SUBMUCOUSAL MYOMA

In Partial Fulfillment OfNursing Care Management 201Related Learning Experience

Submitted by:BSN 3-AGROUP 3

Date of Defend:October 23, 2009

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Introduction

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Fibroids or uterine myomas are benign, non-cancerous growths inside the uterus or in its muscular wall.  Fibroids can vary enormously in size, from that of a pea to that of a melon.  Multiple growths may be present at the same time, anywhere in the uterus.  They are classified according to their location:

Intramural fibroids – develop in the uterine wall.

Subserosal fibroids – develop in the abdomen outside the uterus.

Submucosal fibroids – develop inside the uterine cavity.

Myomas of the uterus are the most common solid pelvic tumours in women, and are present in 20 to 25% of women aged 35 years. Myomas are associated with infertility, the causal relationship in this regard appearing to be more evident for submucosal myomas. Indeed, myomas represent an increasing medical problem in women attempting to conceive at a more advanced age, when the rate of development of these lesions is also increased.

In their submucosal localization, myomas can be treated exclusively using surgical procedures, and they may be accessible by operative hysteroscopy—the standard surgical approach. Several retrospective studies of small cases series were published during the 1990s demonstrating successful reproductive outcome after hysteroscopic removal of submucosal myomas in infertile women. Several hypotheses have been suggested to explain how submucosal myomas cause infertility or repeated abortions, but none is definitive. The aim of this retrospective study was to assess the pregnancy rate compared with the improvement of menstrual pattern in menorrhagic

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women after hysteroscopic resection of submucosal myomas performed in infertile patients.

Most myomas are asymptomatic and do not cause any particular problem.  If this is the case, treatment is unnecessary.

Three Types of Treatments

1) Drugs: anti-haemorrhagics or anti-inflammatories can be used to treat the patient's symptoms. Certain hormones can also be beneficial. However, the efficacy of drugs and hormones is usually limited and their effects temporary.  Moreover, side effects may limit the duration of the course of treatment.

2) Surgical removal: various surgical techniques can be used, depending on the size, number and location of the fibroids: a) Myomectomy involves the individual removal of each

leiomyoma.  Different approaches can be used, including coelioscopy, hysteroscopy or abdominal incision, but all entail a hospital stay of several days followed by a one to six week convalescence period.  Myomectomy can complicate subsequent pregnancies because it causes scarring of the uterine muscle tissue.

b) Hysterectomy involves the removal of the entire uterus by coelioscopy or surgery (either abdominal surgery or via a vaginal approach). This treatment modality definitively eliminates the fibroids but both hospital stay and convalescence period are long.  And of course, hysterectomy abolishes the possibility of later pregnancy.

3) Embolisation: an alternative to surgery which preserves the uterus, since the development of this technique in France in the early 1990's, about 40,000 women have been treated across the world. Embolisation results in shrinkage of the fibroids by blocking their blood supply. This procedure attenuates or abolishes symptoms (pain, bleeding, urination problems, etc.) in 90% of subjects. Embolisation is performed with mild local anaesthesia and involves a hospital stay of under 48 hours.

Postoperative pain is managed with various drugs or by means of a small pump device with which the patient herself can control the dose administered according to her degree of pain.  A normal life style can be resumed within one to two weeks.

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Gordon’s Functional

Health Pattern

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CHIEF COMPLAINTS: Vaginal bleeding, Dysmenorrhea

CURRENT HEALTH HISTORY:For the past 2 years, patient had been experiencing

menstruation that lasted for a month associated with Dysmenorrhea. Last July 2009 due to prolonged, severe uterine pain during menstruation, the patient sought medical health assistance to a private OB-Gynecologist. She was advised to have an ultrasound for further evaluation. Based on the patient’s ultrasound result, the impression was Utero-Prolapsed Endometrial Polyps vs. Prolapsed Submucous Myoma. With these findings, the doctor advised her to undergo for a surgery. Howerver, because of financial constraint, the patient decided to have the surgery done in Ormoc District Hospital. She was admitted at ODH last September 19, 2009, and was scheduled for an operation on 29th of the same month.

PAST MEDICAL HISTORY:Patient claimed that she had experienced common childhood

diseases and minor illnesses, such as common colds, chicken pox, mumps and measles. She considers herself as a healthy individual. Patient also said that she had never been hospitalized before, neither suffered from serious illnesses nor undergone any surgical operation. Common adult illnesses experienced were fever, cough and colds which she self medicated with over-the-counter drugs.

She has no recollection of her immunization status because according to her it was not a common practice during her childhood days.

Patient was an occasional alcohol drinker and tobacco user. Patient claimed no known allergies to drugs, foods or other environmental substances.

FAMILY HISTORY:Patient’s mother passed away of unknown cause. The patient is

the second of the nine siblings of which six are females and three are males. She is married to a fisherman from San Isidro, Villaba Leyte who sometimes earns less than 1 thousand pesos a day. They were blessed with six children; all of them are still living. She claimed her family to be healthy.

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GENOGRAM:

Legends:

- Female - Deceased Female Relative

- Male - Deceased Male Relative

- Client

X

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X

HEALTH PERCEPTION & HEALTH MANAGEMENT:As stated by the client, she perceived herself as a healthy

individual even before she had a surgery. Right now her normal activities are affected due to her post-surgical operation. She can ambulate with the aid of her significant others.

Whenever the patient has a health problem, she just takes a rest or seeks medical assistance to their Barangay Health Center. To keep healthy, the patient does exercises, such as walking and doing household chores.

The patient claimed that she doesn’t know how to do self physical exams, specifically Breast Self Examination, and cannot recall her last immunization.

The patient used to drink alcohol and smoke occasionally. One year ago, she stopped smoking.

NUTRITION & METABOLISM PATTERN:24-hour dietary intake review (her usual daily menu) Breakfast: 1 cup of coffee and 1 piece of bread Snacks: Saging, camote, a cup of coffee Lunch: 1 cup of rice, fish, mixed vegetables Dinner: 1 cup of rice, fish, mixed vegetables

The patient normally eats her meals 8am-12nn-7pm. She doesn’t take any vitamin supplements. Her diet is less in sugar and salt. She drinks powdered juice, beer or tuba occasionally and mostly water. She doesn’t have any difficulty chewing and swallowing food and drinks.

