nurs 6551 application
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Week 9 Assignment
Bethel U. Godwins
Walden University
NURS 6551, Section 8, Primary Care of Women
July 31, 2016
Abnormal Uterine Bleeding
Society for Reproductive Endocrinology and Infertility (SREI, 2012) described abnormal uterine bleeding as bleeding that differs in quality and quantity from normal menstrual bleeding, such as women spotting or bleeding between the women’s menstrual periods; bleeding after sex; bleeding heavier or last more days than normal; and bleeding post menopause. According to SREI (2012), factors that can cause abnormal bleeding include structural abnormalities of the reproductive system, such as uterine polyps, fibroids, and adenomyosis. Furthermore, SREI (2012) explained that vaginal, uterine or cervical lesions, miscarriage, ectopic pregnancy, endometritis, adhesions in the endometrium, and use of an intrauterine device (IUD) can also cause abnormal bleeding. Johns Hopkins Medicine (2016) specified that early recognition of abnormal bleeding, and seeing a health care provider immediately for appropriate diagnosis and treatment increase the chance of successful treatment. Therefore, the author will focus on a single patient comprehensive evaluation, which includes the patient’s personal/health history; physical examination; laboratory/diagnostic tests; diagnosis; treatment/management plan; education strategies; and follow-up care .
General Patient Information
Age: 41-year-old
Race/Ethnicity: Hispanic American
Partner Status: Married
Current Health Status
Chief Complaint: “I have heavy, prolonged menstrual bleeding with severe cramping for the past one year”.
History of Present Illness (HPI): RG is a 41-year-old Hispanic American female who presented to the clinic with complaint of heavy prolonged menstrual bleeding with severe cramping for the past one year. Patient reported sharp pelvic pain during menstruation, bleeding between periods, pain with intercourse, blood clots during periods. Abdominal pain/pressure and bloating. Patient suggested that these symptoms started after her second caesarean section surgery one year ago. Patient also reported that she takes over-the counter medication, such as ibuprofen to relieve the pain. she also suggested that she uses heating pad on her abdomen/pelvic for pain relief, and she stated that she soaks in a warm sitz bath to ease pelvic pain and cramping. Patient also reported fatigue and weakness. Patient further stated that she decided to see an obstetrician and gynecologist (OB/GYN) because the heavy prolonged bleeding with severe menstrual cramp interfere with her regular activities. Patient denied nausea, vomiting, diarrhea, fever, and chills.
Timing/Onset: Patient said one year ago.
Location: The location of the problem as stated by the patient is pelvic/uterus/vaginal.
Duration: 5 to7 days during periods for the past one year.
Quality/Characteristic: Patient reported heavy prolonged menstrual pain; severe, sharp lower abdominal/pelvic cramping/pain, and blood clots during periods.
Aggravating Factors: Monthly periods as stated by the patient.
Relieving/Alleviating Factors: Patient stated that ibuprofen pain medication, heating pad, and/or warm sitz bath help the pain/cramping.
Severity: The severity of the pain/cramping on a pain scale is 10/10 reported by the patient.
Treatments/Therapies: Patient stated that she had not undergone any treatment for the reported problems.
Last Menstrual Period: The last menstrual period reported by patient was 7/5/2016.
Sexual Activity Status: Patient reported being sexually active.
Barrier Prevention: Patient stated she uses natural barrier methods.
Sexual Preference: Patient sexual preference is monogamous/heterogeneous relationship.
Satisfaction with Sexual Activity: Patient reported that she is sexually satisfied with her partner.
Contraception Method: Patient denied using any contraception method.
Patient History
Past medical History (PMH): Anemia and C-section. Patient was delivered full term through vaginal delivery without complications. The birth weight was 8 pounds 10 oz.
Psychological/Mental Health: Patient denied depression, mood swings, anxiety, or mental health problem.
Medications: RG reported that she takes over the counter Motrin 200-400 mg orally every 4-6 hours as needed for pain and cramping.
Allergies: Patient reported no known allergies (NKA).
Past Surgical/Hospitalization History: Patient reported history of C-section twice, and she was hospitalized for 3 days post the C-sections.
Preventive Screening: Patient reported that she had flu shot on 11/20/2015; last mammogram was 2/12/2015 and mammogram was normal; Pap smear was on 2/20/2015, which was also normal; patient also reported that she was up to date with her childhood immunization, but denied pneumococcal vaccination.
Family History: Both father and mother have history of diabetes mellitus type 2 and hypertension. Both parents are still living, and two siblings are still living and well.
Gynecological History: Patient is multipara with 2 pregnancy resulting in two viable offsprings. Patient had her first child at the age of 33 years. Menarche at age 13; periods last between 5 to 7 days. Patient reported heavy prolonged menstrual bleeding with severe cramping; sharp pelvic pain during menstruation; and bleeding between periods for the past one year. Denied vaginal discharge or sexually transmitted infection/disease.
