Republic of the Philippines

Region 2
UNIVERSITY OF LA SALETTE, INC.
Santiago City, Isabela

IN PARTIAL FULFILLMENT OF THE COURSE REQUIREMENT IN MCN

(MATERNAL AND CHILD NURSING) 3

A CASE STUDY

Submitted to:
MRS. JEANE C. LAURELIO, RM, RN, MSN
Instructor

Submitted by:
KHEROVINE C. TAYABAN
Student

23 March 2018
I. INTRODUCTION
Adenomyosis, also referred to as “uterine endometriosis,” is a
benign disease confined to the uterine muscle. Endometrial cells from the
lining of the endometrial cavity, migrate from that lining, most commonly
into the posterior side or back wall of the uterus. As these cells respond to
monthly hormonal changes, blood can get trapped in the myometrium
producing a hard and enlarged uterus. Adenomyosis is most frequently
seen in women in their early to middle 40s and is often associated with
hormone imbalance, usually an excessive estrogen supply. Various
published studies have shown that 12% of patients with Adenomyosis
also have been diagnosed with Endometriosis in other sites outside the
uterus, within the pelvis. As high as 62% of women who had
hysterectomy were found to have this disease on pathology reports.
At this point in research studies, the etiology or cause of
Adenomyosis is unknown. Some studies also suggest that women who
have had prior uterine surgery may be at risk for adenomyosis. A known
genetic link is also present, as with endometriosis, and it does tend to run
in family history. At this point, however, the reason for the disease
continues to be inconclusive.
The severity of the signs and symptoms associated with
Adenomyosis is often directly proportional to the degree of involvement
and penetration into the uterine muscle. The more the disease spreads,
the greater the symptoms. Many patients with Adenomyosis can be
without symptoms (asymptomatic) just like fibroids and endometriosis,
but most commonly women report the following symptoms associated
with their enlarged uterus: dysmenorrhea (painful periods),
hypermenorrhea (heavy periods), prolonged bleeding cycles, cramps,
large clots, abdominal bloating, back pain, severe and increasing
abdominal pain throughout the month, painful intercourse, and nausea
and vomiting.
The only definitive way to diagnose adenomyosis was to perform a
hysterectomy and examine the uterine tissue under a microscope.
However, imaging technology has made it possible for doctors to
recognize adenomyosis without surgery. Using MRI (magnetic resonance
imaging) to confirm a diagnosis of adenomyosis in women with abnormal
uterine bleeding or transvaginal ultrasound, doctors can see
characteristics of the disease in the uterus.
If a doctor’s suspects adenomyosis, the first step is the physical
exam. A pelvic exam may reveal enlarged and tender uterus. An
ultrasound can allow a doctor to see the uterus, its lining, and its
muscular wall. Though ultrasound cannot definitively diagnose
adenomyosis, it can help to rule out other conditions with similar
symptoms.
 Another technique sometimes used to help evaluate the symptoms
associated with adenomyosis is sonohysterography. In
sonohysterography, saline solution is injected through a tiny tube into the
uterus as an ultrasound is given.
Because the symptoms are so similar, adenomyosis is often
misdiagnosed as uterine fibroids.
However, the two conditions are not the same. While fibroids are
benign tumours growing in or on the uterine wall, adenomyosis is less
defined mass of cell with in the uterine wall. An accurate diagnosis is key
in choosing the right treatment.
II. PATIENT’S PROFILE

Name: Patient SEY

Age: 44
Gender: Female
Date of Birth: July 17, 1973
Address: La Paz Saguday Quirino
Civil Status: Married
Occupation: Housewife
Religion: Roman Catholic
Chief Complaints: Excessive vaginal bleeding and severe hypogastric pain
Date of admission: November 30, 2017
Clinical Diagnosis: G8P8(8008), HMB r/o Endometrial pathology, S/P
hysterectomy

III. MEDICAL HISTORY

A. HISTORY OF PAST ILLNESS/PAST MEDICAL HISTORY

The patient stated that she was diagnosed with DM and HPN2
two years ago and been taking her maintenance since then. She also
undergone one major operation on her last pregnancy, a Caesarean
Section due to fetal distress.
She added that every menstruation she always experience
heavy bleeding and dysmenorrhea. This was started when she was 35
years old. Due to heavy bleeding every menstruation, endometrial
pathology performed to her a year ago.

B. HISTORY OF PRESENT ILLNESS

Few hours PTA, the patient complains of dizziness, headache,
and severe bleeding with hypogastric pain. Vitals signs were taken
and all are within normal range except for her BP which was
130/100mmhg. Her LMP was on Nov. 6, 2010.
Ultrasound was ordered and hysterectomy was performed.