BLADDER ELIMINATION PATTERN:She had normal urine elimination. But after removal of her

urinary catheter, she voids five times a day but in small amounts. The amount of her daily voiding is approximately 1 cup, with light yellow color.

BOWEL ELIMINATION PATTERN:Before her hospitalization, she had a regular bowel elimination,

once daily. Since she was hospitalized she seldom eliminates with an interval of 3 days. She doesn’t take any laxatives, or undergone edemas to relieve her discomforts. But she eats fruits and vegetables everyday to increase her fiber intake for easier bowel elimination. She also drinks adequate fluid everyday.

SLEEP-REST PATTERN:The client usually sleeps 6 to 8 hours every night She usually

naps in the afternoon for 15 minutes only. But now that she is

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hospitalized, her sleeping pattern is altered due to heat and discomforts with her environment and present condition.

ACTIVITY & EXERCISE PATTERN:Activity of Daily Living: The patient normally does household

chores and gone to the market to buy their food. Now that she is hospitalized, her activities are altered.

Exercise Routine: Her daily living activities are her means of exercise.

Occupational Activities: The patient doesn’t have a job, she is just a plain housewife.

COGNITION & PERCEPTION PATTERN:Ability to Understand: According to the doctor, her recovery is

progressing. But she still has to have to believe in the determination that she can return to her normal state of health. Her best way to learn something new is by watching shows on television.

Ability to Communicate: Inspite of the pains after the surgery, the patient was relieved to know that she’s cured from her sickness. The patient doesn’t have difficulty expressing herself to her family, but due to the surgery, she cannot communicate well.

Ability to Remember: She verbalized that she was able to recall important past events of her life.

Ability to Make Decisions: The patient informed to us that in making major decisions, the whole family discusses and together decides. Patient stated she did not have any difficulty in decision making especially regarding her surgery, because she knew it will make her feel better.

SELF-PERCEPTION & SELF CONCEPT PATTERN:The patient describes herself as a happy person. Her family gives

her strength, but also gives her weakness. Her family was saddened with her illness but they learned to accept it.

She feels uncomfortable and dissatisfied with her appearance. She also feels pity to other people with disabilities.

ROLES & RELATIONSHIP PATTERN:She is a housewife. Her major responsibility is to take good care

of her family and provide their daily needs. Her family is her priority in her life.

Her neighborhood is clean and peaceful. They lived there for over 10 years already. She is a member of a religious organization, BEC (Basic Ecclesial Community), but recently, she is not active, due to her surgery. She also participated in “PINTAKASI” in their community.

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COPING & STRESS TOLERANCE PATTERN:Her present condition is the most stressful in her life because it

affects her family financially and emotionally.The major change in her life is not being able to perform

normally. Her family helps her to cope up with these changes she undergoes. She often talks and prays with her family. Her family is her inspiration in life. SEXUALITY & REPRODUCTION PATTERN:Menstrual HistoryAge of menarche: 16 years oldMenstruation: 4-5 days duration with moderate flow

Obstetric HistoryNo. of Pregnancy: 5Outcome of Pregnancy: NormalSex and Ages of Children:

VALUES & BELIEF PATTERN:Her family is her priority in life. She is strict in keeping her family

healthy by eating three times a day. She also believes that health is wealth.

Her major source of hope and strength in life is her family and God. Her family prays together every night for continuous blessings and good health.

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Physical Assessment

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MENTAL STATUS AND GENERAL APPEARANCE Patient is 43 years old, female with fair complexion, with a height

of 5’5 feet, and weighs 49 kilos. She can ambulate but with assistance; with stomach binder due to post-surgical incision. Vital signs as of first assessment dated October 6, 2009, are as follows: temperature 37.2°C axillary; heart rate 91 bpm; respiratory rate 26 cpm; BP 110/70 mmHg, taken at the left arm.

Patient is conscious and alert to all questions being asked. She’s able to answer promptly, but not able to expand her answers. Oriented to time, place, person and present situation. She’s also able to recall both long term and short term memories.

HEAD AND SKULLHead is normocephalic, and no lesions noted. Scalp is smooth,

has short, curly hair with white fine hairs noticed. Face is oval in shape. She was asked to elevate, frown or lower

the eyebrows, close the eyes tightly, puff the cheeks, smile and show the teeth, and she all made these procedures with ease. Symmetric facial movements were also noted.

OBSERVE HEAD MOVEMENTThe client’s head movements are still good. She can move her

chin to and from her chest. She can point her chin upward, move her head towards her shoulders and turn her head left and right with less effort.

EYESEyebrows are slightly brown in color and thin, symmetrical and

evenly distributed. Eyelashes are short and straight, no lesions, swelling and secretions noted on the eyelids and on both inner and outer cantus. No edema on the lacrimal glands. Both eyes can move in coordination, with the outer cantus parallel with the pinna of the ears.

EARS AND HEARINGEars are equal in size. Color is the same with that of the skin. No

lesions, abnormalities, swelling or tenderness were found in the auricles and earlobes. Tympanic membrane is pearly gray color. They are symmetrical, firm and not tender. Voice tones are equally heard by both ears.

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NOSE AND SINUSESNose is slightly pointed and symmetrical. Nasal septum is normal

and with no signs of flaring, lesions and swelling. Is able to smell. Some secretions of the nose are noted. It has the same color with the skin of the face, no tenderness or lesions noted in the external nose. Air moves freely as the client breathes through the nares. The internal nasal cavity is normal, the mucosa is pink, and has clear, watery discharge. The sinuses are palpated and no evidence of swelling or lumps noted.

MOUTH AND OROPHARYNXLips are dry and slightly pale. Both upper and lower teeth are

slightly yellowish, but no cavities are noted. Hard and soft palates are intact. The tongue is pink in color, moist, slightly rough, thick, has whitish coating, is smooth, and has lateral margins and no lesions noted. It is located at the center of the mouth, and is freely movable. The gums are slightly dark in color, moist and firm.

NECKNo tenderness, nodules or lumps were noted in the neck. The

muscles in the neck are equal in size, head is centered, and have coordinated smooth movements with no discomforts felt. Head flexes at 45°, hyperextends at 60°, head laterally flexes at 40° and head laterally rotates at least 70°.

The lymph nodes are not palpable. The trachea is in normal placement in the midline of the neck and spaces are equal on both sides. The thyroid gland is not visible on inspection. The gland ascends normally during swallowing.

