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Manuel S. Enverga University Foundation Candelaria Inc. College of Nursing and Allied Health Sciences Academic Year 2011-2012 1st Semester Grand Case Presentation: Uterine Myoma In partial fulfillment of the requirements of BSN Level IV

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Page 1: Myoma Grand Case Pre

Manuel S. Enverga University Foundation Candelaria Inc.

College of Nursing and Allied Health Sciences

Academic Year 2011-2012 1st Semester

Grand Case Presentation: Uterine Myoma

In partial fulfillment of the requirements

of

BSN Level IV

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General Objective:

For the student nurses to have an understanding regarding the disease process and

concept of uterine myoma, through research and through interaction with the client and for the

group to have a cooperation through this case presentation.

Specific Objective:

For the student nurses to apply their knowledge about the disease and to have an

appropriate intervention to the client’s need.

I. Introduction

A uterine myoma is also known as uterine leiomyoma, myoma, fibromyoma,

leiofibromyoma, fibroleimyoma and fibroma is a benign (non-cancerous) tumor that originates

from the smooth muscle layer (myometrium) and the accompanying connective tissue of the

uterus.

Fibroids are the most common benign tumors in females and typically found during the

middle and later reproductive years. While most fibroids are asymptomatic, they can grow and

cause heavy and painful menstruation, painful sexual intercourse, and urinary frequency and

urgency. Some fibroids may interfere with pregnancy although this appears to be very rare.

A. Background of the Study

Incidence

Myoma uterine is not found in teenagers, but the incidence rate increases with age as

women enter their 20’s, 30’s, and 40’s. The rate also increases among women who have

pregnancies later in life, or women who had an uneventful first pregnancy, but whose second

pregnancy is marked by the discovery of a myoma uterine. It should also be noted that African

American women are more likely to develop these tumors than any other ethnic group.

Rationale for choosing the Case

We chose this disease because we believe that this disease can enhance our knowledge

regarding uterine myoma.

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Significance of the study

This will allow the student nurses to gain knowledge about the disease and to have an

overview what will happen if a patient has this kind of disease. It will help the clinical instructors

to assess the degree of knowledge of their students.

Scope and limitation of the study

This study is focused in one patient only who happened to have a uterine myoma

admitted at Quezon Medical Center Gynecological ward. Through the exposure of the students

on the patient in the ward and for unfamiliarity on the disease they decided to choose her to be

the patient in conducting the study.

B. Nursing Theory

a. Self-Care Deficit Theory

Orem's Self-Care Deficit Theory of Nursing is a grand theory, which is comprised of three interrelated theories: 1) the theory of self-care, (2) the self-care deficit theory, and (3) the theory of nursing systems. Incorporated within these three theories are six central concepts and one peripheral concept. Having a thorough understanding of these central concepts of self-care, self-care agency, therapeutic self-care demand, self-care deficit, nursing agency, and nursing system, as well as the peripheral concept of basic conditioning factors, is essential to understanding her general theory (George, 1995, p. 100)

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Orem's theory of self-care takes into consideration several other concepts, namely self-care, self-care agency, basic conditioning factors, and therapeutic self-care demand. According to George (1995), Orem defined self-care as the performance or practice of activities that individuals initiate and perform on their own behalf to maintain life, health and well-being. When self-care is effectively performed, it helps to maintain structural integrity and human functioning, and it contributes to human development

To provide a more clear understanding to the self-care theory, Orem believed that human's has the ability or power to engage in self-care, this concept is know as Self-care agency. The individual's ability to engage in self-care is affected by basic conditioning factors namely age, gender, developmental state, health state, sociocultural orientation, family system factors, resource adequacy and availability (George, 1995).

Within the theory of self-care, Orem identified three categories of self-care requisites: universal self-care requisites, developmental self-care requisites, and health-deviation self-care requisites. Universal self-care requisites are common to all human beings and include physiological and social interaction needs. For example, the sufficient intake of water, air, food and the maintenance of balance in all area of one's life. Developmental self-care requisites are the needs that arise as the individual grows and develops. This is has to do with more specific events in an individual's life, e.g. adjusting to the loss of a job, or adjusting to the birth of a newborn.

Related Literature of the study

Definition

A myoma is a solid tumor made of fibrous tissue, hence it is often called a 'fibroid' tumor. Myomas vary in size and number, are most often slow-growing and usually cause no symptoms.

