Case Presentation:

Endometrial Cancer
Group 2
Fhaye Kristine Kaye Lorenzo
Daphne Barillo
Christie Marie Barillo
Joy Jamili
Alevi Aguilar
Venancio Navarro
Faith Pacure
Karen Dollopac

Area of Exposure: ASMGH-OB Gyne Ward

PM Shift
 Biographic Data
Name: MJB
Age: 43yo
Sex: Female
Civil Status: Single
Address: Barbaza, Antique
Birth place: Barbaza, Antique
Birth date: July 7, 1966
Religion: Aglipayan
Nationality: Filipino
Date of Admission: September 17,2009
Attending Physician: Dr. Maria Ceilo S.
Sansolis
Admitting Diagnosis: Endometrial Cancer
Informant: Client and AJB
Relationship to the Client: Sister
This is the case of MJB, a 43
year-old female, single and a
resident of Barbaza, Antique
presently admitted at Angel
Salazar Memorial General
Hospital with the admitting
diagnosis of Endometrial
Cancer.
 Overview
What is Endometrial Cancer?
Endometrial carcinoma is a kind of cancer that begins in your
uterus. Only women have a uterus. So only women can get this
kind of cancer. Carcinoma refers to cancer that begins in tissues
that form linings throughout the body. The endometrium is the
lining of the inside of the uterus. Endometrial carcinoma is a
cancer that forms from the inner lining of the uterus. Throughout
this section, we refer to it simply as endometrial cancer. Other
kinds of cancer can form in the uterus as well. These are called
uterine sarcomas. They are discussed in their own section.
Endometrial cancer usually takes years to develop. It most often
occurs in women who have already gone through menopause.
 What causes Endometrial/Uterine cancer?

The main cause of most endometrial cancer is too

much of the hormone estrogen compared to the body's
progesterone level. Estrogen makes the lining of the
uterus (endometrium) grow thicker. Progesterone
"opposes" estrogen-your progesterone level goes up
then drops at the end of each menstrual cycle, making
the thick endometrium layer shed away. This is what
you know as menstrual bleeding. When there is too
much estrogen in the body, progesterone can't
do its job. The endometrium gets thicker and
thicker. Over time, the endometrium cells can
become cancerous. 
 Chief Complaint:

Abdominal pain and enlargement

of the abdomen 2 weeks PTA.
 History of the
Present Health Concern

Two weeks PTA, the patient had

tolerable abdominal pain and mild
cramps with enlargement of the
abdomen. Patient did not take any
medications to relieve the pain. Patient
symptoms persisted, thus sought
consultation and was advised for
admission.
 Past Health
The History
client was fully immunized (1BCG, 3DPT,
3OPV, 3 Hepa B and 1measle vaccine). No
known allergies, (-) for Bronchial Asthma, (-)
for Hypertension, and (-) for Diabetes Mellitus.
Patient is also known as an alcoholic drinker,
consumes 2-3 bottles of beer a week. Last
January 2007 the client, undergone surgical
operation, the removal of uterine mass.
 OB Gyne History
The client had her first
menstrual period (menarche) at the
age of 15, with regular intervals
lasting for 3-5 days consuming 2pads
a day. Gravida-0 and Parity-0.
 Physical Assessment
A. General Survey:
Height: 5’4”
Respiratory Rate: 28 breaths/min (tachypnea)- due to
venous obstruction
Brachial Pulse: 145 beats/min (tachycardia)- physical
signs of pain.
Temperature/axilla: 37.9 degrees Celsius
Blood Pressure: 140/100mmHg
Level of Consciousness: lethargic (drowsy, response
to question then fall
asleep) with blunted affect.
B. Skin, hair, and Nails Assessment
1. Skin: tan, dry, and fairly hot to touch. Skin
fold returns to place after 2-3 seconds. She was
pale and cachexic (skin-bone results from the
increase metabolic demand of the tumor). Minimal
moles can be seen on the face. No edema of the
face noted.
2. Hair: black, straight chin level and evenly
distributed hair. (-) for Seborrheic dermatitis and
Pediculusis capitis. No scalp lesions noted.
3. Nails: thick, hard, well-trimmed nails. The
condition of the nail bed is smooth and firm. (-) for
Clubbing or Beau’s lines.
C. Head and Neck Assessment
Head: symmetric, round and in
midline. No visible lesions noted.
Neck: symmetric without
masses, scars, pulsation, lymph
nodes non-palpable. Trachea in
midline. Thyroid gland non-palpable
with strong bounding (+4) carotid
pulse.
D. Eyes: protruded eyes without lesion or edema.
Sclera is white without lesions noted. Eyebrows
sparse with equal distribution. Pupil Equal,
Round, Reactive to Light and Accommodation
(PERRLA) .
E. Ears: Lesion noted at the right auricle.
(papule)
F. Nose and Sinuses: external structure without
deformity. Symmetrical and patent nares with no
inflammation noted. Nasal septum midline without
bleeding perforation or deviation. Frontal and
maxillary sinuses non-tender.
G. Mouth and Pharynx: pale and dry lips. Cheilosis noted.
H. Cardiac Assessment: no vibrations or pulsations noted.
I. Breast Assessment: No discharges from the nipples.
Non-tender and no dimpling or retraction noted.
J. Abdominal Assessment: hard, tender abdomen.
Abdominal girth of 85 cm and fundal height of 33 cm
with palpable mass on the pelvic floor upon Internal
Examination (IE). Visible veins noted due to abdominal
distention.
K. Genitourinary-reproductive Assessment: with
palpable mass on the pelvic floor upon Internal Examination
(IE). With minimal vaginal bleeding. Foley Catheter attached
to urobag draining to a yellowish urine.
 c Planning Nursing Intervention Rationale

Very severe General: Independent:

abdominal pain r/t After days of 1.Perform pain
direct tumor hospital assessment each
involvement. confinement, the time pain occurs. To rule out
patient psychological Note specific worsening of
Subjective Cues: attitude and physical location and underlying
“Gabalik-balik sakit status will be able to intensity (0-10 scale) condition.
kang akon busong” cope with the 2.Monitor vital signs.
situation.
Objective Cues: Dependent:
Facial grimacing Specific: 1. Administer
Pain scale=8/10 After 8H of medication as
(very severe pain) nursing intervention, ordered and
RR = 28 cpm patient will be able indicated especially
To relieve pain
PR = 145 bpm to: for the persistence of felt by the patient.
BP = 140/100 mmHg 1. Tolerate pain and pain. (Tramadol
will have a pain 25mg)
Reference: Nursing Care scale of 4
Plans & Documentation ; 4th
Edition; Linda Moyet (p579) 2. Have a vital signs
within normal range.
Nursing Diagnosis Planning Nursing Rationale
Intervention
Enlargement of the General: Independent:
abdomen r/t Fluid After days of 1.Monitor FH and 1. These
accumulation in the hospital Abdominal girth measurements help
peritoneal cavity confinement, the daily. detect fluid retention
occurs due to the patient psychological and ascites.
direct pressure by attitude and physical 2. Maintain bed rest. 2. Immobility
the tumor or venous status will be able to reduced the risk of
obstruction. cope with the 3. Monitor Intake andinjury.
situation. Output (MIO).
Subjective Cue: 3. Monitor losses
“Gabahol akon Specific: 4. Monitor calculation
busong kag wara rn After 8H of respiratory, bowel
ako kamus-on halin nursing and bladder 4. Level cord
kang sarang semana interventions, function. compression
“ patient will be able influences
to: respiratory
Objective cues: (cervical), bowel
1.Enlargement of the 1.Report decrease in Dependent: (lumbar), and
abdomen with abdominal size and bladder (lumbar)
Fundal Height: fundal height 5. Administer functioning.
33cm medication as
Abdominal Girth: 2. Defecate ordered.
85cm 5. Aids in the
elimination of stool
Reference: Nursing Care Plans
& Documentation ; 4th Edition;
thank you!