ABNORMAL UTERINE

BLEEDING(AUB)
GROUP 3 NR 22
ACKNOWLEDGEMENT
First and foremost, praises and thanks to the God, the almighty, for his
showers of blessings throughout the fulfillment of this study.
We would like to express our deepest gratitude to our former clinical
instructor, Mrs. Marissa M. Goco RN, MAN for giving us the opportunity to
do this study and providing invaluable guidance throughout this study. Her
dynamism, vision, sincerity and motivation have deeply inspired our group.
We would also like to thank Patient A for her bravery, cooperation and for
unhesitatingly giving us information that is needed in the completion of this
study.
 We are extending our heartfelt thanks to our adviser, Mrs. Ma. Lourdez N.
Fernandez and to the faculty for teaching us the methodology to carry out this
case study as clearly as possible. It was a great privilege and honor to work and
study under their guidance. We are extremely grateful for their caring and
sacrifices for educating and preparing us in the future.

WE THANK ALL OF YOU.

CHAPTER I
INTRODUCTION
 BACKROUND OF THE STUDY

• This is a case of 32 years old, female who was admitted at Gat Andres
Bonifacio Memorial Medical Center who was diagnosed with Abnormal
Uterine Bleeding.
• Abnormal uterine bleeding is any heavy or unusual bleeding from the uterus
through the vagina. It can occur at any time during the monthly cycle,
including during the normal menstrual period. Abnormal uterine bleeding
also happens when the patient bleed for too long or it is an extremely heavy
flow.
 OBJECTIVES OF THE STUDY
GENERAL OBJECTIVES
• To enhance skills, comprehension and approach
in the practice of nursing and be able to
establish knowledge in the risk factors,
prognosis nursing management, current trends
and incidence of the disease condition that was
chosen.
• This case study aims to acquire knowledge and
fully understand the disease process of
Abnormal Uterine Bleeding.
SPECIFIC OBJECTIVES
• To gather vital information/data from the patient.
• To make effective nursing care plan to solve health
problems.
• To assess the patient and identify present and
potential problems acquired.
• To render care and health teachings to the patient
and relatives to promote recovery and prevent
complications using the knowledge learned.
• To evaluate the progress of the client through
nursing care.
 SIGNIFICANCE OF THE STUDY

The group chose the case of patient who was diagnosed with abnormal
uterine bleeding because we considered it as a challenging study. The group
sought to know more about this case and how it affects the patient and his
family. We, the students will directly benefit the case study as well the patient.
Through this study, we will be able to understand and apply the nursing process
in doing intervention.
CHAPTER II
NURSING SUMMARY
 HEALTH HISTORY
A. DEMOGRAPHIC PROFILE
Patient A, 32 years old, Female is a Filipino that was born on December 11,
1986 in Bacolod City. A single woman and a Roman Catholic, lives at 148
Aplaya Baseco Port Area Manila. She was a housewife and taking care of her 3
children.
She was admitted at Gat Andres Bonifacio Memorial Medical Center on
November 18, 2019.
B. CHIEF COMPLAINT
The patient was rushed to the ER complaining of menorrhagia at 11 month and
vaginal bleeding. Initial diagnosis is AUB Anemia Severe.
C. HISTORY OF PRESENT ILLNESS
This is a case of 32 years old, female that came in due to vaginal bleeding. 11
months prior to admission, patient started to have an abnormal Bleeding, locating to the
lower quadrant and have severe headache. Patient had confused and unrecalled
management. Two days prior to admission, patient started to have lower quadrant pain
and severe headache that lead to fatigue. One day prior to confinement, patient
experienced left lower quadrant pain 5/10, and non-radiating, spontaneous cramps
associated with vaginal bleeding, no fever, and no other symptoms. No medication
taken or consult done. Twelve hours prior to confinement, pain increased to 8/10 thus
prompting consult.
D. PAST MEDICAL HISTORY
The patient has no past medical history and without any previous surgery.
No allergy to medications. No history of hypertension, diabetes mellitus and
etc. The patient was also found out for anemia.
E. FAMILY HISTORY—GENOGRAM
The patients’ family has no other disease both parents. They don’t have any
allergies even in food and medications.
E. FAMILY HISTORY—GENOGRAM
F. REVIEW OF SYSTEM
For review system of this patient, there’s a fever, anorexia, no eye or ear discharge,
no palpitations, no chest pain, no dysuria. No heat/cold intolerance
GENERAL Awake, not in distress

