborhood and she
mentioned that it is peaceful.

IX. Home and Environment

During the interview, Patient J.R.C. was asked about their home and
environment. She responded that their family resides in a two-story house
constructed with a blend of concrete and wood. Although their house is relatively
small, patient J.R.C. expressed that it is a cozy and comfortable place for them.
With regard to their neighborhood, Patient J.R.C. mentioned that there are several
idle individuals or "tambay," but reassured that their area is safe.

X. Sexuality and Reproductive Pattern

Patient J.R.C. was asked about changes or issues in her sexual
relationship, to which she responded that she did not encounter any problems. She
further added that she is content with her sexual relationship with her spouse, she
responded affirmatively and explained that she became more mature and became
more family oriented after entering into a relationship. Patient J.R.C. is sexually
active without the use of contraceptives. Furthermore, the interviewers asked her
about the onset of her menstruation, to which she responded that her menarche
happened at the age of 15, her last menstruation is in May 2022 but experienced
prolonged and painful periods. When asked if she practices family planning,
patient J.R.C. stated that she underwent ligation by choice.

XI. Coping and Stress Tolerance

In this part, we asked patient J.R.C. about her coping mechanisms in
dealing with stress and problems. The interviewers began by asking if there were
any significant changes in her life in the past year or two, to which she responded
that she underwent surgery to remove her uterus. When asked of her stress coping
mechanisms, she answered that calming herself is the first thing she does under

14
 stress, because she believes that if someone is stressed and that person keeps on
thinking about his/her problems, that person will be more stressed. The
interviewers also asked if patient J.R.C. tense a lot of time, which she answered
no. The follow up question included what helps patient J.R.C. when she is under
stress. She said that she does not use any medicines, recreational drugs, and even
alcohol. She also told us her experience when her father died during that time
after her surgery. She yearns for her father’s comfort as she said that she is a
daddy’s girl, and they live with them. When her father died, she was just always
on her own, laying down, not eating and taking showers. She is depressed and she
told the interviewers that calming herself and eating cake has been effective in
coping with her sadness.

XII. Value and Belief Pattern

In this part, the patient was asked about their values and belief patterns.
The patient responded that both family and work are crucial aspects of their life,
and they play a vital role in maintaining overall well-being and quality of her life.
The patient also mentioned that their family provides emotional support, a sense
of belonging, and a source of love and care. Although the patient identifies as a
Roman Catholic, they do not attend church frequently but do pray regularly. The
patient shared that religion holds significant importance to them and provides a
source of comfort, particularly during difficult times.

XIII. Others
During the follow-up questions, patient J.R.C. stated that there are no
longer concerns she has as well as questions.

D. Physical Examination Findings

I. Vital Signs/ Anthropometric Measures
Temperature: 37 C
Heart/ Pulse Rate: 84 beats per minute
Respiratory Rate: 18
Blood Pressure: 100/70 mmHg
Height: 5 feet or 152 cm
Weight: 54 kilograms or 119 lbs
BMI: 23.2, Normal

During physical examination, client J.R.C.’s temperature is 37 degree

celsius. Her pulse rate is 84 beats per minute with a respiratory rate of 18. The
patient’s blood pressure is 100/70 mmHg which is normal. When measured, her
height is 5 feet flat or 152 in centimeters. Weight is 54 kilograms or 119 pounds.
Her body mass index (BMI) was calculated to be 23.2, indicating that she is
within normal range.

15
 II. General Appearance
Client J.R.C.’s body frame is small, and her posture is upright, as per
physical examination. Gait is normal and coordinated. She appears to be
well-groomed and appropriate. She has a pleasant body and breath odor. She
appeared to be well-developed, hydrated, and nourished, with no obvious physical
deformities. The patient also looks healthy with no signs of distress. She does
appear to be her stated age and does have a positive and welcoming attitude.
During the interview, she presented herself with understandable speech and
language; and she explicitly exhibited her thoughts. The client stated that she has
memory lapses after her myoma operation due to anesthesia.

III. Mental Status

Client J.R.C. is awake, alert and oriented to time, place, person and
situation. No sign of distress upon examination. Patient’s emotional status is
pleasant and has a positive attitude; and she is also cooperative during the
physical examination. Recent and remote memory intact. Good insight and
cognitive function is also observed on the patient. All throughout the examination
she is able to converse effectively throughout the assessment.

IV. Skin
Upon examining the client J.R.C.’s skin is warm, dry and intact without
rashes and lesions and any presence of edema. She has a smooth skin and has a
uniform warm fair skin tone with darker skin tone on exposed areas. When the
patient's skin turgor was examined, it quickly returned to normal, indicating that
she is hydrated. Her fingernails and toenails plate shape is concave indicating that
it is normal. Pink nail beds with no cyanosis or clubbing. The tissue surrounding
her nails was translucent, normal and intact. The nail color immediately returned
to its pinkish color after the blanch test. Hair is evenly distributed.

V. Head and Face

The head is normocephalic and atraumatic without tenderness, visible or
palpable masses, depressions, or scarring. The scalp is normal and is without
lesions. Its color is light compared to the exposed areas. Hair is of normal texture,
smooth, shiny and evenly distributed. Client J.R.C.’s sensation intact over face.
No facial asymmetry, muscles of facial expression intact.