THORAX AND LUNGSAnteroposterior to transverse ratio is 1:2. The chest is

symmetric, and the spine is vertically aligned. Spinal column is straight, right and left shoulders and hips are at same height. The skin and chest wall are intact, with no tenderness and masses noticed.

Full and symmetric chest expansion was observed. Vocal fremitus, is bilaterally symmetrical, and is heard most clearly at the apex of the lungs. She has quiet, rhythmic, and slightly fast respirations and full symmetric excursion.

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PERIPHERAL VASCULAR SYSTEMArms: Are symmetrical, has intact skin, with no edema or tenderness noted. They are able to move freely, with rapid and strong radial pulse felt. Buerger’s test was done and original skin color returns within 10 seconds in the hands. Capillary refill test was made and there was an immediate return of skin color.Legs: Are symmetrical, with no presence of edema, and with visible scars noted in both legs.

BREAST AND AXILLAEBreasts are round in shape, slightly unequal in size, and

generally symmetric. The skin is uniform in color, and is smooth and intact. No tenderness, masses, nodules or nipple discharges were noted.

MOTOR FUNCTIONPatient was sitting on bed with legs slightly flexed with evident

weakness on it. Movements are limited but can reposition herself on bed on her own but with slight facial grimace. She’s able to walk but needs assistance.

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Laboratories

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HEMATOLOGY LABORATORY REPORT9/19/09

Labs Findings/Result Normal Values Interpretation Hct 0.20 38-48%/L severe anemias;

Acute massive blood loss

Neutrophils 0.75 40-60%/L acute infections Trauma/surgery

Lymphocytes 0.75 20-40%/L bacterial infections

LABORATORY REPORT9/20/09

Labs Findings/Result Normal Values Interpretation BUN 1.73 mmol/L 2.1-7.1 mmol/L low protein diet; Starvation

HEMATOLOGY LABORATORY REPORT9/25/09

Labs Findings/Result Normal Values Interpretation Hgb 96gm/L 120-150gm/L various anemias

Severe/prolongedHemorrhage

Hct 29gm/L 38-48%/L severe anemias;Acute massive Blood loss

HEMATOLOGY LABORATORY REPORT9/28/09

Labs Findings/Result Normal Values Interpretation Hgb 7.6 gm/L 12-15gm/L various anemias Severe/prolonged HemorrhageHct 23/L 40-50/L severe anemias

Acute massive Blood loss

HEMATOLOGY LABORATORY REPORT

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9/30/09

Labs Findings/Result Normal Values Interpretation Hct 0.35 38-48% severe anemias

Acute massiveBlood loss

ROENTGENELOGIC REPORT9/19/09

Procedures: Chest PA XRAY# 099168

Findings: The lung fields are clear. The heart is not enlarged. The hemidiaphragms & CP sulci are intact. The osseous & soft tissue structures are

unremarkable.

Impression: No significant chest findings.

ULTRASOUND REPORTGYNECOLOGY

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Referred by: Dr. M. Napasindayao Date: 07/27/09 LMP: 07/11 day 17

Uterus: 7.3x4.0x4.9 cmCervix: 2.4x3.1x3.7 cmEndometrium: 1.0 cmRight Ovary: 2.3x2.0x1.7 cm lateralLeft Ovary: 2.4x2.0x1.8 cm posterolateralOther: No free fluid in the cul de sac

Remarks: The uterus is anteverted w/ irregular contour & heterogenous in echopattern. The endometrium is hyperechoic w/ intact subendometrial halo.Within the vaginal canal is a hyperechogenic structure measuring 6.1x3.3 cm originating w/in the uterus sonologic features suggestive of Prolapsed Endometrial Polyps vs. Prolapsed Submucous Myoma.

The cervix is close,w/o nabothian cyst.Both ovaries appear normal w/ small follicles less than 1cm

in diameter.No fluid in the cul de sac.

Impression: Utero-Prolapsed Endometrial Polyps vs. Prolapsed Submucous

Myoma Both Ovaries appear normal w/ small follicles noted. No fluid in the cul de sac.

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Anatomy and

Physiology

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EXTERNAL GENITALS

Vulva

The external female genitals are collectively referred to as The Vulva. This consists of the labia majora and labia minora (while these names translate as "large" and "small" lips, often the "minora" can be larger, and protrude outside the "majora"), mons pubis, clitoris, opening of the urethra (meatus), vaginal vestibule, vestibular bulbs, vestibular glands.

The term "vagina" is often improperly used as a generic term to refer to the vulva or female genitals, even though - strictly speaking - the vagina is a specific internal structure and the vulva is the exterior genitalia only. Calling the vulva the vagina is akin to calling the mouth the throat.

Mons Veneris

The mons veneris, Latin for "mound of Venus" (Roman Goddess of love) is the soft mound at the front of the vulva (fatty tissue covering the pubic bone). It is also referred to as the mons pubis. The mons veneris is sexually sensitive in some women and protects the pubic bone and vulva from the impact of sexual intercourse. After puberty it is covered with pubic hair, usually in a triangular shape. Heredity can play a role in the amount of pubic hair an individual grows.

Labia Majora

The labia majora are the outer "lips" of the vulva. They are pads of loose connective and adipose tissue, as well as some smooth muscle. The labia majora wrap around the vulva from the mons pubis to the perineum. The labia majora generally hides, partially or entirely, the other parts of the vulva. There is also a longitudinal separation called the pudendal cleft. These labia are usually covered with pubic hair. The color of the outside skin of the labia majora is usually close to the overall color of the individual, although there may be some variation. The inside skin is usually pink to light brown. They contain numerous sweat and oil glands. It has been suggested that the scent from these oils are sexually arousing.

Labia Minora

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Medial to the labia majora are the labia minora. The labia minora are the inner lips of the vulva. They are thin stretches of tissue within the labia majora that fold and protect the vagina, urethra, and clitoris. The appearance of labia minora can vary widely, from tiny lips that hide between the labia majora to large lips that protrude. There is no pubic hair on the labia minora, but there are sebaceous glands. The two smaller lips of the labia minora come together longitudinally to form the prepuce, a fold that covers part of the clitoris. The labia minora protect the vaginal and urethral openings. Both the inner and outer labia are quite sensitive to touch and pressure.

Clitoris

The clitoris, visible as the small white oval between the top of the labia minora and the clitoral hood, is a small body of spongy tissue that functions solely for sexual pleasure. Only the tip or glans of the clitoris shows externally, but the organ itself is elongated and branched into two forks, the crura, which extend downward along the rim of the vaginal opening toward the perineum. Thus the clitoris is much larger than most people think it is, about 4" long on average.