Obstetric History: Gravida 2, Para 2, term 2, preterm 0, spontaneous abortion 0, and living 2 (G2T2P2A0L2). Gravida 1: Delivered at 39 weeks by C-section on 4/20/08 male; Gravida 2: Delivered at 40 weeks by C-section on 2/18/15 female. Patient denied therapeutic abortion (TAB) or spontaneous abortion (SAB); Patient denied preterm or low birth weight baby with no delivery complications. Patient also denied having sexual transmitted disease.
Personal/Social History: Patient is married with 2 children, and lives at home with the husband. Patient is a college graduate; works outside the house as a nurse at a nearby hospital. Patient’s husband works for a computer company. Patient family is a middle income family. Also, patient denied any physical or psychological abuse. Patient denied being exposed to any environmental or occupational health hazards. Patient also denied alcohol consumption, tobacco, or recreational drug use. Patient denied participating in any exercise or physical activity because she is tired after work, and prefers to rest. Patient reported that she eats healthy; she eats low fat, low carbohydrate meals, and she eats fruits and vegetable at least 3 to 4 times a week. Patient stated
that she sleeps well at night, and she usually goes to bed at 9 pm and wakes up at 6 am. Patient drinks a cup of coffee occasional, especially when she is at work to be awake.
Review of System (ROS)
General: RG admitted fatigue and weakness; denied fever /chills; and no weight loss.
Head and Neck: Patient denied headache or dizziness. Patient also denied lumps, neck injury, pain/tenderness or jugular vein distention.
Chest: Patient denied chest pain, cough or shortness of breath.
Heart: RG denied irregular heartbeats, heart attack, or heart murmur.
Breasts: Patient denied nipple discharge, tenderness or swelling.
Gastrointestinal: Patient admitted lower abdominal pain, pressure, and bloating; denied constipation, nausea, vomiting, and diarrhea.
Genitourinary: RG denied urinary tract infection, urinary frequency or burning on urination.
Genital: Patient admitted heavy prolonged menstrual bleeding with severe cramping for one year. Patient admitted sharp pelvic pain during menstruation, bleeding between periods, pain with intercourse, and blood clots during periods. Patient denied vaginal discharge.
Musculoskeletal: RG denied varicosities or extremities problem.
Psychiatric: RG denied depression, anxiety, or any psychiatric problems.
Neurological: Patient admitted fatigue and weakness; denied confusion, seizures, or tingling.
Hematologic: Patient admitted history of anemia; denied blood transfusion or easily bruise or bleeding.
Physical Examination
General exam: Patient appeared well developed and pleasant with good hygiene. Patient also appeared pale and weak. Vital signs: Blood pressure 118/76, heart rate 80, respiration 18,
temperature 98.8, pulse ox 100% on room air. Weight 78.2 kg, height 67 inches, and body mass index (BMI) 27.
HEENT: The head is normaceplalic, atraumatic. The pupils are equal, round, and reactive to light and accommodation. Extraocular movements are intact. Tympanic membrane is gray bilaterally. Oral mucosa is dry. Oropharynx is clear. Nares are patient, no nasal or septal deviation noted. No pharyngeal erythema.
Neck: Noted to be supple without jugular vein distention (JVD), thyromegaly or lymphadenopathy.
Lungs: Noted to be clear to auscultation throughout the lobes; no wheezes or rhonchi noted.
Cardiovascular: Regular rate and rhythm on auscultation, S1 S2 present without murmurs. Palpable pulses noted without peripheral edema.
Gastrointestinal: Bowel sounds are active in all quadrant. Abdomen is soft and tender on palpation.
Breast: The size of the breasts, areolas, and nipples are round and symmetrical with no discoloration, rash, lesions, dimpling, or retraction bilaterally; no masses, lumps, or tenderness noted on palpation bilaterally; and axillary lymph nodes non-palpable.
Pelvic Examination:
Vulva: The hair distribution is normal; no lesion noted.
Vagina: Vaginal walls are pink, and pubic hair is shaven; no lesions, masses, inflammation or discharge noted.
Cervix: Intact cervix with closed os.
Uterus: Enlarged, asymmetrical, soft, boggy and tender.
Laboratory and Diagnostic Tests
Laboratory Test and Results: Pregnancy test: Result is negative. Hemoglobin and Hematocrit (H/H): Result showed H/H 8.7/26.7, which is positive for anemia.
Diagnostic:
Transvaginal ultrasonography of the uterus: Revealed uterine enlargement measuring 12 cm with no leiomyomata; uterine wall thickening; cystic anechoic spaces in the myometrium; heterogeneous echo texture; obscured endometrial/myometrial border; sub endometrial echogenic linear striations; and thickening of the transition zone measuring 12.8 millimeter. The transvaginal sonography is used to rule out possible uterine tumor (Sakhel & Abuhamad, 2012).