VITAL SIGNS BP 100/80 HR: 79 RR: 20 T: 36.9

HEENT Anicteric sclera, Pink conjunctiva, dry lips and oral

mucosa , flay neck veins

CHEST AND LUNGS Symmetric chest expansion, no retractions,

bronchovesicular breath sounds

HEART A dynamic precordium, PMI at 5th ICS LMCL, normal

rate, regular rhythm, no murmurs, S3 or S4

ABDOMEN Flat abdomen, normal active bowel sounds, soft (+)

tenderness on per umbilical area on deep palpitation

DRE No skin tags, no haemorrhoids, good sphincteric tone,

intact rectal vault, no masses palpated,(+) brown fecal

material per examining finger

EXTREMITIES Full pulses, no edema, no cyanosis

G. GORDON’S FUNCTIONAL HEALTH PATTERN

Functional Health Pattern Prior to Hospitalization During Hospitalization Analysis Interpretation

Health-Perception/ Health Patient views herself as a
Management healthy person when she was
still in normal condition.
Patient described her current
condition as going into the
healing phase. She verbalized
that she felts better than
previous days. She actively
participated in the interview
that we conducted during her
stay/s in the hospital. She also
verbalized understanding of
probable causes that might
contribute to the onset of her
illness.
Her current condition was
feeling better and as going into
the healing phase. She is
complying with the prescribed
medication to overcome his
illness.
Health- is a state of complete
physical, mental and social
being not merely the absence
of disease or infirmity.
(Fundamentals of Nursing the
Art and Science of Nursing
Care, 5th edition, Carol Taylor,
Carol Lillis, and Priscilla
Lemone, page 60).
Nutritional/ Patient ate regular diet. She Patient is in diet as tolerated The patient’s nutrition is at risk
Metabolic pattern prefers to eat food twice a day. and has IVF. due to absence of oral food as
When she eat food, she prefer well as patient oral
to vegetables. supplemental nutrition.

Nutrition-basic unit need that

change through the life cycle
and along the wellness-illness
continuum. Metabolism-
aggregate of all chemical
reactions in everybody cell.
(Fundamentals of Nursing the
Art and Science of Nursing
Care, 5th Edition, Carol Taylor,
Carol Lillis, and Priscilla
Lemon, page 1235.
Elimination Patient can’t easily defecate. Patient verbalized that she Patient’s elimination pattern is
Pattern She voided approximately 3-5 can’t defecate. She voided not anatomically normal prior
times a day with discomfort. twice in a day. to hospitalization.

Urinary and Gastrointestinal

System- together provide for
the elimination of body waste.
Urinary system helps to rid the
body of waste products and
materials that exceed bodily
needs. Bowel Elimination
waste products of digestion is
a natural process critical for
human functioning.
(Fundamentals of Nursing the
Art and Science of Nursing
Care,5th Edition, Carol Taylor,
Carol Lillis, and Priscilla
Lemone, page 1289,1137.)
Activity/ Exercise She works from 10pm to The patient is confined in bed and Due to her condition, her
Pattern 7am. She will only have 1 cannot do alternative exercise due to activity of daily living becomes
hour of sleep and would her condition. The patient was also limited.
continue doing the experiencing weakness when
household chores. communicating to others. Activities of Daily Living- are
those performed by person
usually on a daily basis.