Myomas may grow as a single nodule or in clusters and may range in size from 1 mm to more than 20 cm in diameter. Myomas are the most frequently diagnosed tumor of the female pelvis and the most common reason for a woman to have a hysterectomy. Although they are often referred to as tumors, they are not cancerous.

Types

1. Intramural Fibroids are located within the wall of the uterus and are the most common type; unless large,

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they may be asymptomatic. Intramural fibroids begin as small nodules in the muscular wall of the uterus. With time, it may expand inwards, causing distortion and elongation of the uterine cavity.

2. Subserosal fibroids are located underneath the mucosal (peritoneal) surface of the uterus and can become

very large. They can also grow out in a papillary manner to become pedunculated fibroids. These pedunculated growths can actually detach from the uterus to become a parasitic leiomyoma.

 Symptoms of Uterine Myoma may include:

Pelvic pain or pressure

Pain in the back of the legs

Very heavy and prolonged menstrual periods

Pressure on the bowel which may lead to constipation and/or bloating

An enlarged abdomen (this may be mistaken for weight gain or pregnancy)

Pain during sexual intercourse

Pressure on the bladder which results in: a perpetual need to urinate, incontinence, or the inability to empty the bladder

Pathophysiology

Leiomyomas grossly appear as round, well circumscribed (but not encapsulated), solid

nodules that are white or tan, and show whorled appearance on histological section. The size

varies, from microscopic to lesions of considerable size. Typically lesions the size of a grapefruit

or bigger are felt by the patient herself through the abdominal wall.

Microscopically, tumor cells resemble normal cells (elongated, spindle-shaped, with a

cigar-shaped nucleus) and form bundles with different directions (whorled). These cells are

uniform in size and shape, with scarce mitoses. There are three benign variants: bizarre

(atypical); cellular; and mitotically   active.

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II. CLINICAL SUMMARY

A. General Data

Name Mrs. MYOMACase Number 1106547Gender FemaleAge 48 years oldBirth date May 22 1963Birthplace BicolCivil Status MarriedNationality FilipinoReligion Roman catholicOccupation HousewifeS.O Mr. R.SDate of Admission June 15, 2011Time of Admission 2:00 pmPhysician Dr. AgbayaniDiagnosis Uterine Myoma t/c DM

B. Nursing HistoryPresent illness

One week prior to admission the patient experienced hypogastric pain due to her uterine myoma. Her husband decided to brought her in Aurora hospital and was advised to have a surgical operation. Due to financial problem she referred to Quezon Medical Center and immediately admitted for further evaluation and management.

Past Medical History

Three years ago, the patient was diagnosed to have uterine myoma. She was brought to Aurora hospital and was advised for a surgical operation but she doesn’t comply due financial problem. The patient doesn’t have any allergy any foods and medication.

C. Family Genogram

According to Mrs. Myoma there was no known hereditary disease / illness that run in their family.

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D. Social History

Developmental theory (Erik Erickson)

Stage age Central task Indicator of positive resolution

Indication of negative resolution

Intimacy vs. Isolation

(18-40 yrs) young adult (18-54 yrs)

Seek relationship & affiliations with either with opposite sex or with a group of individuals to whom the develop strong personal attachment.

Commitment to other.Close heterosexual relationship.

Withdrawal from such intimacy, solution self absorption & alienation from other.

Generativity vs. stagnation

Middle adult (40 -65yrs) (24 – 54yrs.)

Middle stage is the time where the person generates the virtue of care or the time when he looks into the future of his/her children without children may have sense of generating by helping friends and relative.

The care & concern for next generation.

Self indulgence and resulting psychological improvement

Psychosexual (Sigmund Freud)

Age Name Pleasure source Conflict12yrs and above Genital stage Opposite sex

E. Environmental / Living Condition

The patient lives in Aurora, Quezon with her husband and five children. Their house is located near the sea and it is made of light materials. According to the patient their house is too small for them.

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F. Physical assessment

General condition:

Oriented to spheres (time,date,person) Pale and weak in appearance Vital signs:

T - 36.3 c RR – 26 bpmPR – 86 bpm BP – 110/80 mmHg

Parameters Normal finding Actual finding InterpretationHead Normocephalic with

no abnormal masses. Hair is black,

thick, evenly distributed, curly hair

Head is round, proportion to body

No presence of visible lesion

Normal

Eyes Symmetric to the face, both eyes coordinated with parallel alignment.