Urethra

The opening to the urethra is just below the clitoris. Although it is not related to sex or reproduction, it is included in the vulva. The urethra is actually used for the passage of urine. The urethra is connected to the bladder. In females the urethra is 1.5 inches long, compared to males whose urethra is 8 inches long. Because the urethra is so close to the anus, women should always wipe themselves from front to back to avoid infecting the vagina and urethra with bacteria. This location issue is the reason for bladder infections being more common among females.

Perineum

The perineum is the short stretch of skin starting at the bottom of the vulva and extending to the anus. It is a diamond shaped area between the symphysis pubis and the coccyx. This area forms the floor

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of the pelvis and contains the external sex organs and the anal opening. It can be further divided into the urogenital triangle in front and the anal triangle in back.

The perineum in some women may tear during the birth of an infant and this is apparently natural. Some physicians however, may cut the perineum preemptively on the grounds that the "tearing" may be more harmful than a precise cut by a scalpel. If a physician decides the cut is necessary, they will perform it. The cut is called an episiotomy.

INTERNAL GENITALS

Vagina

The vagina is a muscular, hollow tube that extends from the vaginal opening to the cervix of the uterus. It is situated between the

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urinary bladder and the rectum. It is about three to five inches long in a grown woman. The muscular wall allows the vagina to expand and contract. The muscular walls are lined with mucous membranes, which keep it protected and moist. A thin sheet of tissue with one or more holes in it, called the hymen, partially covers the opening of the vagina. The vagina receives sperm during sexual intercourse from the penis. The sperm that survive the acidic condition of the vagina continue on through to the fallopian tubes where fertilization may occur.

The vagina is made up of three layers, an inner mucosal layer, a middle muscularis layer, and an outer fibrous layer. The inner layer is made of vaginal rugae that stretch and allow penetration to occur. These also help with stimulation of the penis. microscopically the vaginal rugae has glands that secrete an acidic mucus (pH of around 4.0.) that keeps bacterial growth down. The outer muscular layer is especially important with delivery of a fetus and placenta.

Purposes of the Vagina Receives a males erect penis and semen during sexual

intercourse. Pathway through a woman's body for the baby to take during

childbirth. Provides the route for the menstrual blood (menses) from the

uterus, to leave the body. May hold forms of birth control, such as a diaphragm, FemCap,

Nuva Ring, or female condom.

Cervix

The cervix (from Latin "neck") is the lower, narrow portion of the uterus where it joins with the top end of the vagina. Where they join together forms an almost 90 degree curve. It is cylindrical or conical in shape and protrudes through the upper anterior vaginal wall. Approximately half its length is visible with appropriate medical

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equipment; the remainder lies above the vagina beyond view. It is occasionally called "cervix uteri", or "neck of the uterus".

During menstruation, the cervix stretches open slightly to allow the endometrium to be shed. This stretching is believed to be part of the cramping pain that many women experience. Evidence for this is given by the fact that some women's cramps subside or disappear after their first vaginal birth because the cervical opening has widened.

The portion projecting into the vagina is referred to as the portio vaginalis or ectocervix. On average, the ectocervix is three cm long and two and a half cm wide. It has a convex, elliptical surface and is divided into anterior and posterior lips. The ectocervix's opening is called the external os. The size and shape of the external os and the ectocervix varies widely with age, hormonal state, and whether the woman has had a vaginal birth. In women who have not had a vaginal birth the external os appears as a small, circular opening. In women who have had a vaginal birth, the ectocervix appears bulkier and the external os appears wider, more slit-like and gaping.

The passageway between the external os and the uterine cavity is referred to as the endocervical canal. It varies widely in length and width, along with the cervix overall. Flattened anterior to posterior, the endocervical canal measures seven to eight mm at its widest in reproductive-aged women. The endocervical canal terminates at the internal os which is the opening of the cervix inside the uterine cavity.

During childbirth, contractions of the uterus will dilate the cervix up to 10 cm in diameter to allow the child to pass through. During orgasm, the cervix convulses and the external os dilates.

Uterus

The uterus is shaped like an upside-down pear, with a thick lining and muscular walls. Located near the floor of the pelvic cavity, it is hollow to allow a blastocyte, or fertilized egg, to implant and grow. It also allows for the inner lining of the uterus to build up until a fertilized egg is implanted, or it is sloughed off during menses.

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The uterus is only about three inches long and two inches wide, but during pregnancy it changes rapidly and dramatically. The top rim of the uterus is called the fundus and is a landmark for many doctors to track the progress of a pregnancy. The uterine cavity refers to the fundus of the uterus and the body of the uterus.

Helping support the uterus are ligaments that attach from the body of the uterus to the pelvic wall and abdominal wall. During pregnancy the ligaments prolapse due to the growing uterus, but retract after childbirth. In some cases after menopause, they may lose elasticity and uterine prolapse may occur. This can be fixed with surgery.

Some problems of the uterus include uterine fibroids, pelvic pain (including endometriosis, adenomyosis), pelvic relaxation (or prolapse), heavy or abnormal menstrual bleeding, and cancer. It is only after all alternative options have been considered that surgery is recommended in these cases. This surgery is called hysterectomy. Hysterectomy is the removal of the uterus, and may include the removal of one or both of the ovaries. Once performed it is irreversible.

Fallopian Tubes

At the upper corners of the uterus are the fallopian tubes. There are two fallopian tubes, also called the uterine tubes or the oviducts. Each fallopian tube attaches to a side of the uterus and connects to an ovary. They are positioned between the ligaments that support the uterus. The fallopian tubes are about four inches long and about as wide as a piece of spaghetti. Within each tube is a tiny passageway no wider than a sewing needle. At the other end of each fallopian tube is a fringed area that looks like a funnel. This fringed

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area, called the infundibulum, lies close to the ovary, but is not attached.

STRUCTURELOCATION & DESCRIPTION

FUNCTION

CervixThe lower narrower portion of the uterus.

During childbirth, contractions of the uterus will dilate the cervix up to 10 cm in diameter to allow the child to pass through. During orgasm, the cervix convulses and the external os dilates

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ClitorisSmall erectile organ directly in front of the vestibule.

Sexual excitation, engorged with blood.