Exercise- active exertion of

muscles involving the
Contraction and relaxation of
muscle groups. (Fundamentals
of Nursing the Art and Science
of Nursing Care, 5th edition,
Carol Taylor, Carol Lillis, and
Priscilla Lemone, page 1114)
Self-Perception- As a Mother, she felt She sees herself adjusting from
Self-Concept that she must be her illness but sometimes she is
Pattern strong in order to losing self-confidence, anxious,
support her family. and fear due to her condition and
lacked motivation to light activity
such as light exercise and self-
care. She stated improvement
from her well-being since the
start of her hospitalization. She
has problems w/ her current
state appearance but she said
that it will take time to boost her
confidence due to her
conditions.
The patient adjusted from
her illness but she seems
she is losing self-
confidence, anxious, and
fear due to her condition.
Self-Concept- is an
individual’s perception of
self.
(De Laune and Ladner,
Fundamentals of Nursing 3rd
edition)
Sleep/ Rest Patient usually She stated that she has
Pattern Has 1 hour of sleep Inadequate sleep and rest. Her
usually wakes up 8 or sleep wake cycle seemed altered
9 o’clock in the as she is in complete bed rest
morning. throughout the day. She
appeared due to restless due to
undesired environment upon
assessment.
The patient has
Inadequate sleep and rest.
Altered sleep-wake cycle
and she spent most of the
time resting and lying in
bed and she appeared mild
restless.
Sleep- is a state of rest
accompanied by altered
consciousness a relative in
activity. (Fundamentals of
Nursing the Art and Science
of Nursing Care, 5th edition,
Carol Taylor, Carol Lillis,
Priscilla Lemone, page
1169).
Role-Relationship She is not married She stated that she is a Her family support and love
Pattern yet but she has a live- housewife and she takes care of never fades.
in partner, who gives her children and live-in partner.
support to her 3 She still feels her role as a Role- refers to a set of
beloved children. mother through hospitalized. expected behaviour
determined by familial,
cultural and social norms.
(Fundamentals of Nursing
the Art and Science of
Nursing Care, 5th edition,
Carol Taylor, Carol Lillis,
Priscilla Lemone, page 183).
Sexuality/ She was sexually She was not sexually active
Reproductive active and she has because of her condition.
Pattern no problems with She has no reproductive
her sexuality. dysfunctions and has no
problems with her sexuality.
She stated that she is already
contented with her two
children.
She was not sexually
active.
Sexuality- is the degree
to which a person
exhibits maleness or
femaleness, physically,
emotionally and
mentally. (Fundamentals
Nursing the Art and
Science Nursing Care 5th
edition, Carol Taylor,
Carol Lillis, and Priscilla
Lemone, page 931).
Coping and She talks to her She considered chatting with The patient wants to
Stress Tolerance mom and live-in her live-in partner and family ignore her illness with
Pattern partner to as her coping mechanism. the presence of others.
overcome her The patient seldom feels
stress. Sometimes stressed as it might affect his Stress- condition in
she also wants health. Though she which human system
quiet environment sometimes feels anxious responds to change in
to relieved tension. because she surrounding in its normal balance state.
the ward does not match her (Fundamentals Nursing
desired environment. the Art and Science
Nursing Care, 5th edition,
Carol Taylor, Carol Lillis,
and Priscilla Lemone,
page 850).
Value- Belief The patient is a She usually prays whenever In spite of her illness,
Pattern Roman Catholic. she thinks about her she still believes that
She talked and condition. God loves her and will
thanked God in her guide her through the
own way by course of her distant.
praying. Value is a set of beliefs
that are meaningful in
life.
(De Laune and Ladner,
Fundamentals of
Nursing, 3rd edition).
LABORATORY DIAGNOSTIC
EXAMINATION
 COURSE IN THE WARD
NOVEMBER 20, 2019

ORDER SIGNIFICANCE

> May transfer to gyne ward

> Monitor VS The policy is important for baseline data.

> Watch out for vaginal bleeding Is performed to monitor the amount of blood loss.
> Tranexamic Acid 50g IV q 8 Tranexamic Acid is given to treat heavy bleeding.

> Ferrous Sulfate 1 tab BIF Ferrous Sulfate was given to as an iron

supplement to treat or prevent low blood levels or

irons.

> Ascorbic Acid 50g/tab OD Ascorbic Acid was given for prevention or

treatment of hemovascular disorders,

Burns, delayed fractures and wound healings.