Eyebrows evenly distributed

Symmetrical in shape and size

Both eyes are coordinated

Good PERRLA White sclera is

seen around the iris

No redness or lesion

Normal

Ears Symmetrically aligned to the face, firm and not tender without discharge

Symmetrically aligned to the face

Firm and no tender

No discharge noted

No palpable masses along the pinna

Normal

Nose Symmetric and straight, no discharge

Symmetric both nostril

No discharge or flaring

Normal

Mouth Pinkish color of lips, Pale and dry lips Normal

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moist tongue at midline, no lesion

Gums are moist Tongue at midline

without lesionNeck Coordinated and

smooth movement no masses, tenderness

Coordinated movement

No masses, tenderness

Normal

Chest Symmetric chest expansion, quiet, rhythmic and effortless respiration

Symmetric chest expansion

Normal breath sound

Not in resp. distress

Normal

Abdomen Unblemished skin, uniform in color, no masses, soft

With abdominal pain at hypogastric area

With masses Non tender

abdomen Soft abdomen Enlarged

abdomen

Presence of masses that indicates illness and pain that indicates an infection and had an abnormal size

Genito-urinary Can defecate and urinate without any distraction or harmful feeling, and normal structure

Defecated once a day

No painful urination

Normal

Upper and lower extremities

No lesion, can move freely with capillary refill of (2-3 sec.)

With slow movement

Upper extremities is symmetrical in size

Lower extremities is symmetrical in size

No swelling and lesion

Normal

Skin Pinkish in color, without lesion

Poor skin turgor Cold to touch pallor

Not normal it is a manifestation of poor circulation of blood

G. Patterns of functioning

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Function of health pattern

Before hospitalization During hospitalization Interpretation

Health management pattern

she takes her medicine if there is pain

She takes her medicine daily

The patient takes her medicine daily in the hospital.

Nutritional / metabolic:a. number of meal

per dayb. appetitec. glass of water

d. body build

e. height and weight

three times a day

normal appetite

6 to 8 glass of water

Normal body built for Filipino women

5’2ft / 59

three times a day

normal appetite

6 to 8 glass of water

Normal body built

5’2 ft / 59

The patient eat, drink normally and has a normal body built

Eliminationa. Frequency of

elimination

b. Amount of urine per

c. Frequency bowel movement

d. Consistency of stool

e. Amount of defecated per day

Urinated 3 -8 times a day

Defecated 1 – 2 times a day

1.5 L to 2 L

5 -10

Yellowish in color

1/4kg

Urinated 3 – 6

Defecated 1- 2

1.5L to 2L

5 – 10

Yellowish in color

1/4kg

The patient elimination was normal

Activity and exercisea. Exercise

b. Fatigability

c. ADL

the patient exercise is walking and doing household work

she rest after her work

she make her household work

walking

rest

sleep and rest

The patient’s activity lessen in the hospital. The only exercise that she can do is walking.

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Cognitive / Perception

a. OrientationThe patient was oriented to three spheres (time, place, person).

b. ResponsivenessThe patient was able to response to the student nurse when asking question and was able to verbalized understanding of her condition.

Role / Relationship

The patient has five children. She do all the household chores. She wakes up early and prepares her children for school together with her husband.

Self Perception

The patient is aware of her condition and she knows that she needs surgical operation.

Self Concept

The patient’s idea to seek medical consultation is good for her health. At first she doesn’t comply with the doctor’s advice about her condition due to financial problem. But recently she decided to have a surgical operation due to different signs and symptoms that she experience that causes her to feel uncomfortably.

Coping with Stress

She seeks her family’s advice and made some relaxation technique such as reading news paper, talking to her friends and family and sleeping.

Values and Belief

She prays to God every day. She believes that God has the power to change her condition.

H. Course in the Ward

JULY 03,2011

DAY DOCTOR’S ORDER NURSING ACTION WITH TATIONALE

1 12mn > RBS=311 mg/dL

7pm > RBS=226 mg/dL

Monitor patient’s RBS level especially after

every meal. The normal RBS level is ranging

from 70-150 mg/dL, it rises every after meal.

150mg/dL and above are indicative of

hyperglycemia or high blood sugar and

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diabetes mellitus.

JULY 04, 2011

2

12mn > RBS=269mg/dL - Regular insulin 3 units sc now 6am > RBS= 377 mg/dL - Regular insulin 5units sc now

9:30am > RBS= 259mg/dL - Regular insulin 3 units sc now

> follow up for FBS

result

7:20pm > RBS= 263 mg/dL - Regular insulin 3 units sc now

Monitor RBS level, the patient should be

given insulin 3units for 269mg/dL and

259mg/dL and 5 units for 377 md/dL level of

RBS. Because insulin remove excess glucose

from the blood, which otherwise would be

toxic.