Fallopian tubes

Extending upper part of the uterus on either side.

Egg transportation from ovary to uterus (fertilization usually takes place here).

Hymen

Thin membrane that partially covers the vagina in young females.

Labia majoraOuter skin folds that surround the entrance to the vagina.

Lubrication during mating.

Labia minoraInner skin folds that surround the entrance to the vagina.

Lubrication during mating.

Mons

Mound of skin and underlying fatty tissue, central in lower pelvic region

Ovaries (female gonads)

Pelvic region on either side of the uterus.

Provides an environment for maturation of oocyte. Synthesizes and secretes sex hormones (estrogen and progesterone).

Perineum

Short stretch of skin starting at the bottom of the vulva and extending to the anus.

UrethraPelvic cavity above bladder, tilted.

Passage of urine.

Uterus Center of pelvic cavity.To house and nourish developing human.

Vagina

Canal about 10-8 cm long going from the cervix to the outside of the body.

Receives penis during mating. Pathway through a womans body for the baby to take during childbirth. Provides the route for the menstrual blood (menses) from the uterus, to leave the body. May hold forms of birth control, such as an IUD, diaphragm, neva ring, or female condom

Vulva Surround entrance to the reproductive tract.(encompasses all

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external genitalia)

EndometriumThe innermost layer of uterine wall.

Contains glands that secrete fluids that bathe the utrine lining.

MyometriumSmooth muscle in uterine wall.

Contracts to help expel the baby.

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Pathophysiology

Risk Factors:

Increased risk of fibroidsa. overweight womenb. Advancing agec. Black womend. Family historye. Nulliparity

Lower risk of fibroidsa. five pregnancies or moreb. menopausec. oral contraceptive

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d. tobacco use

increased level of secretion of estrogen & secretion of progesterone

somatic mutation of normal myometrium

growth of myoma (submucous)

abnormal backache constipation endometrial pressure bleeding

pelvic pressure/ bloating urinary problems pain sensation

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Ideal Signsand

Symptoms

IDEAL S/S PATIENT’S MANIFESTATION SCIENTIFICBASIS

Abnormal endometrial The patient consumed Submucous myoma can Bleeding 5 sanitary napkin in increase the size & A day surface mucosal

necrosis & infection,which led

to bleeding

Pain sensation Patient experienced Uterine submucous

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Abdominal pain with myoma stimulate Pain scale of 8 spastic contraction

Which can cause acute

Abdominal pain

Backache pressure Patient claimed to have Due to the pressure A slight backache created by the Myoma in which Creates a feeling of Heaviness or bearing

Down sensation.

Constipation Patient had not defecated Growth in the posterior For 3 days wall of the uterus Myoma can oppress

rectum causing

constipation Or even difficult

defecation

Urinary problems Urinary frequency in small Oppression in the bladder Amounts causing frequent/difficult

Urination.

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Summary of SignificantFindings

SIGNIFICANT FINDINGS NURSING DIAGNOSIS

Health History:

Gordon’s Functional Health Pattern:

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Constipation Impaired bowel elimination r/t

Irregular defecation habit

Decrease Time of Sleep Altered sleep pattern r/t

Uncomfortable sleep environment

Guarding of the Incision Area Risk for infection r/t tissue

Trauma secondary to surgicalIncision.

Inadequate Exercise Activity intolerance r/t fatigue

Decrease Movement Activity intolerance r/t fatigue

Physical Assessment:

Dry Skin Self-care deficit r/t inability to Perform ADL.

Decrease Appetite Imbalance Nutrition less thanBody requirements r/t Inabilityto ingest food secondary to surgical incision.

Surgical Incision Acute pain r/t tissue trauma

secondary to surgical incision.

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Laboratories:

Hematology Laboratory Report

Significant Findings Nursing Diagnosis

Hct Fluid volume deficit r/t active Fluid loss secondary to bleeding

Neutrophils Risk for infection r/t inadequate

Secondary defenses secondary To decreased hemoglobin

Lymphocytes Risk for infection r/t inadequate

Secondary defenses secondary To decreased hemoglobin

BUN Starvation related to lack ofNutritional Intake.

Hgb Fluid volume deficit r/t active fluid Loss secondary to bleeding

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Drug Study

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GENERIC NAME: SCOPALAMINE HYDROBROMIDE

BRAND NAME: hyosine HBr

CLASSIFICATION Anticholinergic, Antiemetic, Anti-motion sickness drug,

antimuscarinic, antiparkinsonian, Antispasmodic, Belladona alkaloid, Parasympatholytic Therapeutic actions

MECHANISMS OF ACTIONS Anti motion-sickness, drug not understood; antiemetic action

may be mediated by interference with cholinergic impulses to the vomiting center, has sedative and amnesia-ionducing properties, blocks effects of acetylcholine at Muscarinic, cholinergic receptors that mediate effects of parasympathetic postganglionic impulses, thus depressing salivary and bronchial secretions, inhibiting vagal influences on the heart, relaxingthe GI and Gi tracts, inhibiting gastric secretions, relaxing the pupil of the eye (mediatric effect), and preventing accommodation of near vision. (cycloplegic effect)

INDICATIONS Transdermal system: prevention and control of nausea and

vomiting associated with motion sickness and recovery from surgery. Adjunctive therapy with antacids and H2 anqtihistamines in peptic ulcer supportive treatment of functional GI disorder (diarrhea, pylorospasm, hypermobility, IBC, spastic colon, acute intrcolitis, panscreatitis, infant colic). Pre-anesthetic medication to control bronchial, nasal, pharyngeal and salivary secretions: prevent bronchospasm and laryngospasm; block cardiac vagal inhibitory reflexes during introduction and intubation; produce sedation. Introduction of obstetric amnesia with analgesic calming delirium. Treatment of postencephalitic parkinsonism and paralysis agitants;relief of symptoms in spastic states.

Opthalmic solution: diagnostically produce mydriasis and cycloplegia, preoperative and postoperative status in the treatment of Iredocyclitis.

CONTRAINDICATIONS Contraindicated with hypersensitivity to anticholinergic drugs;

glaucoma; adhesive between iris and lens; sterosing peptic ulcer, pyloroduodenal obstruction, paralytic, intestinal  atony, severe ulcerative colitis, toxic megacolon, symptomatic prostatic hypertrophy,

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bladder neck obstruction+, bronchial asthma, COPD, cardia arethmias, tachycardia, myocardial ischemia; impaired metabolic, liver, renal function ( increase likelihood of adverse CNS effects); myasthenia gravis, pregnancy ( causes resp.depression in neonates, contributes to neonatal hemorrhage); lactation period. Use cautiously with down syndrome, brain damage, spasticity, hypertension, hyperthyroidism; glaucoma or  tendency to glaucoma ophthalmic solution.