Magnetic Resonance Imaging (MRI): MRI is ordered to obtain a high resolution image of the uterus as well as verifying/confirming the suspected diagnosis. The MRI result revealed that the junctional zone of the uterus is thickened and measures 12.8 millimeter. Also, MRI revealed an ill-defined ovoid and diffuse region of thickening with striated appearance (Sakhel & Abuhamad, 2012).
Differential Diagnoses
The differential diagnoses of the patient clinical presentation as described by Schuiling and Likis (2013) include: Adenomyosis, uterine fibroids and endometrial hyperplasia. However, the primary diagnosis for the patient is Adenomyosis.
Adenomyosis: Schuiling and Likis (2013) described adenomyosis as a benign, common condition that involves the movement of endometrial tissue into the uterine muscles. The definitive cause of the adenomyosis is unknown, but the condition is common among women with elevated levels of estrogen; the condition usually ceases post menopause when estrogen levels are reduced. Risk factors explained by Taran, Stewart, and Brucker (2013) include multiparity; previous uterine surgery, such as C-section, dilatation/curettage, or fibroids
removal surgery; and women at reproductive age, especially between the age of 40s or 50s. furthermore, Taran et al. (2013) specified that the clinical presentation entails chronic pelvic pain, prolonged menstrual cramps, heavy menstrual bleeding, spotting between periods, abdominal tenderness, painful intercourse, longer periods than normal, blood clots during periods. Taran et al. (2013) also explained that finding during physical examination include enlarged, tender, soft and boggy uterus. According to Taran et al. (2013) diagnosis is made based on sonographic or MRI results, and treatment is not recommended for women with mild form of adenomyosis, except when the symptoms interfere with daily activities. Taran et al. (2013) further explained that treatment options include anti-inflammatory medications; hormonal treatments; endometrial ablation; uterine artery embolization, MRI-guided focused ultrasound surged or hysterectomy, which is the definitive treatment for adenomyosis.
Adenomyosis is selected as the primary diagnosis because the aforementioned patient’s clinical presentation, physical examination findings, and diagnostic tests results are synonymous with adenomyosis aforementioned associated signs and symptoms; risk factors; physical examination findings; and diagnostic test results.
Uterine Fibroids: Women’s Health (WH, 2015) described uterine fibroid to be muscular tumors that develop in the uterine wall, which can also be referred to as leiomyoma or myoma. Uterine fibroids are usually non-cancerous, and can be single or multiple tumors in the uterus. According to WH (2015), women risk for developing uterine fibroid are increased by age, such as women in their 30s and 40s until menopause when the fibroids commonly shrink. Other risk factors include family history, ethnic origin, obesity and eating habits. Symptoms of fibroids as explained by WH (2015) involve lower back pain; pain during sex; heavy bleeding; painful menses, enlarged lower abdominal, frequent urination; and lower abdominal/pelvic feeling of fullness. Physical examination shows reveal painless, firm, irregular pelvic mass. According to WH (2015), diagnosis is done using transvaginal ultrasound, MRI, hysteroslpingography, hysteroscopy, and endometrial biopsy. Fibroid is not selected as the primary diagnosis because there is no visualization of the fibroid during pelvic examination or on sonography test. Moreover, severe pain is noted during pelvic exam. Furthermore, sonographic result is more consistent with adenomyosis rather than fibroids.
Endometrial Hyperplasia: Cancer Research of United Kingdom (CRUK, 2014) described endometrial hyperplasia as thickening of the covering of the uterus due to excessive growth of the cells that covers the uterus, and endometrial hyperplasia can lead to womb cancer. Risk factors according to CRUK (2014) include- age over 35 years; white race; nulliparity; older age at menopause; obesity; cigarette smoking; family history of ovarian, colon, or uterine cancer; early menarche; and history of diabetes, polycystic ovary syndrome, thyroid disease and gallbladder disease. The CRUK (2014), explained that the condition is caused by imbalance of to the estrogen and progesterone. According to CRUK (2014), signs and symptoms of endometrial hyperplasia includes abnormal, prolonged, heavy periods; bleeding between periods; shorter than 21 days’ menstrual cycles; and bleeding after menopause. Also, diagnosis is established by vaginal ultrasound scan, dilatation and curettage, or hysteroscopy.
23rd ed. Philadelphia, PA: Lippincott Williams &.Wilkins; 2014presentation, physical findings during examination; and diagnostic results are not synonymous with the signs and symptoms; physical examination finding, risk factors and diagnostic
results associated with endometrial hyperplasia (American College of Obstetricians and Gynecologist, 2016).
