DIVINE WORD COLLEGE OF BANGUED

BANGUED, ABRA
DEPARTMENT OF NURSING
Bachelor of Science in Nursing

In Partial Fulfillment of
the Requirements in NCM 107

A Case Study on
SUBMOCOUSAL MYOMA WITH SEVERE ANEMIA

BSN 2

GROUP 8
BAYLE, DONNA MAE
BAYLE, JOYCE
CARDENAS, LJ SHAIRA
GABAT, ARIES
GO, ALEXI JUILA
INCIONG, LAWIN
PACIOLES. KAFFIANA ZHAIRA
PENSAYO, STEPHANIE KEITH
ROSEL, LANA SHANNEN
WILSON, SHERY-ANN
2022
 TABLE OF CONTENTS

I. Introduction 1
II. History and Assessment
A. Patient’s Profile 8
B. Medical Health history
i. Past Medical History 9
ii. Present Medical History 9
iii. Obstetric History 9
C. Family Genogram 11
D. Physical Assessment 12
III. Anatomy and Physiology 15
IV. Pathophysiology 19
V. Laboratory Tests and Diagnostic Test 21
VI. Drug Study 26
VII. Nursing Care Plan 30
VIII. Updates 33
IX. References 35
X. Photo Documentation 36
 I. INTRODUCTION

Uterine fibroids or uterine myomas, are benign tumors of the uterine smooth
muscle and extracellular matrix and are extremely common in women of reproductive
age. They are noncancerous tumors that grow within or along the walls of the uterus.
They are primarily made up of smooth muscle cells and range dramatically in size. The
cause of uterine fibroids is not known. However, research suggests each tumor develops
from an abnormal muscle cell in the uterus and multiplies rapidly when encountering the
estrogen hormone, which promotes the tumor's growth. Studies also suggest genetics and
prolonged exposure to estrogen may increase the risk of developing fibroids. (Ferri, F.,
2019)

Depending on the location, myomas are classified into three types:

 Intramural uterine fibroids are the most common type of uterine fibroid and
are found within the muscular wall of the uterus.
 Subserosal uterine fibroids are a type of fibroids that is found outside the
uterus.
 Submucosal uterine fibroids are not as common as the other types of uterine
fibroids. This type grows just beneath the surface of the uterus lining and
protrude outward.

Several factors may affect a woman’s risk for having uterine fibroids, including
the following:

 Age (older women are at higher risk than younger women) - Although it can develop
fibroids at any reproductive age, they're most likely when a woman is in her 40s to
mid-50s.
 Ethnic origin - African-American women are more likely to develop fibroids
compared to other ethnicities.
 Obesity - Women who are overweight are at higher risk for fibroids. For very heavy
women, the risk is two to three times greater than average.

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 Family history of uterine fibroids - Having a family member with fibroids increases
a woman’s risk. If a woman's mother had fibroids, her risk of having them is about
three times higher than average.
 No history of pregnancy – Never having given birth to a child or nulliparity is a risk
factor. Increasing parity, on the other hand) is protective against fibroids.
 Eating habits - Eating a lot of red meat (e.g., beef) and ham is linked with a higher
risk of fibroids. Eating plenty of green vegetables seems to protect women from
developing fibroids.

The following are factors that may lower the risk of fibroids:

 Pregnancy (the risk decreases with an increasing number of pregnancies)

 Long-term use of oral or injectable contraceptives

Although they are noncancerous and extremely common, not all fibroids cause
symptoms. Many women who have fibroids don't have any symptoms. In those that do,
symptoms can be influenced by the location, size and number of fibroids.

In women who have symptoms, the most common signs and symptoms of uterine
fibroids include:

 heavy menstrual bleeding or menstrual periods lasting more than a week -

Uterine fibroids may put pressure against the uterine lining, which can cause
more bleeding than usual. The uterus may not contract properly, which means
it can't stop the bleeding. Fibroids may stimulate the growth of blood vessels,
which contributes to heavier or irregular periods and spotting between
periods.
 pelvic pressure or pain - Pressure on the uterine lining may also cause
abdominal or pelvic pain.
 frequent urination - Furthermore, if fibroids begin to grow larger, or if there
are numerous tumors, they may expand the uterus. This can cause the uterus
to compress the bladder, reducing its capacity to hold enough urine. This, of
course, often results in frequent urination.

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  difficulty emptying the bladder - an enlarged uterus can put pressure on the
area where the bladder is connected to the urethra. This can lead to difficulty
fully emptying the bladder.
 Constipation - The uterus lies directly in front of the distal end (last section) of
the colon which controls bowel movements. Fibroids that develop in the back
of the uterus can press on the colon from the outside, which can lead to
significant constipation.
 backache - Rarely, fibroids press against the muscles and nerves of the lower
back and cause back pain.
 Leg pain - This can happen when fibroids become so large that they begin to
press on nerves and blood vessels that extend to the legs, causing immense
pain and discomfort in the legs.

If the woman is experiencing symptoms from her fibroids — including anemia

from the excess bleeding, moderate to severe pain, infertility issues or urinary tract and
bowel problems — treatment is usually needed to help. The treatment plan will depend
on a few factors, including: the amount of fibroids patient has, the size of fibroids, the
location of the fibroids, the symptoms she is experiencing related to the fibroids, the
desire for pregnancy and the desire for uterine preservation.

The decision to perform surgery for uterine leiomyomata is complex and varies
from patient to patient based on their medical comorbidities, surgical history, clinical
scenario and patient preference. In general, consideration for a hysterectomy is performed
in patients with:

 Excessive uterine bleeding.

 Profuse bleeding causing lifestyle derangements that is refractory to
medical management
 Uterine bleeding that results in anemia
 Pelvic discomfort caused by myoma
 Acute and severe
 Chronic lower abdominal pain or low back or pelvic pressure with
evidence of sizeable leiomyoma on imaging studies

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  Leiomyomata that are palpable abdominally

Uterine fibroids are generally harmless and often go away on their own. When
symptoms occur, however, untreated fibroids can interfere with a person’s quality of life
and may lead to complications such as anemia. Anemia is a condition when the body
doesn’t have enough healthy red blood cells to function properly. This can happen when
uterine fibroids cause heavy bleeding.