VI. Eyes
When the eyes were examined, they were found to be normal. Client
J.R.C.'s brows were exactly the right thickness and are symmetrical to each other.
The lashes on her eyes were thick and long. The skin on the eyelids was intact,
and there was no discharge, swelling, or lesions. The lids close symmetrically as
well. Conjunctivae are pink, sclerae are white, and there is no jaundice. There is
no en- or exophthalmos or lid ptosis. External ocular movements (EOMs) are
intact, and there is no strabismus or nystagmus. Pupils are equal round, do
respond to light, and accommodate (PERRLA). According to the patient, her
visual acuity is 125/100 indicating that she has poor eyesight, in result, she has

16
 corrective lenses to assist her vision. She added that she is near-sighted. Upon
checking her peripheral vision, she can see well from her left and right side.

VII. Ears
The color of ears and the face of patient J.R.C. are the same. Ears are
symmetrical, no indication of tenderness whenever they fold. There is hair in the
ear canal but no discharge. She was unable to respond to ticking as we do the
Watch Tick Test, which is expected as people age. Patient J.R.C. could hear
clearly on both sides of her ears and repeat what I said as we did the whisper test.

VIII. Nose
The patient's nose is symmetrical, with no discharges, and shows no signs
of discomfort or pain when pinched. As we did the patency test she was able to
breathe through both sides of her nose. The nasal septum is located in the midline
and the sinuses are not inflamed.

IX. Mouth
The lips are moist, pinkish, soft, hydrated and have a symmetrical contour.
There are no cracks, lesions, or cyanosis. There are six missing teeth and the
gums are pinkish and have no tenderness. Tongue is on the midline with visible
veins and no lesions and no signs of tenderness or pain. She has no trouble
swallowing. The speech of the patient is good and understandable.

X. Pharynx
Patient J.R.C.’s uvula is on the midline with no deviation, no redness or
any signs of lesions. She also has a light pink and soft palate and there are visible
bony prominences. Tonsils don't have any redness or any signs of inflammation.

XI. Neck
The neck of the patient was smooth, and had no palpable nodules. There is
also no pain as verbalized by the client. There is no tenderness and no palpable
lymph nodes. The trachea is located in the midline which is also normal.

XII. Breast and Axillae

Patient J.R.C. disagreed to do the procedure related to her breast and
axillae but according to her self examination, there are no lumps, soreness, or any
nipple discharge in her both breasts. There are also no palpable masses in her
axillae.

XIII. Chest and Lungs

Patient J.R.C. has an inspiration and expiration ratio of 1:2. Her breath
sounds clear during inspiration and expiration, no adventitious sound and she has
a muffled voice. Her antero-posterior-lateral ratio is normal. There are no lesions,
masses and no pain was felt during the physical examination, crepitus are not
palpable. Her chest expansion is normal with rise and fall of 4cm and is
symmetrical. Fremitus are not palpable and there is no pain that was reported.

17
 When we percussed the patient’s chest, we heard resonant sounds. The position of
her sternum is in midline and the slope of her ribs are downward. Anterior breath
sounds are equal and no abnormal sounds were heard.

XIV. Heart
Patient J.R.C.’s pulsations have no leaps and heat. Her apical impulse is
palpable. She has 84 beats per minute. S1 is loudest in the tricuspid valve and S2
is the loudest in the pulmonic valve. There are no extra sounds, no murmurs, and
no adventitious heart sounds.

XV. Abdomen
Upon inspecting patient J.R.C.’s skin in her abdomen, there are no
discoloration, rashes, and lesions but there are visible stretch marks because of
giving birth and there are also hysterectomy scars. The location of her umbilicus
is in midline and there are no protrusion. She has a protuberant abdomen and is
asymmetrical due to myoma surgery. Upon auscultation of the abdomen, it has
active bowel sounds and in terms of vascular sounds, there are gurgling sounds
and no aortic bruit sounds. When it comes to the percussion of the patient’s
abdomen, in the upper quadrant, there is dullness and in the lower quadrant, it is
tympanic. The span or height of her liver is 10 cm and her spleen is 6 cm. There is
no pain and discomfort when palpated. There are no masses, no swelling of
umbilicus and its surrounding area. The abdominal aorta is slightly tender and has
a regular pulse. The liver is smooth, no tenderness, no pain, and no enlargement
when palpated as well as the spleen, kidneys and urinary bladder.

XVI. Genitalia and Anus

Patient J.R.C. disagreed to do the procedure related to her genitalia and
anus.

XVII. Back and Extremities

Patient J.R.C.’s gait is normal, steady, and maintains balance. Her
peripheral pulses are symmetrical and normal. Joints have no deformities, no
crackling sounds, no discoloration and edema, and have 100% muscle strength
that resists hands. She has a normal curvature from side and behind of her
spine.There is no tenderness and no pain in her spine and can execute with ease
when ROM of the cervical spine is done. Her nail condition is all normal and is
good in color, texture, and strength. Her muscle tones and strengths are all
normal, good and shows no signs of abnormality, difficulty and discomfort. Her
spine is in midline and has no abnormalities.

18