Management Plan
Diagnosis: The only definitive diagnosis of adenomyosis is established after uterus is examined post hysterectomy. However, clinical findings that helped in the diagnosis of the patient includes enlarged, asymmetrical, soft, boggy and tender uterus during pelvic examination and aforementioned sonographic and MRI findings, which synonymous with the diagnosis of adenomyosis (Sakhel & Abuhamad, 2012).
Treatment: Treatment was considered based on the patient clinical presentations, and collaborative agreement with the patient, the author, and the preceptor for total hysterectomy after explanation of the treatment options to the patient. Patient selected hysterectomy because patient does not want to have another child. According to Schuiling and Likis (2013) explanations, patient was advised to continue with the over-the counter anti-inflammatory drug: Motrin 200-400 mg orally every 4-6 hours as needed for pain and cramping until hysterectomy is performed. Also, Ferrous sulfate 325 mg orally three times a day for anemia was prescribed. Patient was educated to take the medication on an empty stomach one hour before meal or 2 hours after meal for optimum absorption.
Patient Education: Patient was educated on the risk factors for adenomyosis, the causes, symptoms, diagnosis, and treatment options. Patient was educated that most women with adenomyosis does not have any symptoms, but adenomyosis is usually found after the tissue obtained from the uterus has been biopsied after pelvic surgery. Patient was also informed that the C-section she had twice during child birth may have put her at risk for adenomyosis. Patient was informed that the symptoms of adenomyosis goes away after menopause or after hysterectomy. Patient was educated that all options of treatment must be tried before hysterectomy, but patient opted for hysterectomy without trying all options of treatment. furthermore, patient was educated to continue the home remedy, such as continuation of the use of the heating pad, warm soak bath, and continuing with the over the counter Motrin to alleviate the pain associate with the condition. Finally, patient was educated on the psychological and emotional effects of adenomyosis and hysterectomy surgery because some women grieve on the loss of their womb, which may put them into depression as a result of that; the patient has to be completely sure that she really wants to do the surgery at her age now or wait and do the surgery in the future (University of Maryland Medical Center, 2016).
Follow Up Care: In consideration of the Schuiling and Likis (2013) discussion, patient was schedule to follow-up in 6 weeks for follow-up on the patient’s anemia and surgical work up labs, such as complete blood count, complete metabolic panel, prothrombin time and international normalized ratio(PT/INR). Also, an electrocardiogram (EKG) and chest x-ray was ordered to rule out any cardiac problem that would complicate the hysterectomy surgery. The patient’s H/H came up to 11.5/38.9 and all the other laboratory and diagnostic result was normal. The Total hysterectomy surgery was performed on 7/27/2016. Surgery was successful, and patient was schedule to follow up in six eek post-surgery.
Conclusion
The author selected a patient at the author’s clinical site, and obtained a complete health history following the patient care from the beginning of the clinical up to 9 weeks of clinical. The author also used the patient health information and clinical presentation to come up with a diagnosis of adenomyosis. The author developed an appropriate treatment plan with the patient in collaboration with the author’s preceptor incorporating the author’s classroom knowledge with the author’s chosen nursing theorist. Finally, the patient was educated on the condition and follow up care.
References
American College of Obstetricians and Gynecologist. (2016). Endometrial
Hyperplasia. Retrieved from http://www.acog.org/Patients/
FAQs/Endometrial-Hyperplasia
Cancer Research of United Kingdom. (2014). Endometrial hyperplasia. Retrieved from http://www.cancerresearchuk.org/about-cancer/cancers-in-general/cancer-questions/endometrial-hyperplasia
John Hopkins Medicine. (2016). Recognizing gynecologic problems. Retrieved from http://www.hopkinsmedicine.org/healthlibrary/
conditions/adult/gynecological_health/recognizing_gynecologic_ problems_85,P00584/
Sakhel, k., & Abuhamad, A. (2012). Sonography of adenomyosis. Journal of Ultrasound in Medicine, 31(12), 805-808.
Schuiling, K. D., & Likis, F. E. (2013). Women’s gynecologic health (2rd ed.). Burlington, MA: Jones and Bartlett Publishers.
Society for Reporoductive Endocrinology and Infertility. (2012). Abnormal uterine bleeding. Retrieved from http://www.socrei.org/BOOKLET_abnormal_uteine_bleeding/
Taran, F. A., Stewart, E. A., & Brucker, S. (2013). Adenomyosis: Epidemiology, risk factors, clinical phenotype and surgical and interventional alternative to hysterectomy. Geburtshilfe Frauenheilkunde, 73(9), 924-931.
University of Maryland Medical Center. (2016). Adenomyosis. Retrieved from
http://umm.edu/health/medical/ency/articles/adenomyosis
Women’s Health. (2015). Uterine fibroids fact sheet. Retrieved from
http://www.womenshealth.gov/publications/our-publications/fact-sheet/uterine-fibroids.html#c