Some uterine fibroids may also interfere with the probability of becoming
pregnant, and may increase the chance of miscarriage, but more research is needed here.
In these cases, treatment can help people become and stay pregnant.

Rarely, uterine fibroids can become very large, twisted, or infected. These
situations can create symptoms that are intense, and may require immediate medical
treatment.

Myomas affect, with some variability, all ethnic groups and approximately 50%
of all women during their lifetime. While some remain asymptomatic, myomas can cause
significant and sometimes life-threatening uterine bleeding, pain, infertility, and, in
extreme cases, ureteral obstruction and death.

A study conducted in 2016 by Chibber, S. et. Al., suggests that there are
significant ethnic differences in fibroid prevalence and related uterine anatomy even in
asymptomatic women. The research found that when compared to other groups, fibroid
prevalence and size remained the highest among African American women. Rates in East
Asian women and South Asian women were similar to those found in Caucasian women.
Rates and sizes were lowest among Hispanic women, which could indicate later age of
onset and/or a different pathophysiology. Comparisons of uterine anatomy also showed
that African American women had significantly larger ovarian volumes and thicker
endometrium. Collectively, these results warrant an exploration of ethnic-specific
consideration when developing treatment options for patients with fibroids.

In relation to that, a research conducted by (Murji, A. et. Al., 2020) concluded

that Black and East Asian women have an increased clinical manifestation of uterine
fibroids compared to White women and prefer uterine preservation. There is a

4
discrepancy between disease burden and patient-reported outcomes that may reflect
ethnocultural differences in disease experience.

It’s extremely rare for a fibroid to go through changes that transform it into a
cancerous or a malignant tumor. In fact, one out of 350 people with fibroids will develop
malignancy. There’s no test that’s 100% predictive in detecting rare fibroid-related
cancers. However, people who have rapid growth of uterine fibroids, or fibroids that
grow during menopause, should be evaluated immediately.

In 2019, a study was conducted by the Philippine Obstetrical and Gynecological

Society wherein 135 accredited hospitals all over the Philippines submitted their census
on the number of obstetric and gynecologic cases from January 2019 to December 2019.
A total of 365,947 cases were reported, 11% (39,921) were gynecologic cases.

Among the 39,921 gynecologic cases reported, Leiomyoma (24%), Abnormal

Uterine Bleeding-Polyp (AUB-P) (22%), and Abnormal Uterine Bleeding-Malignancy
(AUB-M) (12.87%) were the top gynecologic diagnosis.

There's no single best approach to uterine fibroid treatment — many treatment

options exist. Many women with uterine fibroids experience no signs or symptoms, or
only mildly annoying signs and symptoms that they can live with.

5
 Medications for uterine fibroids target hormones that regulate your menstrual cycle,
treating symptoms such as heavy menstrual bleeding and pelvic pressure. They don't
eliminate fibroids, but may shrink them.

Gonadotropin-releasing hormone (GnRH) agonists. Medications

called GnRH agonists treat fibroids by blocking the production of estrogen and
progesterone, putting you into a temporary menopause-like state. As a result,
menstruation stops, fibroids shrink and anemia often improves.

A doctor may recommend a hysterectomy to treat uterine fibroids, endometriosis,

adenomyosis and other potential causes of pelvic pain or abnormal uterine bleeding.
Hysterectomy may also be used to treat uterine prolapse and gynecologic cancers.

There are three types of hysterectomy, depending on which structures or organs are
removed:

• A Total Hysterectomy - A total hysterectomy is the removal of the entire uterus,

including the cervix (the lower, narrower portion of the uterus).

• A Supracervical Hysterectomy - A supracervical hysterectomy is the removal of

the upper part of the uterus. The cervix is left in place. This type of procedure may be
done if patient wants to keep your cervix or if difficulties arise during surgery that make
removal of the cervix complicated.

• A Radical Hysterectomy - A radical hysterectomy is a total hysterectomy that also

involves removing tissues around the uterus called the parametrium. This procedure is
usually reserved for cases where cancer is present.

The type of hysterectomy performed is often dependent on a woman’s medical

history, pre-existing health conditions and goals. The doctors pair careful analysis and
examination with compassion – so patients can openly discuss their needs, wants and
fears and we can develop a custom surgical plan together.

Total abdominal hysterectomy bilateral salpingo oophorectomy (TAHBSO) is the

removal of entire uterus, the ovaries, fallopian tubes and the cervix. TAHBSO is usually
performed in the case of uterine and cervical cancer. This is the most common kind of

6
hysterectomy. Removal of the ovaries eliminates the main source of the hormone
estrogen, so menopause occurs immediately.

Although the death rate from a hysterectomy is low (less than 1 percent) surgical
complications are very real and can result in any of the following: infection, hemorrhage
during or following surgery and/or damage to internal organs such as the urinary tract or
bowel. Hysterectomy is the most common major gynecological surgical procedure
performed in women, and 33.5% of these are done for myomas.

7
 II. HISTORY AND ASSESSMENT
A. PATIENT’S PROFILE

Name: Aughntee Mayo

Age: 40
Ward: Ob-Gyne Ward
Room: Ob-Gyne Room 2
Bed: Ob-Gyne 2 Bed 3
Sex: Female
Birthdate: October 13, 1982
Birthplace: Ilo-Ilo City. Ilo-Ilo, Philippines
Address: Bucay, Abra, Philippines
Nationality: Filipino
Religion: Roman Catholic
Occupation: Housewife
Case Number: 019105
Hospital Number: 000000000019105
Date Of Admission: November 9, 2022
Time Of Admission: 9:00 am
Date of Discharge: November 18, 2022
Time of Discharge: 11:34:22 am
Chief Complaint: Dizziness, two menstruation cycles in the last two months, consuming
4 to 5 pads a day
Admitting Diagnosis: Anemia, G3p3 (3003), Abnormal Uterine Bleeding.
Final Diagnosis: Submucous Myoma, Severe Anemia
Admitting Physician: Dr. Barbie
Attending Physician: Dr. Barbie

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B. MEDICAL HEALTH HISTORY
i. Past Medical History

Patient stated that she had experienced mumps, measles, common coughs,
colds and flu when she was a kid, and was treated without the supervision of a
physician. Patient also stated that she experienced frequent dizziness during her
childhood, whereas no medical check-ups were conducted about this concern. With
regards to any allergies, she has none when it comes to food and medication.