C. FAMILY HISTORY OF THE DISEASE

According to the patient, her father has hypertension. Her
mother side has a history of diabetes mellitus. She also told us that
one of her aunt was diagnosed with myoma.
IV. COMPLETE PHYSICAL ASSESMENT
A. VITAL SIGNS

Normal Range Result Interpretation

Temperature 36.5-37.5 c 36.8 c normal

Respiration 18-20cpm 21 cpm normal

Pulse 60-100bpm 78 bpm normal

Blood Pressure 120/80mmhg 130/100 Slightly

elevated/abnormal

B. HEAD-TO-TOE ASSESSMENT (Post-Op)

PARTS NORMAL FINDINGS REMARKS

Hair -free from -Hair is black, normal

lice,nits and fine, and even
dandruff. in distribution

-can be black
brown or
burgundy
depending on the
race

Scalp -lighter in color -Scalp is clean normal

than the and dry
complexion

Eyes -pupils of the -No presence normal

eyes are black of swelling,
and equal in size. redness, or
lesions of the
- pupils equally
eye
round respond to
 light -No inward or
accommodation outward
turning of eyes

Ears -there is no -Ears are equal normal

discharge or in size
lesion noted at
-ears are
the ear canal
symmetrical to
the eyes

-Skin is smooth
with no lesions

Mouth - the lips are -lips are pale in abnormal

uniformly pink; color.
moist

Nose Appeared -Nasal normal

symmetric, structure is
straight and both smooth
uniform in color and symmetric

Abdomen - unblemished -With presence Abnormal due to her

skin and is of incision and operation
uniform in color. the presence of
bandage below
- symmetric
umbilicus
contour
-Bandage is
clean and free
of drainage

Upper -symmetrical in -no presence of normal

extremities size and length. edema

- without scars -free from scar

and lesions on
both extremities

Lower -symmetrical in -no presence of normal

 extremities size and length. edema

-no muscle
atrophy

Skin -uniform in color -black Abnormal due to

discoloration insulin medication
- unblemished
at the buttocks.
and no presence
of any foul odor.

C. Review of systems

 Neuromuscular: weakness of muscles

 Integumentary: Paleness

 Respiratory: (+) positive DOB (Difficulty of Breathing)

 Digestive: Sometimes Constipate

 Female Reproductive Organ: Pain during intercourse, vaginal

bleeding, pain during menses
V. DIAGNOSTIC EXAMINATIONS

RADIOLOGY RESULT

NAME: Patient SEY

AGE: 44Y/O
ADDRESS: Lapaz, Saguday, Quirino
EXAMINATION: PELVIC UTZ

RESULT: Uterus in enlarged measuring 8.9 x 7.8 x 6.8 cm

 VI. ANATOMY AND PHYSIOLOGY

The Uterus

- Is a hollow, muscular organ that is shaped like an inverted pear The uterus,
or womb, is the part of female reproductive system in which a baby grows. It
is above the vagina, between the bladder and rectum. It is about 7 cm long
and 5 cm across at the widest point. The uterus is held in place within the
pelvis by several ligaments,
Parts:
 fundus is the top of the uterus.
 body is the main part of the uterus and includes the uterine
cavity.
 cervix is the lower, narrow part of the uterus.

Layers:
 endometrium is the inner layer that lines the uterus. It is
made up of 9enopause cells that make secretions.
 myometrium is the middle and thickest layer of the uterus
wall. It is made up mostly of smooth muscle.
 perimetrium is the outer serous layer of the uterus. The
serous layer secretes a lubricating fluid that helps to reduce
friction. The perimetrium is also part of the peritoneum that
covers some of the organs of the pelvic.
Function
The uterus received a fertilized egg and protects the fetus (baby) while
it grows and develop. The uterus contracts to push the baby out of the body during
birth.
Every month, except when a woman is pregnant or has reached
9enopause, the lining of the uterus grows and thickens in the preparation for
pregnancy. If the woman doesn’t get pregnant, the lining is shed through the cervix
into the vagina and out of the body. This is called menstruation. This process
continues until 9enopause.
VII. PATHOPHYSIOLOGY

Cause Risk factors

 High Estrogen Level
 Stress
 20-40% of women at 35 y/o
 Unknown
 Premenopausal women
 Mulitiparity
 Cesarean Section

Endometrial cells invade the myometrium

Endometrial tissues deposits in the myometrium

Growth of endometrial tissue

Myometrium become enlarge

Sign and symptoms

 Prolonged menstrual cramps

 Spotting between periods

 Heavy menstrual bleeding

 Longer menstrual cycle

 Tenderness in the abdominal area