SIDE EFFECTS CCNS=pupil dilation, photophobia, blurred vision, headache, drowsiness, dizziness, mental confusion, excitement, restlessness, hallucinations delirium the presence of pain. CV=palpitations, tachycardia GI=dry mouth, constipation, paralytic ileus, altered taste perception, nausea, vomiting dysphagia, heartburn. GU=urinary resistancy and retention, impotence

Hypersensitivity: Anaphylaxis, urtecaria, other dermatologic effects. Other: suppression of lactation, flushing, fever, nasal congestion, decrease sweating  

NURSING INTERVENTIONS 1) Ensure adequate hydration; provide environmental control to

prevent hyperpyrexia. 2) Teaching points 3) Take as prescribed, 30-60 mins. Before meals, avoid excessive

dosage 4) Avoid hot environment. You will be heat intolerant, and dangerous

reactions may occur. 5) Avoid alcohol; serious sedation may occur. 6) When using transdermal system, take care to wash hands

thoroughly after handling patch and dispose of patch properly to avoid contact with children ad pets.

7) You may experience these side effects:dizziness, sedations, drowsiness (use caution driving or performing task that requires alertness)constipation (ensure adequate fluid intake, proper diet) dry mouth, blurred vision, sensitivity to light ( reversible, avoid task that require acute vision, wear sunglasses);impotence (reversible); difficulty urinating (empty bladder before taking drug)

8) Report rash, flushing, eye pain, difficulty breathing, tremors, loss of coordination, regular heartbeat, abdominal distention, hallucinations, severe or persistent dry mouth, difficulty urinating, constipation, sensitivity to light

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GENERIC NAME: METRONIDAZOLE

BRAND NAME: Viaflex

CLASSIFICATION Antibacterial, antibiotic, antiprotozoal, Amobacide

MECHANISM OF ACTION Bactericidal; inhibits DNA synthesis in specific amoerobes,

causing cell death; antiprotozoal-trichomonacidal, amebicidal.

INDICATION1) Acute infection susceptible anaerobic bacteria.2) Acute intestinal amoebiasis3) Amoebic liver abscess4) Trichomoniasis (acute and partners of patient with acute infection) 5) Bacterial vaginosis6) Preoperative, intra-operative, post-operative prophylaxis for patient

undergoing colorectal surgery. 7) Topical application; Treatment of inflammatory papules, pustules

and erythema of rosacea.8) Unlabeled uses; Prophylaxis for patient undergoing gynecologic

abdomen surgery.

CONTRAINDICATION:1) Contraindicated with hypersensitivity to metronidazole; pregnancy

(do not use in 1st trimester)2) Use cautiously with CNS disease, hepatic disease, candidiasis, blood

dyscrasis, and lactation.

SIDE EFFECTSCNS=Headache, dizziness, vertigo, insomnia, incoordiantion, seizures, peripheral neuropathy, fatigue.GI=Unpleasant metallic taste, anorexia, nausea, vomiting, diarrhea, GI upset and cramps.GU=Dysuria, incontinence, darkening of the urine.LOCAL=thrombophlebitis, redness, burning dryness and skin irritation.OTHER=Severe, disufiram-like interaction with alcohol, candidiasis (super infection)

NURSING INTERVENTION:1) Administer oral doses with food.2) Apply topically (metrogel) after cleansing the area. Advise patient

that cosmetics may be used over the area after application.3) Reduce dosage in hepatic disease.

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GENERIC NAME: CEFOROXIME

BRAND NAME: Ceftin

CLASSIFICATION Antibiotic, Cephalosporine (2nd generation)

MECHANISM OF ACTIONBactericidal; inhibits synthesis of bacterial cell wall, causing cell

death.

INDICATION1. Oral

-Pharyngitis, tonsillitis caused by streptococcus pyogens. -Otitis media caused by streptococcus pneumonae, S. pyogens, haemophilus influenzae, moraxella catarrhalis.

-Low respiratory infections caused by S. pneumonae, haemophilus parainfluenzae. -UTI caused by Escherichia coli, klebsiella pneumonae. -Uncomplicated gonorrhea -Skin and skin structure infections, including impetigo caused by S. aureus, S. pyogens.-Treatment of early lymedisease.

2. Parenteral -Lower respiratory infections caused by S. pneumonae, S. aureus, E. coli, klebsiella pneumonae, H. influenzae, S. pyogens.

-Dermatologic infections caused by S. aureus, S. pyogens, E.coi, pneumonae, enterobacter.

-UTI’s caused by E. coli, K. pneumonae-Uncomplicated and disseminated gonorrhea caused by

N.gonorrhea-Septicemia caused by S. pneumonae, S. aureus, E. coli, K.

pneumonae, h. influenzae.-Meningitis caused by S. pneumonae, H. influenzae, S. aureus,

N. meningitides.-Bone and joint infections due to S. aureus.-Pre-operative prophylaxis

SIDE EFFECTS:CNS=Headache, dizziness, lethargy, paresthesis.GI=Nausea, vomiting, diarrhea, anorexia, abdominal pain, flatulence, pseudomembranous.GU=NephotoxicityHEMATOLOGIC Bone marrow depression (decrease WBC, decrease platelet, decrease hematocrit)

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HYPERSENSITIVITY= Ranging from rash to fever to anaphylaxis; serum sickness reaction.LOCAL Pain, abcess at injection site, phlebitis, inflammation at IV siteOTHER=Superinfections, disulfram-like readction with alcohol.

NURSING INTERVENTIONS1. Culture infection and a range for sensitivity test before and

during therapy if expected response is not seen.2. Give oral drug with food to decrease GI upset and enhance

absorption.3. Give oral drug to children who can swallow tablet; crushing the

drug results in a bitter unpleasant taste.4. Have vitamin K available in case hypoprothrombinimia occurs.5. Discontinue if hypersensitivity reaction occurs.