In her adulthood, she was only hospitalized twice during the delivery of her
second and third child. All of her three children underwent Normal Spontaneous
Delivery.

ii. Present Medical History

On the 8th day of November 2022, she went to their local RHU in Bucay,
Abra for check-ups regarding her issues: the rate of occurrence and strength of
dizziness grew as she experienced heavy bleeding, and for having two periods a
month for two months. She was referred to Abra Provincial Hospital, the same day.
After a routine assessment, her admitting doctor, Dr. Barbie, ordered a Complete
Blood Count (CBC) Test. She underwent an initial diagnosis of uterine bleeding,
severe anemia. Later on, the doctor ordered an ultrasound scan which revealed a
submucous myoma. Which disclosed her final diagnosis as submucous myoma,
severe anemia.

iii. Obstetric History

GTPALM scoring

G– 3, T – 3, P – 0, A – 0, L – 3

 Menstrual History
a. Past Menstrual Cycle

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o Regularity
- Patient stated she had a regular menstruation since her first period
o Duration of the cycle
- Every 17th of the month
o Amount of bleeding
 Number of days
- The patient reported of having three to four days of
menstrual bleeding per 28 days of menstrual cycle.
 Volume
- The patient reported having a normal flow, and consuming
at least 7-8 pads per menstrual period.
o Associated pain.
- The patient reported of not having pain during menstruation.

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C. FAMILY GENOGRAM

11
 D. PHYSICAL ASSESSMENT

POST OP

IV.  ASSESSMENT (November 17, 2022)

A. CEPHALOCAUDAL

1. GENERAL ASSESSMENT
 Conscious and coherent
 Warm to touch 
 Responsive to all questions asked
 Extremely weak appearance

 Endomorphic body build

VITAL SIGNS:

Temperature: 35.1°C

Pulse rate: 59 bpm

Respiratory rate: 27 BPM

Weight: 57kg

2. INTEGUMENTARY SYSTEM
 No excessive sweating
 Pale skin
3. HEAD AND FACE
 Colored brown, evenly distributed
 Normocephalic and proportionate to body size
 No evidence of bulging/masses or injuries
4. EYES
 PERRLA
 Same level with each other

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  No discharges noted
5. EARS
 Symmetrical
 Proportionate with head and face
 No visible lumps and lesions
 No diminished hearing acuity
6. NOSE
 Unimpaired sense of smell
 No discharges noted
 No deformities nor deviations noted
7. MOUTH AND LIPS
 Lips closed symmetrically, no lumps
 (-) Swelling of Gums
 Tongue is centrally positioned, pink and moist
 Uvula is pink, smooth and upwardly movable
 Buccal mucosa is pink, smooth, and moist
 Complete teeth with no loose, missing chipped or broken teeth.
8. NECK
 (-) Jugular distention
 Normal ROM
9. CHEST
 Respiratory rate: 27 cpm, not too deep nor shallow
 Normal breath sounds

 (-) Chest retractions

 No swelling

10. ABDOMEN
 No rashes
 (-) Abdominal distention
 Incision site is approximately 7 inches located at the lower abdomen
 No signs of infection on site

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11. GENITO-URINARY
 IFC intact

 UO of 300 cc within the shift

12. UPPER EXTREMITIES

 Presence of IV line regulated at 31-32 gtts/min on the left metacarpal vein
 No edema noted
 limited ROM

13. LOWER EXTREMITIES

 limited ROM
 No edema noted

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 III. ANATOMY OF ORGANS INVOLVED

UTERUS

The corpus is
further divided into
the lower uterine
segment and the
fundus. The cervix is
a narrow cylindrical
passage which
connects at its lower
end with the vagina.
At its upper end, the
cervix widens to form the lower uterine segment (isthmus); the lower uterine segment in
turn widens into the uterine fundus.

The corpus is the body of the uterus which grows during pregnancy to carry a
fetus.

Extending from the top of the uterus on either side are the fallopian tubes
(oviducts); these tubes are continuous with the uterine cavity and allow the passage of an
ova (egg) from the ovaries to the uterus where the egg may implant if fertilized.

The thick wall of the

uterus is formed of three
layers: endometrium,
myometrium, and serosa.
The endometrium (uterine
mucosa) is the innermost
layer that lines the cavity of
the uterus.

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 Throughout the menstrual cycle, the endometrium grows progressively thicker
with a rich blood supply to prepare the uterus for potential implantation of an embryo. In
the absence of implantation, a portion of this layer is shed during menstruation.

The myometrium is the middle and thickest layer of the uterus and is composed of
smooth (involuntary) muscle. The myometrium contracts during menstruation to help
expel the sloughed endometrial lining and during childbirth to propel the fetus out of the
uterus. The outermost layer, or serosa, is a thin fibrous layer contiguous with extrauterine
connective tissue structures such as ligaments that give mechanical support to the uterus
within the pelvic cavity. Non-pregnant uterine size varies with age and number of
pregnancies, but is approximately three and a half inches long and weighs about one sixth
of a pound.

UTERINE FIBROIDS

Uterine leiomyomas, commonly

known as fibroids, are well-
circumscribed, non-cancerous tumors
arising from the myometrium (smooth
muscle layer) of the uterus. In addition
to smooth muscle, leiomyomas are also
composed of extracellular matrix (i.e.,
collagen, proteoglycan, fibronectin).
Other names for these tumors include
fibromyomas, fibromas, myofibromas,
and myomas.

Leiomyomas are the most common solid pelvic tumor in women, causing
symptoms in approximately 25% of reproductive age women. However, with careful
pathologic inspection of the uterus, the overall prevalence of leiomyomas increases to
over 70%, because leiomyomas can be present but not symptomatic in many women. The
average affected uterus has six to seven fibroids.

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 Leiomyomas are usually detected in women in their 30's and 40's and will shrink
after menopause in the absence of post-menopausal estrogen replacement therapy. They
are two to five times more prevalent in black women than white women. Risk for
developing leiomyomas is also higher in women who are heavy for their height and is
lower in women who are smokers and in women who have given birth. Although the high
estrogen levels in oral contraceptive pills have led some clinicians to advise women with
leiomyomas to avoid using them, there is good epidemiologic evidence to suggest that
oral contraceptive use decreases the risk of leiomyomas.