To follow FBS result because it also

measure of the sugar level in the blood and it

is one of the test that is used to diagnosed

diabetes mellitus

Monitor again the RBS level, the patient

should be given insulin 3 units for 263mg/dL

level of RBS. Because when control of

insulin levels fails, diabetes mellitus will

result

It should also be given subcutaneous.

Because subcutaneous injections are highly

effective in administering vaccines and

medications such as insulin

III. Clinical Discussion of the Disease

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A. Anatomy and Physiology

Uterus

Anatomy

The uterus is located inside the pelvis immediately dorsal to the urinary

bladder and ventral to the rectum. The human uterus is pear-shaped and about 3 in. (7.6 cm)

long.

Regions

From outside to inside, the path to the uterus is as follows:

1. Cervix uteri - "neck of uterus"

a. External orifice of the uterus

b. Canal of the cervix

c. Internal orifice of the uterus

2. corpus uteri - "Body of uterus"

a. Cavity of the body of the uterus

b. Fundus (uterus)

Layers

The layers, from innermost to outermost, are as follows:

Endometrium 

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The lining of the uterine cavity is called the "endometrium". It consists of the functional

endometrium and the basal endometrium from which the former arises. The endometrium builds

a lining periodically which is shed or reabsorbed if no pregnancyoccurs. Shedding of the

functional endometrial lining is responsible for menstrual bleeding (known colloquially as a

"period" in humans with a cycle of about 28 days) throughout the fertile years of a female and

for some time beyond

Myometrium 

The uterus mostly consists of smooth muscle, known as "myometrium." The innermost

layer of myometrium is known as thejunctional zone, which becomes thickened

in adenomyosis.

Parametrium 

The loose connective tissue around the uterus.

Perimetrium 

The peritoneum covering of the fundus and ventral and dorsal aspects of the uterus.

Blood supply

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Vessels of the uterus Schematic diagram of uterine arterial

vasculature seen as a cross-section through the myometrium andendometrium.

The uterus is supplied by arterial blood both from the uterine artery and the ovarian artery.

Function

1. The uterus consists of a body and a cervix.The cervix protrudes into the vagina.

2. The uterus is essential in sexual response by directing blood flow to the pelvis and to the

external genitalia, including the ovaries, vagina,labia, and clitoris. The uterus is needed

for uterine orgasm to occur.

3. The reproductive function of the uterus is to accept a fertilized ovum which passes

through the utero-tubal junction from the fallopian tube. It implants into

the endometrium, and derives nourishment from blood vessels which develop exclusively

for this purpose. The fertilized ovum becomes an embryo, attaches to a wall of the uterus,

creates a placenta, and develops into a fetus (gestates) until childbirth.

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ACTUAL PATHOPHYSIOLOGY

Predisposing Factors:-Age-Race-Early Menarche

Precipitating Factors:-High fat diet-Obesity-Anxiety/Stress -Coffee/ Caffeine intakeEtiology:

Unknow

Estrogen Dominance or increase in Estrogen production

Proliferation of cells in uterus (Sub mucous)

Overgrowth the endometrial lining

Myoma: Development of uterine fibroid

Interference in the vascular supply

Degeneration of the interior part of fibroid

s/sx: -hypogastric pain-mass on lower abdomen

Uterine Cavity begins to stretch or increase in size

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SEROASAL

Arouses on three different part

PATHOPHYSIOLOGYGeneral

Result on abnormal cell proliferation or growth

Etiologic FactorModifiableLifestyleHigh amount of fatty intakeAlcohol drinkingSmoking mother

Non Modifiable20-20% women on reproductive yearBetween 25 and 45 years of ageAnovulatory cycleHigh level of unopposed estrogenHeredity-cellular, immunity failure

FIBROIDS FORMATION

INTRACAVITARY

INTRAMURAL

Continues stress on myometriumMultiple Fibroids

Continuous growth of cell, cell formation

Necrosis formation on the surface of endometrium overlying the myoma Other symptom resulted from the continuous growth of myoma

Abnormal BleedingMenorrhagiaMetrorhagia

Progressing degeneration-hypogastric pain

Torsion of the pedunculated myoma

BackachePressureBloatingConstipationUrinary problem