18.21 Spotlight Application

This spotlight activity demonstrates how a nurse provides care to a client with a reproductive alteration by using the nursing process and clinical judgment model.^[1]

Situation/Background

A 34-year-old client presents at the gynecology clinic with complaints of heavy menstrual bleeding and pelvic pain. The client is a hotel executive and reports a history of irregular menstrual cycles since adolescence, with worsening symptoms in recent months. She describes experiencing prolonged menstrual periods with significant clotting, leading to some anxiety and disruptions in  daily life.  The client has an involved partner.

The client’s medical history includes a diagnosis of hypertension managed with antihypertensive medication. She denies any significant psychiatric conditions. She has no history of gynecologic surgeries or pregnancies.

Assessment

The client’s vital signs indicate a blood pressure of 130/80 mm Hg, a heart rate of 72 beats per minute, a respiratory rate of 18 breaths per minute, and a normal body temperature. During the pelvic examination, the health-care provider documented finding an enlarged uterus. Further diagnostic procedures, including ultrasound and a pelvic MRI, reveal the presence of benign uterine growths known as fibroids. The client expresses concern about the impact of these growths on her fertility and overall well-being.

Critical Thinking Questions

1. What assessment data should the nurse analyze when creating a nursing care plan?

Subjective Data 

• Menstrual history: Frequency, duration, and severity of bleeding; presence of clots and need for frequent pad/tampon changes; impact of symptoms on daily life, work, and activities.
• Pain assessment:  Location, intensity (pain scale 0-10), and aggravating or relieving factors.
• Reproductive health concerns: Desire for future pregnancy and concerns about fertility, impact of symptoms on sexual health and intimate relationships.
• Emotional and psychological well-being: Anxiety or stress levels related to symptoms; concerns about treatment options (medications, surgery, fertility preservation).

Objective Data

• Vital signs: Blood pressure: 130/80 mm Hg (within prehypertensive range); heart rate: 72 bpm (normal); respiratory rate: 18 breaths per minute (normal).
• Physical examination findings: Note enlarged uterus that was found on pelvic exam by the health care provider.
• Laboratory/diagnostic test results:

• • Hemoglobin and hematocrit levels (assess for anemia)
  • Iron studies (assess for iron deficiency from chronic blood loss)
  • Pelvic ultrasound and MRI (confirm uterine fibroids)

2. Based on the assessment data, what NANDA nursing diagnosis apply to this client? NANDA Nursing Diagnoses

• Chronic Pain related to the presence of uterine fibroids as evidenced by patient reports of persistent pelvic pain.
• Ineffective Coping related to anxiety about fertility and health concerns as evidenced by verbalized distress.
• Fatigue related to excessive blood loss as evidenced by reports of low energy and prolonged menstrual periods.
• Deficient Knowledge related to uterine fibroids and treatment options as evidenced by the clients concerns about fertility and overall well-being.

3. What are some examples of goals and SMART outcome criteria for this client?

• Goal 1: Reduce heavy menstrual bleeding
  • SMART outcome criteria 1: “Within three months of treatment, the client will report a reduction in menstrual bleeding, with fewer days of excessive bleeding and reduced clotting.”
  • SMART outcome criteria 2: “Within three months, the client’s hemoglobin levels will be within the normal range.”
  • SMART outcome criteria 3: “Within three months of treatment, the client will report reduced fatigue.”
• Goal 2: Provide pain management and comfort
  • SMART Goal: “Within two weeks, the client will report a reduction in pelvic pain intensity from an 8/10 to a 4/10 using prescribed pain management techniques.”
• Goal 3:  Improve client knowledge about fibroid management
  • SMART outcome criteria: “By the end of the teaching session, the client will demonstrate an understanding of fibroid treatment options, including medical and surgical interventions.”
• Goal 4: Promote Healthy Coping and Emotional Well-being:
  • “By her next follow-up visit, the client will verbalize reduced anxiety regarding fertility after receiving education on available treatment options.”

4. What nursing interventions should the nurse plan to implement?

Managing Heavy Menstrual Bleeding and Preventing Anemia

• Monitor hemoglobin and hematocrit levels regularly.
• Encourage iron-rich foods (spinach, red meat, beans) and over the counter iron supplements.
• Educate on tracking menstrual cycles and bleeding patterns to assess symptom progression.
• Discuss potential medical treatments (hormonal therapy, nonsteroidal anti-inflammatory drugs, tranexamic acid).

 Alleviating Pelvic Pain

• Encourage the use of heat therapy (warm compress on lower abdomen).
• Educate on pain-relief strategies such as over-the-counter NSAIDs (e.g., ibuprofen).
• Discuss the potential role of physical therapy or gentle exercise for pain relief.
• Explain surgical options if pain persists despite conservative treatment.

Enhancing Knowledge on Treatment and Fertility Options

• Explain different treatment options (e.g., medications, uterine artery embolization, myomectomy, hysterectomy).
• Discuss fertility options if the client desires future pregnancy.
• Educate on lifestyle modifications, such as maintaining a healthy weight and managing stress, which may influence fibroid symptoms.