Leiomyomas are classified by their location in the uterus. Subserosal leiomyomas

are located just under the uterine serosa and may be pedunculated (attached to the
corpus by a narrow stalk) or sessile (broad-based). Intramural leiomyomas are found
predominantly within the thick myometrium but may distort the uterine cavity or cause
an irregular external uterine contour. Submucous leiomyomas are located just under the
uterine mucosa (endometrium) and, like subserosal leiomyomas, may be either
pedunculated or sessile. Tumors in subserosal and intramural locations comprise the
majority (95%) of all leiomyomas; submucous leiomyomas make up the remaining 5%.

Although this classification scheme is widely used by clinicians, it suffers from

the limitation that few leiomyomas are actually a single "pure" type. Most leiomyomas
span more than one anatomic location and, therefore, are hybrids (e.g., a predominantly
intramural leiomyoma with a submucous component). Other types of leiomyomas include
"parasitic" myomas, which receive their blood supply from structures other than the
uterus (e.g., the omentum), and seedling myomas, which have a diameter of less than or
equal to four millimeters.

Transformation of uterine leiomyomas (benign) to

uterine leiomyosarcomas (malignant smooth muscle tumors of the uterus) is extremely
rare, and, in fact, many researchers and clinicians believe this type of transformation
never occurs. However, without pathologic examination of the uterus, this determination
is not possible. Uterine leiomyosarcomas are found in approximately 0.1% of women
with leiomyomas and are reported to be more frequently associated with large or rapidly

17
growing fibroids. Therefore, surgical intervention may be undertaken in women with
these types of tumors to rule out leiomyosarcoma, a rare but medically important lesion.

18
 IV. PATHOPHYSIOLOGY

Predisposing factor: Precipitating factor:

Age (40) Eating habits
Obesity
↑Adipose tissue
↑Estrogen Production
Estrogen stimulates Conversion of androgens
proliferation of uterine into estrogen
smooth muscles

Benign proliferation of
monoclonal myometrial cells
into discrete masses

SUBMUCOUS MYOMA

↑Endometrial Surface ↑ Stimulation ↑ Pressure on

Area: 10.03 cm growth of Blood Endometrium
Vessels

Frequent Urination
Uterine Bleeding

Constipation
Severe Anemia

Difficulty emptying
Low PLT: 415 x MCHC: bladder
Hemoglobin: 10^3/uL 28.8 g/dL
6.7 g/dl
Pelvic pressure or
Low RBC: pain
3.24 μ

↑Chance of
miscarriage

↓Fertility

LEGEND
DIAGNOSIS CLINICAL MANIFESTATION LAB/DIAGNOSTIC TEST COMPLICATIONS
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 For women at the reproductive age, there is increased estrogen production.
Estrogen stimulates proliferation of uterine smooth muscles. Factors like abnormal
weight (overweight), increased adipose tissue, and the conversion of androgens into
estrogen can cause benign proliferation of monoclonal myometrial cells into discrete
masses called myomas.

Submucosal myomas put pressure on the uterine lining causing an increase in the
endometrial surface area which can cause abnormal bleeding.

Fibroids can also stimulate the growth of blood vessels which contribute to heavy
menstrual bleeding and spotting between periods. Anemia can be caused by uterine
bleeding and is one of the complications of untreated fibroids.

Fibroids putting pressure on the uterine lining can also affect surrounding organs
like the bladder and the colon which lead to frequent urination, difficulty voiding the
bladder and constipation.

Myomas can also press against nerves and blood vessels of the lower back which
can cause back pain and leg pain.

When left untreated, complications like infertility, higher chances of miscarriages,

anemia can occur.

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 V. LABORATORY TESTS AND DIAGNOSTIC TEST

I. ACTUAL AND DIAGNOSTIC EXAMS

HEMATOLOGY

Date: 11-9-22

Parameter Result Ref. Range

WBC 4.3 x 10^3/uL 4.0 - 10.0
Lymph # 1.3 x 10^3/uL 0.8 - 4.0
Mid # 0.5 x 10^3/uL 0.1 - 1.5
Gran # 2.7 x 10^3/uL 2.0 - 7.0
Lymph % 28.7 % 20.0 - 40.0
Mid % 11.8 % 3.0 - 15.0
Gran % 37.5 % 50.0 - 70.0
HGB L 5.3 g/dl 11.0 - 15.0
RBC 3.33 μ 10^6/uL 3.50 - 5.00
HCT L 19.6 % 37.0 - 47.0
MCV L 58.9 fL 80.0 - 100.0
MCH L 15.9 pg 27.0 - 34.0
MCHC L 27.0 g/dL 32.0 - 36.0
RDW - CV H 22.0 % 11.0 - 16.0
RDW - SD 44.6 fL 35.0 - 56.0
PLT H 458 x 10^3/uL 100 - 300
MPV 9.3 fL 6.5 - 12.0
PDW 16.5 9.0 - 17.0
PCT 0. 276 % 0.108 - 0.282
SIGNIFICANCE

 Low level of HGB indicates excessive blood loss due to uterine bleeding that
causes anemia
 Low levels of RBC indicate excessive blood loss due to uterine bleeding that
causes anemia
 Low levels of HCT indicates low level of RBC due to excessive blood loss due to
uterine bleeding that causes anemia
 Low levels of MCH indicates smaller RBC size, and low levels of HGB due to
uterine bleeding that causes anemia
 low levels of MCHC indicates smaller RBC size, and low levels og HGB due to
uterine bleeding that causes anemia
 Low levels of MCV indicates a smaller size of RBC due to low HGB due to
excessive blood loss due to uterine bleeding that causes anemia
 High levels of RDW-CV indicate: most of the RBC are different in size.
 High PLT indicates presence of uterine bleeding that causes anemia

