Dysfunctional Uterine Bleeding secondary to Submucous Myoma

A Case Study Presented to

The Faculty of the College of Nursing

University of Cebu Lapu-Lapu and Mandaue

Looc, Mandaue City

In Partial Fulfilment

Of the Requirement in

Nursing Care Management 102

Submitted By:

Latoja, Darnley Lovielyn C.

BSN II

March 2018
 Table of Contents

Page No.

I. INTRODUCTION...............................................................................5

II. GENERAL DATA................................................................................7

III. OBSTETRIC GYNECOLOGICAL HISTORY............................................ 8

IV. PAST HEALTH HISTORY....................................................................8

V. CLIENT CLINICAL COURSE IN THE UNIT............................................9

VI. GORDON’S FUNCTIONAL HEALTH PATTERN......................................10

1. Health Perception – Health Management

Pattern

2. Nutritional – Metabolic Pattern

3. Elimination Pattern

4. Activity – Exercise Pattern

5. Sleep Rest Pattern

6. Cognitive – Perception Pattern

7. Self Perception and Self Concept Pattern

8. Role – Relationship Patterns: Genogram

9. Sexuality – Reproductive Pattern

10. Coping – Stress Tolerance Pattern

11. Value – Belief Pattern

VII. ENVIRONMENTAL HISTORY.............................................................15

VIII. PHYSICAL ASSESSMENT..................................................................16

IX. DEVELOPMENTAL DATA.................................................................. 19

 X. ANATOMY, PHYSIOLOGY AND

RELATED PATHOPHYSIOLOGY

A. Anatomy and Physiology of the System Involved...........................21

B. Conceptual Framework on the Pathophysiology

of Dysfunctional Uterine Bleeding secondary to

Submucous Myoma................................................................... 24

C. Discussion of the Pathophysiology ...............................................26

D. Symptomatology........................................................................27

XI. MEDICAL MANAGEMENT.................................................................27

A. Diagnostic Studies

B. Results and Findings (present the laboratory tests)

C. Treatments and Procedures

D. Medications

E. Diet

XII. NURSING MANAGEMENT

A. Goal of Care...............................................................................33
Assessment
Diagnosis
Planning

B. Actual Care Given.......................................................................34

Interventions

C. Problems encountered during the Implementation

of Nursing Care..........................................................................35

D. Restorative Measures Used.........................................................35

E. Evaluation..................................................................................36
 F. Patient Teaching.........................................................................36

XIII. CONCLUSION/RECOMMENDATION.................................................. 37

XIV. IMPLICATION OF THE STUDY......................................................... 38

A. Nursing Education – Knowledge or Information

B. Nursing Practice – Skills

C. Nursing Research – for baseline information

for future study

APPENDICES

Appendix A: Permit Letter

Appendix B: Nursing Care Plan

Appendix C: Discharge Plan (M E T H O D S)

Appendix D: Drug Study

Appendix E: IVF Study

REFERENCES
APPENDICES