> Refer To keep track of patient referrals throughout the

care continuum.
 CHAPTER III
DISCUSSION OF THE DISEASE
 A. DEFINITION AND DESCRIPTION OF THE DISEASE

Abnormal Uterine Bleeding (AUB)

Abnormal uterine bleeding (formerly, dysfunctional uterine bleeding
[DUB]) is irregular uterine bleeding that occurs in the absence of
recognizable pelvic pathology, general medical disease, or pregnancy. It
reflects a disruption in the normal cyclic pattern of ovulatory hormonal
stimulation to the endometrial lining. Bleeding may be heavier or lighter
than usual and occur often or randomly.
 AUB CAN OCCUR

•As spotting or bleeding between your periods

•After sex
•For longer days than normal
•Heavier than normal
•After menopause
•It does NOT occur during pregnancy. Bleeding during pregnancy
has different causes. If you have any bleeding when you are
pregnant, be sure to call your health care provider
 CAUSES
Some of the causes of abnormal bleeding include the following:
•Problems with ovulation
•Fibroids and polyps
•A condition in which the endometrium grows into the wall of the uterus
•Bleeding disorders
•Problems linked to some birth control methods, such as an intrauterine device
(IUD) or birth control pills
•Miscarriage
•Ectopic pregnancy
•Certain types of cancer, such as cancer of the uterus
 SYMPTOMPS OF AUB MAY INCLUDE

•Bleeding or spotting from the vagina between periods

•Periods that occur less than 28 days apart (more common) or more than
35 days apart
•Time between periods changes each month
•Heavier bleeding (such as passing large clots, needing to change protection
during the night, soaking through a sanitary pad or tampon every hour for 2
to 3 hours in a row)
•Bleeding that lasts for more days than normal or for more than 7 days
 SYMPTOMPS OF AUB MAY INCLUDE

OTHER SYMPTOMS CAUSED BY CHANGES IN HORMONE LEVELS MAY

INCLUDE:
•Excessive growth of body hair in a male pattern (hirsutism)
•Hot flashes
•Mood swings
•Tenderness and dryness of the vagina
•A woman may feel tired or fatigued if she loses too much blood over time. This is a
symptom of anemia.
 B. ANATOMY AND PHYSIOLOGY

The uterus is a hollow muscular organ located in the female pelvis between the
bladder and rectum. The ovaries produce the eggs that travel through fallopian tubes.
The main function of the uterus is to nourish the developing fetus prior to birth. It also
provides waste removal, helping to keep the fetal environment clean.
The uterus has three parts. The fundus or the top of the uterus, above the entry point
of the uterine tubes. The body or the usual site for
implantation of blastocyst. The cervix or the lower
part of the uterus linking it with the vagina.
This part is structurally and functionally different
to the rest of the uterus.
C. PATHOPHYSIOLOGY
D. DRUG STUDY
CHAPTER IV
NURSING MANAGEMENT
A. NURSING CARE PLAN
 B. DISCHARGE PLAN

M- MEDICATION
● Advice the patient to take the entire course of any prescribed medications.
● Medication must be continued according to the NURSING CARE PLAN
● Doctor’s instruction to ensure optimum recovery.
● Explain in a manner that can be understood as to name, actions, side effects
etc.
E- EXERCISE
● Keep emotional stress under control by using relation technique such as
muscle relaxationexercise.
T- TREATMENT
● Get plenty of rest.
● Adequate rest is important to maintain progress toward full recovery and to
avoid relapse.
H- HEALTH TEACHING
● Advise the patient to avoid any kind of heavy work.
● Instruct the patient to eat healthy foods.
● Advise the family to provide emotional support.
O- OPD
● Keep all of follow up appointments.
● Even though the patient feels better there is a possibility to relapse. It is
important to have the doctor monitor its progress.
● Advise the patient to comply with treatments.
D- DIET
● Drink a lot of fluids, especially 8 glasses of water a day at least.
● liquid will keep patient from being dehydrated
● Advice patient to eat a balanced diet that is high in iron and vitamin C. Foods
rich in iron include red meat, shellfish, eggs, beans, and green leafy vegetables.
S- SPIRITUAL
● Advise the significant others to guide and support the patient by uplifting her
spiritual being.
● Maintain positive out looking life.