GENERIC NAME: ranitidine hydrochloride

BRAND NAME: Zantac

CLASSIFICATION Histamine2 (H2) antagonist

MECHANISM OF ACTIONCompetitively inhibits the action of histamine at the H2 receptors

of the parietal cells of the stomach, inhibiting basal gastric acid secretion and gastric acid secretion that is stimulated by food, insulin, histamine, cholinergic agonists, gastrin and pentogastrin.

INDICATION1. Short term treatment of active duodenal ulcer at reduced

dosage.2. Maintenance therapy for duodenal ulcer at reduced dosage.3. Short term treatment of active, benign gastric ulcer4. Short term treatment of GERD5. Pathologic hypersecretory conditions6. Treatment of erosive esophagitis7. Treatment of heartburn, acid indigestion, sour stomach.

CONTRAINDICATIONS Contraindicated with allergy to ranitidine, lactation.

Use cautiously with impaired renal or hepatic function pregnancy.

SIDE EFFECTS:CNS=Headache, malaise, dizziness, somnolence, insomnia, vertigo.CV=Tachycardia, Bradycardia, PVC (Rapid IV Administration)

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Dermatologic= Rash and alopecia.GI=Constipation, diarrhea, nausea, vomiting, abdominal pain, hepatitis, increase ALT level.GU=Gynecomastia, impotence or decreased libido.

HEMATOLOGIC=Leukopenia, granulocytopenia, thrombocytopenia and pancytopenia. LOCAL=Pain at IM site, local burning or itching at IV site.

NURSING INTERVENTIONS:1. Administer oral drug with meals and at bedtime.2. Decrease doses in renal and liver failure.3. Provide concurrent antacid therapy to relieve pain.4. Administer IM dose undiluted, deep into large muscle group.5. Arrange for regular follow up, including blood tests to evaluate

effects.

GENERIC NAME: TRAMADOL HYDROCHLORIDE

BRAND NAME: Ultram, Ultram ER

CLASSIFICATION Analgesic (Centrally acting)

MECHANISM OF ACTIONBinds to un-opioid receptors and inhibits the reuptake of

norephinephrine and serotonin; causes many effects similar to the opioids-dizziness, somnolence, nausea, constipation but does not have the respiratory depressant effects.

INDICATION1. Relief of moderate to moderately severe pain.2. Relief of moderate to severe chronic pain in adults who need

around the clock treatment for extended period (ER tablets).

CONTRAINDICATIONS1. Contraindicated with allergy to tramadol or opioids or acute

intoxication with alcohol, opioids, or psychoactive drugs.2. Use cautiously in pregnancy; lactation; seizures; concomitant use

of CNS depressants, MAOI, SSRI, TCA; renal impairment; hepatic impairment.

SIDE EFFECTSCNS= Sedation, dizziness or vertigo, headache, confusion, dreaming, sweating, anxiety, seizures.CV= Hypotension, tachycardia, bradycardia.DERMATOLOGIC= sweating, pruritus, rash, pallor, flatulence.

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OTHER= Potential for abuse, anaphylactoid reactions.

NURSING INTERVENTIONSControl environment (temperature, lighting) if sweating or CNS

effects occur.

DRUG NAME: METOCLOPROMIDE

CLASSIFICATIONAntiemetic, Dopaminergic, GI stimulant

MECHANISM OF ACTIONStimulate motility of upper GI tract without stimulating gastric,

biliary, or pancreatic secretions; ppears to sensitize tissues to action of acetylcholine; relaxes pyloric sphincter, which, when combined with effects on motility, accelerates gastric emptying and intestinal transit; little effect on gallbladder or colon motility; increases lower esophageal sphincter pressure; has sedative properties; induces release of prolactin.

INDICATION1. Relief of symptoms of acute and recurrent diabetic gastroparesis2. Short term therapy (4-12 weeks) for adults with sympathetic

gastroesophageal reflux who fail to respond to conventional therapy.

3. Parenteral: prevention of nausea and vomiting associated with emetogenic cancer chemotherapy.

4. Prophylaxis of postoperative nausea and vomiting when nasogastric suction is undesirable.

5. Single-dose parenteral use: Stimulation of gastric emptying and intestinal transit of barium when delayed emptying interferes with radiologic examination of the stomach or small intestine.

CONTRAINDICATION1. Contraindicated with allergy to metoclopromide; GI hemorrhage,

mechanical obstruction or perforation; pheochromocytoma; epilepsy.

2. Use cautiously with previously defected breast cancer (one third of such tumors are prolactin dependent); lactation, pregnancy; fluid overload; renal impairment.

SIDE EFFECTCNS=Restlessness, drowsiness,fatigue, lassitude, insomnia, extrapyramidal reactions, parkinsonism-like reactions, akathisia, dystonia, myoclonus, dizziness, anxiety.CV=Transient hypertension

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GI=Nausea, diarrhea

NURSING INTERVENTIONS1. Monitor blood pressure carefully during IV administration.2. Monitor for extrapyramidal reactions, and consult physician if

they occur.3. Monitor diabetic patients, arrange for alteration in insulin dose or

timing if diabetic control is compromised by alterations in timing of food absorption.

GENERIC NAME: PARACETAMOL

CLASSIFICATION Antipyretic, Analgesic

MECHANISM OF ACTIONParacetamol has long been suspected of having a similar

mechanism of action to aspirin because of the similarity in structure. That is, it has been assumed that paracetamol acts by reducing production of prostaglandins, which are involved in the pain and fever processes, by inhibiting the cyclooxygenase (COX) enzyme.

INDICATIONThe preparation is indicated in diseases manifesting with pain

and fever: headache, toothache, mild and moderate postoperative and injury pain, high temperature, infectious diseases and chills (acute catarrhal inflammations of the upper respiratory tract, flu, small-pox, parotitis, etc.).

CONTRAINDICATIONSParacetamol should not be used in hypersensitivity to the

preparation and in severe liver diseases.

SIDE EFFECTS In rare cases hypersensitivity reactions, predominantly skin

allergy (itching and rash), may appear. Long-term treatment with high doses may cause a toxic hepatitis with following initial symptoms: nausea, vomiting, sweating, and discomfort. Occasionally a gastrointestinal discomfort may be seen.

NURSING INTERVENTIONS Assessment & Drug Effects

1. Monitor for S&S of: hepatotoxicity, even with moderate acetaminophen doses, especially in individuals with poor nutrition or who have ingested alcohol over prolonged periods;

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poisoning, usually from accidental ingestion or suicide attempts; potential abuse from psychological dependence (withdrawal has been associated with restless and excited responses).

