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

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 clients 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 20s, 30s, and 40s. 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.

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)

Orem's theory of self-care takes into consideration several other concepts, namely selfcare, 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,

 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.

II. CLINICAL SUMMARY A. General Data Name Case Number Gender Age Birth date Birthplace Civil Status Nationality Religion Occupation S.O Date of Admission Time of Admission Physician Diagnosis B. Nursing History Present 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. Mrs. MYOMA 1106547 Female 48 years old May 22 1963 Bicol Married Filipino Roman catholic Housewife Mr. R.S June 15, 2011 2:00 pm Dr. Agbayani Uterine Myoma t/c DM

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 doesnt comply due financial problem. The patient doesnt 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.

D. Social History Developmental theory (Erik Erickson) Stage age Central task Indicator of positive resolution Commitment to other. Close heterosexual relationship. Indication of negative resolution Withdrawal from such intimacy, solution self absorption & alienation from other.

Intimacy vs. Isolation

(18-40 yrs) young adult (1854 yrs)

Generativity vs. stagnation

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

Seek relationship & affiliations with either with opposite sex or with a group of individuals to whom the develop strong personal attachment. 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 12yrs and above Name Genital stage Pleasure source Opposite sex Conflict

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.

F. Physical assessment General condition: Oriented to spheres (time,date,person) Pale and weak in appearance Vital signs: T - 36.3 c RR 26 bpm PR 86 bpm BP 110/80 mmHg Normal finding Normocephalic with no abnormal masses. Actual finding Hair is black, thick, evenly distributed, curly hair Head is round, proportion to body No presence of visible lesion 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 Symmetrically aligned to the face Firm and no tender No discharge noted No palpable masses along the pinna Symmetric both nostril No discharge or flaring Interpretation Normal

Parameters Head

Eyes

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

Normal

Ears

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

Normal

Nose

Symmetric and straight, no discharge

Normal

Mouth

Pinkish color of lips, moist tongue at midline, no lesion Coordinated and smooth movement no masses, tenderness Symmetric chest expansion, quiet, rhythmic and effortless respiration

Neck

Chest

Abdomen

Unblemished skin, uniform in color, no masses, soft

Genito-urinary

Upper and lower extremities

Can defecate and urinate without any distraction or harmful feeling, and normal structure No lesion, can move freely with capillary refill of (2-3 sec.)

Pale and dry lips Gums are moist Tongue at midline without lesion Coordinated movement No masses, tenderness Symmetric chest expansion Normal breath sound Not in resp. distress With abdominal pain at hypogastric area With masses Non tender abdomen Soft abdomen Enlarged abdomen Defecated once a day No painful urination With slow movement Upper extremities is symmetrical in size Lower extremities is symmetrical in size No swelling and lesion Poor skin turgor Cold to touch pallor

Normal

Normal

Normal

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

Normal

Normal

Skin

Pinkish in color, without lesion

Not normal it is a manifestation of poor circulation of blood

G. Patterns of functioning Function of health pattern Health management pattern Nutritional / metabolic: a. number of meal per day b. appetite c. glass of water d. body build e. height and weight Elimination a. Frequency of elimination b. Amount of urine per c. Frequency bowel movement d. Consistency of stool e. Amount of defecated per day Activity and exercise a. Exercise Before hospitalization she takes her medicine if there is pain three times a day normal appetite 6 to 8 glass of water Normal body built for Filipino women 52ft / 59 Urinated 3 -8 times a day Defecated 1 2 times a day 1.5 L to 2 L 5 -10 Urinated 3 6 Defecated 1- 2 1.5L to 2L 5 10 The patient elimination was normal During hospitalization Interpretation She takes her medicine daily The patient takes her medicine daily in the hospital. The patient eat, drink normally and has a normal body built

three times a day normal appetite 6 to 8 glass of water Normal body built 52 ft / 59

Yellowish in color 1/4kg

Yellowish in color 1/4kg The patients activity lessen in the hospital. The only exercise that she can do is walking.

b. Fatigability c. ADL

the patient exercise is walking and doing household work she rest after her work she make her household

walking

rest sleep and rest

work Cognitive / Perception a. Orientation The patient was oriented to three spheres (time, place, person). b. Responsiveness The 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 patients idea to seek medical consultation is good for her health. At first she doesnt comply with the doctors 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 familys 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 1 DOCTORS ORDER 12mn > RBS=311 mg/dL 7pm > RBS=226 mg/dL NURSING ACTION WITH TATIONALE Monitor patients 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 diabetes mellitus. JULY 04, 2011 12mn Regular > RBS=269mg/dL 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 9:30am > RBS= 259mg/dL Regular insulin 3 units sc now > follow up for FBS result 2 7:20pm > RBS= 263 mg/dL Regular insulin 3 units sc now 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

6am > RBS= 377 mg/dL Regular insulin 5units sc now

III. Clinical Discussion of the Disease 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. b. c. 2. External orifice of the uterus Canal of the cervix Internal orifice of the uterus 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 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

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

ACTUAL PATHOPHYSIOLOGY

Predisposing Factors: -Age -Race -Early Menarche

Etiology: Unknown

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

Estrogen Dominance or increase in Estrogen production

Proliferation of cells in uterus (Sub mucous) Overgrowth the endometrial lining Myoma: Development of uterine fibroid Uterine Cavity begins to stretch or increase in size

Interference in the vascular supply

Degeneration of the interior part of fibroid

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

PATHOPHYSIOLOGY General
Etiologic Factor
Non Modifiable Modifiable

20-20% women on reproductive year Between 25 and 45 years of age Anovulatory cycle High level of unopposed estrogen Heredity-cellular, immunity failure

Lifestyle High amount of fatty intake Alcohol drinking Smoking mother

Result on abnormal cell proliferation or growth

FIBROIDS FORMATION Arouses on three different part

INTRACAVITARY INTRAMURAL SEROASAL

Continues stress on myometrium Multiple Fibroids

Continuous growth of cell, cell formation

Necrosis formation on the surface of endometrium overlying the myoma

Torsion of the pedunculated myoma

Other symptom resulted from the continuous growth of myoma

Abnormal Bleeding Menorrhagia Metrorhagia

Progressing degenerationhypogastric pain

Backache Pressure Bloating Constipation Urinary problem