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HEMATOLOGY

Date: 11-10-22

Parameter Result Ref. Range

WBC 4.3 x 10^3/uL 4.0 - 10.0
Lymph # 1.3 x 10^3/uL 0.8 - 4.0
Mid # 0.5 x 10^3/uL 0.1 - 1.5
Gran # 2.5 x 10^3/uL 2.0 - 7.0
Lymph % 29.3 % 20.0 - 40.0
Mid % 12.0 % 3.0 - 15.0
Gran % 58.7 % 50.0 - 70.0
HGB L 6.7 g/dl 11.0 - 15.0
RBC 3.72 μ 10^6/uL 3.50 - 5.00
HCT L 23.2 % 37.0 - 47.0
MCV L 62.6 fL 80.0 - 100.0
MCH L 18.0 og 27.0 - 34.0
MCHC L 28.8 g/dL 32.0 - 56.0
RDW - CV H 24.7 % 11.0 - 16.0
RDW - SD 48.8 fL 35.0 - 56.0
PLT H 415 x 10^3/uL 100 - 300
MPV 9.4 fL 6.5 - 12.0
PDW 16.3 9.0 - 17.0
PCT 0. 268 % 0.108 - 0.282

SIGNIFICANCE

 Low level of HGB indicates excessive blood loss due to uterine bleeding that
causes anemia
 Low levels of RBC indicate excessive blood loss due to uterine bleeding that
causes anemia
 Low levels of HCT indicates low level of RBC due to excessive blood loss due to
uterine bleeding that causes anemia
 Low levels of MCH indicates smaller RBC size, and low levels of HGB due to
uterine bleeding that causes anemia
 low levels of MCHC indicates smaller RBC size, and low levels og HGB due to
uterine bleeding that causes anemia
 Low levels of MCV indicates a smaller size of RBC due to low HGB due to
excessive blood loss due to uterine bleeding that causes anemia
 High levels of RDW-CV indicate: most of the RBC are different in size.
 High PLT indicates presence of uterine bleeding that causes anemia

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HEMATOLOGY

Post-BT CBC

Date: 11-15-22

Parameter Result Ref. Range

WBC 5.7 x 10^3/uL 4.0 - 10.0
Lymph # 5.6 x 10^3/uL 0.8 - 4.0
Mid # 0.7 x 10^3/uL 0.1 - 1.5
Gran # 3.4 x 10^3/uL 2.0 - 7.0
Lymph % 27.4 % 20.0 - 40.0
Mid % 13.2 % 3.0 - 15.0
Gran % 59.4 % 50.0 - 70.0
HGB L 10.4 g/dl 11.0 - 15.0
RBC 4.7 μ 10^6/uL 3.50 - 5.00
HCT L 34.0 % 37.0 - 47.0
MCV L 72.2 fL 80.0 - 100.0
MCH L 22.2 pg 27.0 - 34.0
MCHC L 30.5 g/dL 32.0 - 56.0
RDW - CV H 29.1 % 11.0 - 16.0
RDW - SD H 66.4 fL 35.0 - 56.0
PLT H 338 x 10^3/uL 100 - 300
MPV 8.3 fL 6.5 - 12.0
PDW 15.3 9.0 - 17.0
PCT 0.270 % 0.108 - 0.282

SIGNIFICANCE

 Low level of HGB indicates excessive blood loss due to uterine bleeding that
causes anemia
 Low levels of RBC indicate excessive blood loss due to uterine bleeding that
causes anemia
 Low levels of HCT indicates low level of RBC due to excessive blood loss due to
uterine bleeding that causes anemia
 Low levels of MCH indicates smaller RBC size, and low levels of HGB due to
uterine bleeding that causes anemia
 low levels of MCHC indicates smaller RBC size, and low levels og HGB due to
uterine bleeding that causes anemia
 Low levels of MCV indicates a smaller size of RBC due to low HGB due to
excessive blood loss due to uterine bleeding that causes anemia
 High levels of RDW-CV indicate: most of the RBC are different in size.
 High levels of RDW-SD indicate: most of the RBC are different in shape.
 High PLT indicates presence of uterine bleeding that causes anemia

23
 BLOOD CHEMISTRY

Date: 11-10-22

Test Full name Concentration Unit Result Remark Reference

Cholesterol Cholesterol 136.6 Mg/dL Normal <=200.0
Trygylceride Trygylceride 43.8 Mg/dL Normal <=150.0
Glucose Glucose 93.10 Mg/dL Normal 71.00-
Hexokinase Hexokinase 99.00
HDL HDL 63.5 Mg/dL RFH 40.0-60.0
Creatinine Creatinine 0.7 Mg/dL Normal 0.6-1.1
Sox Sox
Blood Urea Blood Urea 15.0 Mg/dL Normal 6.0-24.0
Nitrogen Nitrogen
Blood Uric Blood Uric 3.4 Mg/dL Normal 2.7-7.3
Acid Acid
ALT/SGPT ALT/SGPT 10.7 U/L Normal <=34.0
AST/SGOT AST/SGOT 28.7 U/L Normal <=31.0
LDL LDL 53.19 Mg/dL Normal <=135.00

SIGNIFICANCE

 The high level of HDL indicates the large volume of uterine fibroids

24
 ULTRASOUND REPORT
GYNECOLOGY
Date: 11-10-22

Requesting Physician: Dr. Barbie

UTERU 9.30 x 8.0 x 7.16 ANTEVERTED RETROVERTED

S

ABNORMALITIES NOTED:
A. MYOMA Nodular hyperechoic mass 5.78 x 4.92 cc
suggestive of Intramural with submucous
component
B. ADENOMYSIS
C. OTHERS

Endometrium A. Thin Thick 1.03 cm hypo Iso Hyper-echoic triple

line

ADNEXIA X x cm
Right Ovary
LOCATED Lateral Postero-Lateral Posterior Dominant
to Uterus Follicle cm

ADNEXIA X x cm
Left Ovary
LOCATED Lateral Postero-Lateral Posterior to Dominant
Uterus Follicle cm

Abnormalities Noted:

CERVIX x x cm Nabothian Cyst Present None

IMPRESSION: Enlarged anteverted uterus with thickened endometrium

Intramural posterior myoma with submucous component.
Normal both ovaries

25
 VI. DRUG STUDY DRUG STUDY
Mechanism of
Generic Name Indication Nursing Implications Rationale
Action
Tramadol Tramadol modulates Tramadol is used to 1. Check the medication ordered.  To ensure that the
the descending pain relieve moderate to medication was
pathways within the moderately severe 2. Read the medication ordered.
Brand Name information.
central nervous pain. Tramadol  To have adequate knowledge
Ultracet
system through the extended-release about the drug.
binding of parent and tablets and capsules 3. Assess for hypersensitivity
Classification M1 metabolite to μ- are only used by to the drug.  To decrease the incidence
Opiate opioid receptors and people who are 4. Check the dose, time, and of untoward reactions.
(narcotic)analgesic the weak inhibition of expected to need route.  To ensure the desired
the reuptake of medication to relieve dose, frequency, and right
norepinephrine and pain around-the-clock. 5. Perform hand hygiene. route.
serotonin.
D.R.F.F.T  To prevent
6. Prepare medications for one contamination/spread of
Dosage:100mg patient at a time. microorganisms.
Route: IV  To prevents errors in
Frequency: q8 7. Identify the patient. medication administration.
Form: Vial  To ensures the right patient
Timing: 9:00 am, 5:00 pm, 1:00 am 8. Perform necessary receives the medications and
Precautions Contraindications assessment prior to helps prevent errors.
Use cautiously with the following Contraindicated with the medication administration.  To establish specific
conditions: following conditions: 9. Explain the purpose and parameters prior to
This medicine may cause adrenal Tramadol is contraindicated action of medication to the administration.
gland problems. Check with your in patients who have had a patient.  To reduce anxiety, to gain
doctor right away if you have hypersensitivity reaction to any compliance, and to know
darkening of the skin, diarrhea, opioid.  10. Assist the patient to an what to expect.
dizziness, fainting, loss of appetite, upright position. (Note:  To protects the patient
mental depression, nausea, skin depending on the route of from aspiration
rash, unusual tiredness or administration).
11. Store the medicine at room  To preserve the medicine.
weakness, or vomiting.
temperature away from
moisture and heat.
12. Document the administration  Timely documentation helps
of the medication immediately to ensure patient safety.
after administration.
Side Effects Adverse Reactions

26
.  shallow (Note: depending on the route of
 Headaches breathing, administration).
 Feeling sleepy  difficulty or
 Feeling or being sick noisy breathing,
 Dry mouth  confusion,
 Sweating  more than usual
 Low energy sleepiness

DRUG STUDY
Generic Name Mechanism of Indication Nursing Implications Rationale
Action
Tranexamic Acid The binding of Decrease heavy 1. Check the medication ordered.  To ensure that the
plasminogen to fibrin menstrual bleeding and medication was ordered.
induces fibrinolysis - by cause necrosis of the 2. Read the medication  To have adequate knowledge
Brand Name occupying the necessary fibroids. information. about the drug.
Cyklokapron binding sites tranexamic
acid prevents this 3. Assess for hypersensitivity to  To decrease the incidence of
dissolution of fibrin,
Classification the drug. untoward reactions.
thereby stabilizing the clot  To ensure the desired dose,
Antifibrinolytics 4. Check the dose, time, and
and preventing frequency, and right route.
hemorrhage. route.
D.R.F.F.T 5. Perform hand hygiene.
 To prevent
Dosage:1gram contamination/spread of
microorganisms.
Route: IV 6. Prepare medications for one
 To prevents errors in
Frequency: q 8 patient at a time. medication administration.
Form: Ampule  To ensures the right patient
7. Identify the patient.
Timing: 7am, 3pm, 11pm receives the medications and
Precautions Contraindications 
helps prevent errors.
Before taking tranexamic acid, tell Tranexamic acid can cause 8. Perform necessary assessment To establish specific
your doctor or pharmacist if you are fibroid necrosis and prior to medication parameters prior to
allergic to it; or if you have any infarction, resulting in pain administration.
administration. 
other allergies. This product nay and providing a site for To reduce anxiety, to gain
9. Explain the purpose and action
contain inactive ingredients, which infection. Tranexamic acid compliance, and to know
of medication to the patient. what to expect.
can cause allergic reactions or other has been associated with 
problems. deep vein thrombosis and 10.Assist the patient to an upright
To protects the patient from
is therefore contraindicated aspiration
position. (Note: depending on
in women who have or are
the route of administration).
at risk of developing 
thromboembolic disease. 11.Administer the medications: To facilitate swallowing of
a. Offer water. solid drugs.

To encourage the patient’s
b. Ask the patient preference participation in taking the
Side Effects Adverse Reactions
 medications.

27
 diarrhea  seizures, in taking the medications
by hand or in a cup.
 dizziness  pulmonary embolism,
c. Remain with the patient
 nausea and vomiting,  deep vein thrombosis, until each medication is
 muscle pain.  anaphylaxis, swallowed.
 headaches, 12.Store the medicine at room
temperature away from
 backache,
moisture and heat.
 abdominal pain, 13.Document the administration
 nausea, of the medication
immediately
 vomiting,
after administration.
 diarrhea, (Note: depending on the route of
 fatigue, administration).

DRUG STUDY
Mechanism of
Generic Name Indication Nursing Implications Rationale
Action
Cefuroxime Binds to bacterial cell Serious lower 13. Check the medication ordered.  To ensure that the
membranes inhibits cell respiratory tract medication was
wall Synthesis. infection, UTI, skin 14. Read the medication ordered.
Brand Name information.
Therapeutic Effect: structure infection,  To have adequate kno
Ceftin
Bactericidal septicemia, meningitis about the drug.
and gonorrhea. 15. Assess for hypersensitivity
Classification to the drug.  To decrease the incid
Antibiotics 16. Check the dose, time, and of untoward reactions
route.  To ensure the desired
dose, frequency, and
D.R.F.F.T 17. Perform hand hygiene. route.
Dosage: 750 mg
Route: IV  To prevent
18. Prepare medications for one contamination/spread
Frequency: q 8 patient at a time. microorganisms.
Form: Vial  To prevents errors in
19. Identify the patient. medication administra
Timing: 9:00 am, 5:00 pm, 1:00 am
Precautions Contraindications  To ensures the right p
Use cautiously with the following Contraindicated with the 20. Perform necessary receives the medicatio
conditions: following conditions: assessment prior to helps prevent errors.
 Cefuroxime may cause  Patient with medication administration.  To establish specific
diarrhea, and some cephalosporin 21. Explain the purpose and parameters prior to
cases it can be severe. hypersensitivit action of medication to the administration.
 Do not take any y or patient.  To reduce anxiety, to
medicine or give cephamycin compliance, and to kn
medicine to your child hypersensitivit 22. Assist the patient to an what to expect.
to treat diarrhea y. upright position. (Note:  To protects the patien
without first checking depending on the route of from aspiration
with your doctor. administration).
23. Store the medicine at room  To preserve the medic
temperature away from
moisture and heat.
Side Effects Adverse Reactions 24. Document the administration  Timely documentatio

