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General Objectives:
This case study aims to gather significant information that contributes to giving
nursing care to a patient diagnosed with endometrial hyperplasia. This also intends to
help the patient achieve the maximum level of health within his capability.
Specific Objectives:
• Conduct a comprehensive interview
• Assess patient from head to toe
• Know the management of endometrial hyperplasia
• Correlate patient’s laboratory result with his illnesses
• Administer medications as ordered
• Provide health education to patient and patient’s SOs
• Assist in patient’s mobility
• Implement nursing care plans
• Implement a discharge plan
Introduction:
ENDOMETRIAL HYPERPLASIA
Definition:
Heavy menstruation
Extended menstruation
Menorrhagia
Irregular menstruation
Medical Management:
Progestin therapy
GENOGRAM:
Legend:
- endometrial hyperplasia
GORDON’S FUNCTIONAL HEALTH PATTERN
ELIMINATION PATTERN
Patient says she usually defecates every morning . Her stool is usually soft,
yellow and has no bleeding. She had a history of constipation and diarrhea. She doesn’t
have any history of incontinence. She usually void 3 times a day. Her urine is usually
yellow.
ACTIVITY-EXERCISE PATTERN
Patient rates her self-care in feeding as 0, bathing /hygiene as 0,
dressing/grooming as 0, toileting as 0 and ambulation as 0 with 0 as completely
independent. She has no oxygen use at home. She uses only 1 pillow to sleep. Her works
are washing clothes and sweeping the floor. Her way of exercise is walking but not
regularly. Her hobbies are listening to music and watching television.
COGNITIVE-PERCEPTUAL PATTERN
Patient J.D. doesn’t have any difficulty in decision-making. She can define what
his current problem is that she is having heavy vaginal bleeding. She thinks all will be
alright after her stay in the hospital.
ROLE-RELATIONSHIP PATTERN
Patient’s J.D. live with her family. She has no children. She is the only daughter
of the family. She likes to watch TV. She likes being stagnant.
PHYSICAL ASSESSMENT
General Appearance:
Patient J.D. is fat. She is infused with D5NM 1L@40gtts/min at her right arm.
Her weight is 80 kgs and her height is 5’.
Musculoskeletal system
• posture erect
• shoulders, arm and elbows are symmetrical, no redness, swelling or deformity
• hands and fingers are symmetric, non tender, without nodules
• knees are in alignment with each other
• feet are in alignment with lower legs
• lower leg in alignment with upper leg
• toes and feet are in alignment with the lower leg
Neurologic
• conscious
• good eye contact, smiles, and frowns appropriately
• speech moderate tone, clear
• able to hear
• able to swallow
• follows directions accurately
• recalls recent events without difficulty
• her eyes are in coordinated motion in all directions
• can identify correct flavor
LABORATORY EXAMINATION
Brand
ANATOMY AND PHYSIOLOGY
Uterus
The uterus is located inside the pelvis immediately dorsal (and usually somewhat
rostral) to the urinary bladder and ventral to the rectum. The human uterus is pear-shaped
and about 3 in. (7.6 cm) long. A females uterus can be divided anatomically into four
segments: The fundus, corpus, cervix and the internal os.
Regions
• Vulva
• Vagina
• Cervix uteri - "neck of uterus"
o External orifice of the uterus
o Canal of the cervix
o Internal orifice of the uterus
• corpus uteri - "Body of uterus"
o Cavity of the body of the uterus
o Fundus (uterus)
Layers
Endometrium
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.
Damage to the basal endometrium results in adhesion formation and/or fibrosis
(Asherman's syndrome). In most mammals, including humans, the endometrium
builds a lining periodically which is shed or reabsorbed if no pregnancy occurs.
Shedding of the functional endometrial lining in humans is responsible for
menstrual bleeding (known colloquially as a woman's "period") throughout the
fertile years of a female and for some time beyond. In other mammals there may
be cycles set as widely apart as six months or as frequently as a few days.
Myometrium
The uterus mostly consists of smooth muscle, known as "myometrium." The
innermost layer of myometrium is known as the junctional zone, which becomes
thickened in adenomyosis.
Perimetrium
The loose surrounding tissue is called the "perimetrium."
Peritoneum
The uterus is surrounded by "peritoneum."
The uterus provides structural integrity and support to the bladder, bowel, pelvic
bones and organs. The uterus helps separate and keep the bladder in its natural position
above the pubic bone and the bowel in its natural configuration behind the uterus. The
uterus is continuous with the cervix, which is continuous with the vagina, much in the
way that the head is continuous with the neck, which is continuous with the shoulders. It
is attached to bundles of nerves, and networks of arteries and veins, and broad bands of
ligaments such as round ligaments, cardinal ligaments, broad ligaments, and uterosacral
ligaments .
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.
Precipitating factors:
obesity
age
exposure to unopposed endogenous
or exogenous estrogen/tamoxifen
infertility + nulliparity
family history of endometrial cancer
Hyperestrogenism
6.7..Encourage
Encourage
theparticipation in recreation
patient to avoid alcohol.
. R: That
R: Enhances sense of well
can precipitate being.
acute attack.
7.8. Review
Providefoods
assistive
that devices
are rich in purines like sardines, anchovies, shell
R: Fish
Aidsand
patient’s mobility.
organ meats.
R: To avoid foods that precipitate Acute attacks.
DISCHARGE PLAN
1. Medications
Name of drug Dosage and Route Curative Effects Side Effects
Frequency
2. Exercise / Activity
:__________________________________
__________________________________
Procedure or Steps:
_________________________________________________________________
_________________________________________________________________
______________
Restrictions:_______________________________________________________
______
( ) others __________________
5. a.. Observed signs and symptoms that need reporting:
____________________________________________________________________
____________________________________________________________________
a. Prescribed Diet:
b. Restrictions:
A. Discharge Details
b. Accompanied by:
___________________________________________________________
c. Mode of Transportation:
______________________________________________________
____________________________________________________________________
______
____________________________________________________________________
______
August Angelo Asido
Ije Bactol
Mark Anthony Degamo
Jeralden Bolo
Mary Jane Lamoste
Catherine Rose Macabata
Ma. Luisa Mantilla
Junalie Verano