2. Patient & Family Education3. Do not take other medications (e.g., cold preparations)

containing acetaminophen without medical advice; overdosing and chronic use can cause liver damage and other toxic effects.

4. Do not self-medicate adults for pain more than 10 d (5 d in children) without consulting a physician.

5. Do not use this medication without medical direction for: fever persisting longer than 3 d, fever over 39.5° C (103° F), or recurrent fever.

6. Do not give children more than 5 doses in 24 h unless prescribed by physician.

7. Do not breast feed while taking this drug without consulting physician.

GENERIC NAME: NICOTINAMIDE MONONUCLEOTIDE

BRAND NAME: Nicotinamide

CLASSIFICATIONNucleotides

MECHANISM OF ACTIONTreatment with high doses of nicotinamide (niacinamide, vitamin

B3) prevents or delays insulin-deficient diabetes in several animal models of type 1 diabetes and protects islet cells against cytotoxic actions in vitro. In recent-onset type 1 diabetes, nicotinamide administration improves beta-cell function, without significantly decreased insulin requirements. This review discusses the possible mechanism of action of nicotinamide in vivo. It is proposed that the key target of nicotinamide is the poly(ADP-ribose)polymerase (PARP), and to a lesser extent (mono)ADP-ribosyl transferases (ADPRTs). Suppression of PARP activity by nicotinamide not only decreases consumption of NAD+, the substrate of PARP, but also has major regulatory effects on gene expression, as shown for the major histocompatibility complex class II gene. In addition, PARP activity controls early steps of apoptosis. The possible suppression of ADPRTs by nicotinamide would also affect CD38, a membrane-bound external ADP-ribosyl transferase with potent immunoregulatory properties. Taken together, it is proposed that high doses of nicotinamide primarily affect ADP-ribosylation reactions in beta-cells as well as in immune cells and the endothelium. As a consequence, cell death

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pathways and gene expression patterns are modified, leading to improved beta-cell survival and an altered immunoregulatory balance.

INDICATIONIndicated for non-pregnant patients with acne vulgaris, rosacea

or other inflammatory skin disorders who are deficient in, or at risk of deficiency in, one or more of the components of Nicomide®.

CONTRAINDICATIONSNicomide® is contraindicated in patients with hypersensitivity to

any of its components. Supplemental copper is contraindicated in those with Wilson's disease (hepatolenticular degeneration) a disease of abnormal copper accumulation.

SIDE EFFECTSAllergic sensitization has been reported rarely following oral and

parenteral administration of Folic Acid. At recommended doses, Nicomide® is expected to be well tolerated. Gastrointestinal distress such as nausea or vomiting have been associated with the administration of nicotinamide or zinc at doses greater than the recommended dose of Nicomide®.

Nicotinamide: Dizziness, headache, hyperglycemia, nausea, vomiting, diarrhea, elevations in liver function tests, hepatotoxicity, blurred vision, flushing, rash.

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Discharge Plan

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HEALTH VISIT:

Advise the patient regarding her next visit for health as scheduled by DRA. AGUDO.

o Her next visit is on October 16, 2009 at ODH 10:00 a.m.

ACTIVITY LEVEL:

Discuss with patient the type and degree of any resulting impairment and disabilities.

Encourage the patient to do ROM exercises to promote muscle strength, endurance and control, such as:

o Flexion – Raise each arm from a position by the side forward and upward to a position beside the head.

o Extension – Move each arm from a vertical position beside the head forward and downward to a resting position at the side of the body.

o Hyperextension – Move each arm from a resting side position to behind the body.

o Abduction – Move each arm laterally from a resting position at the sides to a side position above the head, palm and hand away from the head.

o Adduction – Move each arm from a position at the sides across the front of the body as far as possible.

Instruct the patient to avoid heavy activities at home and in the community.

Encourage the patient good nutrition and diet.

SIGNS AND SYMPTONS:

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Advise the patient to consult her physician immediately if the following signs and symptoms of infection will appear:

Fever above 38°C Pain not relieve with Physician’s medication Swelling at the incision site Redness around the area of incision Foul smelling discharges Presence of pus around the area of incision

MEDICATION:

Provide information about the importance of continuing her medication which are as follows:

o Vitamins (Lieroferon) {1 cap OD}o Multivitamins and minerals with lysine {1 cap OD}o Nicotinamide

Advise the patient certain information pertaining to drugs prescribed including side effects.

Stressed the importance of proper intake of medication. High dosage may result to a serious adverse effect.

Provide information not to take alcohol when taking the medications. It may interfere with the absorption of the therapeutic effect of the drug.

Emphasize to the patient that smoking may decrease drugs effectiveness.

INCISION CARE:

Discuss the importance of proper wound dressing. Improper wound dressing may lead to infection.

Instruct the patient to observe proper aseptic techniques or wash hands before cleaning her wound at home.

Teach the patient the proper cleaning of wound. Advise the patient to use antiseptic solution such as betadine,

sterile gauze and bandage in cleaning the wound.

NUTRITION:

Advise patient to eat foods high in protein. This is to promote wound healing.

Emphasize the importance of eating nutritious foods. Encourage client to eat well balanced diet which include meat,

fish, liver, egg yolk (rich in protein), green leafy vegetables and

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fruits (rich in vitamins and minerals). Citrus foods (vitamin C) for absorption of Iron.

Encourage patient to drink enough fluid daily.

EDUCATION:

Discuss the related factors affecting wound healing, such as age and inadequate dressing technique, medication and over activity.

Advise client or significant others to keep surroundings clean and stress free to avoid infection.

Teach the client proper hygiene and good sanitation. Teach the client the importance of good nutrition and proper

diet. Advise the SO to give the client the whole support needed. Advise patient to follow the discharge instructions given. Encourage patient to submit to physical rehabilitation, keeping in

mind the goal to return to the highest level of function and independence as possible and restore activities of daily living.

Teach the patient proper wound care to prevent of infection. Encourage patient to have adequate rest and sleep to enhance

recovery.

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Nursing Care Plans

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Table of Contents

Submucosal Myoma

Introduction Gordon’s

Functional Health Pattern

Physical Assessment

Laboratory Findings Anatomy and

Physiology Pathophysiology Ideal Signs and

Symptoms Summary of

Significant Findings Drug Study Discharge Plan Nursing Care Plans

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10

1418

2931

33

364852

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