28
 Nausea CV: Phlebitis, of the medication immediately to ensure patient safet
 Vomiting thrombophlebitis after administration.
 Diarrhea GI: pseudomembraniouscolitis, (Note: depending on the route of
 Strange taste in the mouth amorexia ematologic, hemolytic administration).
 Stomach pain may occur anemia, thrombocytopenia,
transient neutropenia,

29
 DRUG STUDY
Mechanism of
Generic Name Indication Nursing Implications Rationale
Action
Ketorolac Anti-inflammatory Short-term 1. Check the medication ordered.  To ensure that the
and analgesic management of medication was
2. Read the medication ordered.
Brand Name activity; inhibits moderating severe information.  To have adequate kno
Toradol prostaglandins and acute pain for about the drug.
leukotriene single dose 3. Assess for hypersensitivity
Classification synthesis treatment to the drug.  To decrease the incid
4. Check the dose, time, and of untoward reactions
Anti-pyretic route.  To ensure the desired
NSAID dose, frequency, and
D.R.F.F.T 5. Perform hand hygiene. route.
Dosage: 30 mg (3 dose)
 To prevent
Route: IV 6. Prepare medications for one contamination/spread
Frequency: q6 patient at a time. microorganisms.
Form: Ampule  To prevents errors in
7. Identify the patient. medication administra
Timing: 9 am, 3 am
Precautions Contraindications  To ensures the right p
Use cautiously with the following Contraindicated with the 8. Perform necessary receives the medicatio
conditions: following conditions: assessment prior to helps prevent errors.
Be aware that patient may Contraindicated medication administration.  To establish specific
9. Explain the purpose and parameters prior to
be at risk for CV events, GI with significant action of medication to the administration.
bleeding, renal toxicity, renal impairment, patient.  To reduce anxiety, to
monitor accordingly. aspirin allergy, compliance, and to kn
recent GI bleed or 10. Assist the patient to an what to expect.
upright position. (Note:  To protects the patien
perforation Use from aspiration
depending on the route of
cautiously with administration).
impaired hearing; 11. Store the medicine at room  To preserve the medic
allergies; hepatic temperature away from
conditions. moisture and heat.
12. Document the administration  Timely documentatio
Side Effects Adverse Reactions of the medication immediately to ensure patient safet
 Headache  CV: edema after administration.
 Dizziness (Note: depending on the route of
 EENT: tinnitus administration).
 Diarrhea  GI: dyspepsia, GI
 Sweating pain, peptic
 Somnolence ulceration,
 Constipation stomatitis, GI
hemorrhage
 GU: renal
impairment
 Other: pain at
injection site

30
 NURSING CARE PLAN
Assessment
Subjective Data:

“Agsasakit bagbagik, ta gamin kalkalpas ti opera’k”, as verbalized by the patient.

Objective Data:
-VS taken as follows: - Grimacing
Temperaure – 35.1 °C - Pain Scale: 8/10
BP – 150/80 mmHg - Guarding behavior
PR – 59 bpm
RR – 27 BPM
SpO2 – 98 %
Nursing Diagnosis

Acute pain related to postoperative surgical incisions as evidenced by subjective and objective cues

Planning

After 4 hours of nursing intervention, patient will be able report pain is relieved/controlled.

Nursing Interventions Rationale

 Assessed level of pain and monitored VS  Serves as baseline data
 Obtained client assessment to pain  To rate out worsening of underlying
including location, characteristics, condition/development of complications.
onset/duration, intensity, precipitating,
and aggravating factors.
 Evaluated client’s response to analgesic  Increasing or decreasing dosage, stepped program
and assisted in transitioning or altering helps in self-management of pain.
drug regimen, based on individual needs
and protocols.
 Acknowledged the pain experience and
 Reduces defensive responses, promotes trust, and
convey acceptance of client’s response to
enhances cooperative with regimen.
pain.
 Encouraged adequate rest periods.
 To prevent fatigue that can impair ability to manage
or cope with pain.
 Discussed with SO(s) ways in which they
 Family members/SOs was provided assistance by
can assist client with pain management.
transporting client to prevent walking long
distances, or by taking on client’s strenuous chores,
supporting timely pain control, encouraging eating
nutritious meals to enhance wellness, and providing
gentle massage to reduce muscle tension.
 To maintain acceptable level of pain.
 Administered analgesics, such as
Ketorolac and Cefuroxime as indicated.

Evaluation

After 4 hours of rendering nursing intervention, patient reported decreased pain.

VII. NURSING CARE PLAN

31
 NURSING CARE PLAN
Assessment
Subjective Data:
“Hanpy unay naimbagan sugat ko”, as verbalized by the patient

Objective Data:
 VS at home. - with surgical incision at the lower abdominal area
T- 36.4 C - with dry intact dressing at the surgical site
BP- 100/70 mmHg
PR- 55 bpm
RR- 18 BPM
SpO2- 97%

Nursing Diagnosis

Impaired Skin Integrity related to surgical procedure

Planning

Within 2 hours of nursing intervention, the patient will be able to manifest dry and intact wound dressing.

Nursing Interventions Rationale

 Assessed operative site for redness,  To check integrity monitor progress of healing
swelling, lose sutures, or soaked dressing
 Monitored VS  Serves as baseline data
 Encouraged patient to verbalize her any  To allow continuous monitoring and assessment of
untoward feelings especially pain, patient condition
discomfort as well as changes noted in
operative site
 Encouraged patient to engage ambulation  To promote circulation to the surgical site for
and have her SO assist her in such activities timely healing
 Instructed patient and SO to refrain from
touching/scratching operative site  To avoid accumulation of moisture at the operative
 Provided regular dressing care site this may lead to skin breakdown
 To prevent harbor in operative site

Evaluation

After 2 hours of nursing intervention, the patient has able to manifest dry and intact wound dressing.