Addressing Emotional Well-being and Coping Strategies

• Provide emotional support and reassurance regarding fibroid management and fertility concerns.
• Refer to a gynecologist specializing in fertility if the client is considering future pregnancy.
• Offer referrals to counseling or support groups for individuals managing fibroids.

5. Explain how the nurse will evaluate if the interventions were effective.

Nursing Assessment: At the follow-up visit, the nurse reviews the outcome criteria of the nursing care plan and  plans to evaluate progress by asking:

• “Has your pelvic pain improved with the pain management strategies we discussed?”
• “Do you feel more informed and confident about your treatment options?”
• “How is your energy level compared to your last visit?”

The nurse gathers the following data:

• The client reports that her diet has increased consumption of iron rich foods daily
• The client verbalized the use of heat therapy and NSAIDS has alleviated pain resulting in a report of 2 on the pain scale today
• The client reports participation in the clinic support group for management of fibroids resulting in less stress regarding fibroids.
• The client reports increased energy and less daily fatigue.
• The client reports that after exploring the medication options, she would like to try tranexamic acid as a non-hormonal option for treatment
• The client’s recent CBC indicates an improved hemoglobin level although it is still below normal reference range.

Analysis: The nurse uses the data gathered to evaluate if the the previously established outcome criteria were met, partially met, or not met:

Goal 1: Reduction in Heavy Menstrual Bleeding

SMART Outcome Criteria: “Within three months of treatment, Molly will report a reduction in menstrual bleeding, with fewer days of excessive bleeding and reduced clotting.”

The nurse evaluates that this outcome was partially met based on the following data:

• The client reports that menstrual periods are significantly lighter after three months of hormonal treatment (e.g., progestin therapy or GnRH agonists).
• The client no longer experiences large clots and does not require frequent pad/tampon changes.
• The client notices some reduction in bleeding, but her periods are still longer than normal (lasting 8-9 days instead of 4-5 days).
• The client still experiences moderate clotting and occasional episodes of breakthrough heavy bleeding.
• The nurse adjusts her treatment plan, suggesting continuing medication for another three months or exploring alternative therapies (e.g., IUD or surgical options).

SMART outcome criteria 2: “Within three months, the client’s hemoglobin levels will be within the normal range.”

The nurse evaluates that this outcome was partially met based on the following data:

• The client’s hemoglobin level has improved but is still below the normal reference range.

SMART outcome criteria 3 : “Within three months of treatment, the client will report reduced fatigue.”

The nurse evaluates that this outcome was met based on the following data:

• The client states she feels less fatigued due to decreased blood loss.

Goal 2: Provide pain management and comfort

SMART Outcome Criteria: “Within two weeks, the client will report a reduction in pelvic pain intensity from an 8/10 to a 4/10 using prescribed pain management techniques.”

The nurse evaluates that this outcome was partially met based on the following data:

• The client reports her pain decreased from 7/10 to 3/10 after starting NSAIDs and hormonal therapy, but pain still peaks before and during menstruation (pain reduced from 7/10 to 5/10)..
• The client no longer experiences constant pelvic discomfort and can work without disruptions.
• The client  continues to take pain medication more frequently than what she stated was desired.

Goal 3:  Improve client knowledge about fibroid management

SMART outcome criteria: “By the end of the teaching session, the client will demonstrate an understanding of fibroid treatment options, including medical and surgical interventions, and express confidence in her treatment plan.”

The nurse evaluates that this outcome was partially met based on the following data:

• The client clearly explains the pros and cons of hormonal therapy, minimally invasive procedures (e.g., uterine artery embolization), and surgical options.
• The client decides to continue medical management for now but is aware of her future options if symptoms persist.
• The client understands the basics of treatment options but still feels uncertain about surgery if medical therapy does not work. She requests more time to consider and asks for another consultation before deciding.

Goal 4: Promote Healthy Coping and Emotional Well-being

SMART Outcome Criteria: “By the next follow-up visit, the client will verbalize reduced anxiety regarding fertility after receiving education on available treatment options.”

The nurse evaluates that this outcome was partially met based on the following data:

• The client states she feels reassured after discussing fertility-preserving options, such as myomectomy or assisted reproductive techniques.
• The client no longer feels overwhelmed or panicked about her ability to conceive in the future.
• The client still worries about future pregnancy risks but acknowledges that having more information has helped.
• The client remains undecided on whether to pursue further fertility evaluations but is considering a consultation with a reproductive specialist.

Nursing Action: The nurse modifies the care plan to address the partially met outcome criteria by adding the following nursing interventions:

• Provide health teaching regarding tranexamic acid based on the client’s decision to try this as a non-hormonal option for treatment
• Encourage follow up discussion of the treatment plan and any fertility concerns with the health care provider (e.g., medication adjustments, additional testing).
• Provide additional health teaching about nonpharmacological pain interventions, such as gentle exercise and dietary changes
• Reinforce health teaching about iron-rich foods (spinach, red meat, beans) and advocate for a prescription of iron supplements.
• Schedule follow-up visits to track symptom progression and evaluate the client’s desire for further treatment options.