32
 NURSING CARE PLAN
Assessment
Anxiety with regards to the duration of healing of incision.
Objective Data:
-VS at home. - Grimacing
Temperaure – 36.4 °C - (+) surgical incision intact dressing
BP – 100/70 mmHg
PR – 55 bpm
RR – 18 BPM
SpO2 – 97 %

Nursing Diagnosis
Risk for infection related to post-operative surgical incision.
Planning
After 1 hour of nursing interventions, patient will have knowledge in identifying the risk factors
of infection, and be free from any signs and symptoms of related to infection.
Nursing Interventions Rationale
 Assessed for presence of host-specific factors
that affect immunity:
1. Extremes of age  Elderly and newborn are more susceptible to disease and
infection than the general population
2. Presence of underlying disease  The client may have a disease that directly impacts the
immune system or may be weakened by prolonged
diseases conditions
3. Lifestyle  Personal habits or living situations such as persons
sharing close quarters and/or equipment
4. Nutritional status  Malnutrition weakens the immune system; elevated
serum glucose levels provide growth media for
pathogens
5. Trauma  Loss of skin and tissue integrity, invasive diagnostic
procedure or surgery, premature rupture of amniotic
membrane, urinary catheterizations, sharps, and
needlesticks are common paths of pathogen entry
 That could be signs of developing localized infection
 Changes in skin color and warmth at insertion
 That could be signs of developing systemic infection
sites of invasive lines, sutures, surgical incisions,
and wounds  To help the patient identify the present risk factors that
may add up to the infections.
 Changes in mental status, skin warmth and color,
heart, and respiratory rate  To help the client modify/changed avoid some of the
environmental factors present which could reduce the
 Note risk factors for occurrence of infection in
incidence of infection.
incision.
 Antibiotics will help kill and stop the proliferation and
 Shared health teachings especially in
growth of the bacteria which could cause infection.
identification of environmental risk factors that
could add up on infection.
 Taking antibiotics such as Cloxacillin, as ordered
by the physician.
Evaluation
After 1 hours of nursing intervention, patient was able to gain knowledge and was able to identify the risk factor of
infection, and freed from any signs and symptoms of related to infection.

33
 I. UPDATES

The NIHR-funded femme trial led by a collaborative group of researchers at the

university of oxford, St George’s hospital London, and the universities of Birmingham
and Glasgow, compared two competing treatments which allow fertility for symptomatic
uterine fibroids, to see which option best reduced symptoms and improved the patient’s
quality of life.

The results from the trial, which was published in the new England journal of
medicine, showed that myomectomy, a surgical procedure performed to remove uterine
fibroids, resulted in a small but significantly higher quality of life compared with uterine
artery embolization (UAE). UAE is a minimally invasive procedure which shrinks the
fibroids by placing tiny beads into the blood vessels which supply them.

Fibroids may also be associated with infertility and problems during pregnancy,
including miscarriage and preterm birth. As more women are having children at a later
age, fibroids are becoming more of an issue for them and safe and effective fertility
sparing treatments are needed.

Two hundred and fifty-four eligible women, wishing to reduce fibroid symptoms
were recruited from over 29 UK hospitals to participate in the trial. Researchers
compared the two fertility preserving treatments for uterine fibroids on two patient
groups. The first patient group consisted of women with an intention to conceive whilst
the second group was made up of black women (who have a particularly high incidence
of uterine fibroids).

The women were randomized to receive either a myomectomy or UAE procedure.

The trial revealed that contrary to popular belief, rates of conception were shown to be
broadly similar between the myomectomy and UAE group. Although too few trial
participants were trying to get pregnant to be able to determine with certainty whether
there was an impact of either treatment on pregnancy rates, which was higher in the UAE
group.

Klim McPherson, visiting professor of public health epidemiology at oxford

university and study chief investigator, said: “These findings are important and reveal

34
new evidence for our understanding of the best treatment for women with fibroids who
wish to avoid a hysterectomy.

“It is worth noting that the myomectomy group reported only marginally higher
quality of life score than the uterine artery embolization group, although on average
women in both groups saw improvements. Interestingly, the perceived drawback
associated with embolization, that it might affect the working of the ovaries, was not
supported by the evidence in this trial.”

Professor Andy Shennan, professor of obstetrics, and clinical director NIHR

clinical research network south London, said, “this work is a major contribution to
knowledge on the management of the most common tumor in women of reproductive
age. The researchers found a significant but small advantage for myomectomy in terms of
quality of life, while observing slightly more pregnancies in the uae arm, which provides
wider treatment choices for women with symptomatic fibroids.”

II.

35
IX. REFERENCES:

Stewart EA, et al. (2019). Uterine leiomyomas (fibroids): Epidemiology, clinical

features, diagnosis and natural history.
https://www.uptodate.com/contents/search.
Stewart, E. A. (2015). Uterine fibroids. New England Journal of Medicine.
https://www.nejm.org/doi/full/10.1056/NEJMcp1411029?page=&sort=oldest
Cleveland Clinic. Uterine fibroids. https://my.clevelandclinic.org/health/diseases/9130-
uterine-fibroids
Dr. Nithin Jayan. (2018, July 06). Causes of Uterine Fibroids | Fibroids in Uterus.
Medindia. https://www.medindia.net/patients/patientinfo/fibroids-in-uterus-
causes.htm.
Weiss, K. (2020). The Link Between Uterine Fibroids and Heavy Menstrual Bleeding.
https://www.everydayhealth.com/womens-health/uterine-fibroids-heavy-
menstrual-bleeding/
USA Fibroid Centers. Fibroids Frequent Urination in Women.
https://www.usafibroidcenters.com/uterine-fibroid-symptoms/frequent-urination/
#:~:text=If%20fibroids%20begin%20to%20grow,often%20results%20in
%20frequent%20urination.
Lipman, J. (Sept. 2020). Ask Dr. John Lipman: “Can Fibroids Cause Constipation?”
Atlanta Fibroid Center. https://atlii.com/can-fibroids-cause-constipation/
Macauayon, A. et. Al. (2020). POGS 2019 Report of Obstetrical and Gynecological
Indicators of Healthcare. Philippine Obstetrical and Gynecological History.
http://pjog.org/article-detail.php?id=227
NIHR (2020, July 30) “New research reveals important discovery for women who have
fibroids”. https://www.nihr.ac.uk/news/new-research-reveals-important-
discovery-for- women-who have-fibroids/25163

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X. PHOTO DOCUMENTATION

37