Abnormal Uterine Bleeding: A Comprehensive Nursing Diagnosis Guide

Introduction

Abnormal uterine bleeding (AUB) is a prevalent gynecological issue defined by changes in the regularity, frequency, volume, or duration of uterine bleeding in non-pregnant women. It significantly affects women’s physical health, emotional well-being, and overall quality of life. Effective nursing care is essential for women experiencing AUB, requiring a holistic approach that addresses not only the physical symptoms but also the psychological and educational needs of the patient. This article provides an in-depth guide to nursing diagnosis for abnormal uterine bleeding, focusing on key assessments, diagnoses, planning, interventions, and evaluations to facilitate comprehensive and patient-centered care.

Nursing Assessment for Abnormal Uterine Bleeding

A thorough nursing assessment is the cornerstone of effective care for patients with abnormal uterine bleeding. This systematic process is vital for understanding the patient’s unique situation, identifying potential underlying causes of AUB, and developing a personalized nursing care plan. The assessment involves gathering detailed information across several key areas.

Detailed Medical History

• Gynecological History: Document any prior diagnoses of gynecological conditions such as polycystic ovary syndrome (PCOS), endometriosis, uterine fibroids, or bleeding disorders. Note any past treatments, surgeries (e.g., dilation and curettage – D&C, hysterectomy), and their outcomes.
• Bleeding History: Carefully explore the onset, duration, frequency, and pattern of abnormal bleeding. Determine if the bleeding is intermenstrual, postcoital, or postmenopausal. Note any triggers or relieving factors identified by the patient.
• Reproductive History: Gather information about parity, pregnancy history, miscarriages, abortions, and any complications during previous pregnancies.
• Medical Conditions: Investigate the presence of systemic diseases such as thyroid disorders, diabetes mellitus, liver disease, or coagulation disorders, as these can contribute to AUB.
• Medication Review: Obtain a complete list of current medications, including prescription drugs, over-the-counter medications, herbal supplements, and hormonal therapies. Pay particular attention to anticoagulants, corticosteroids, and hormonal contraceptives, as these can influence uterine bleeding.
• Contraceptive History: Document the patient’s current and past contraceptive methods, including intrauterine devices (IUDs), oral contraceptives, implants, and barrier methods. Note the duration of use and any associated bleeding issues.
• Adherence to Treatments: Assess the patient’s adherence to prescribed medications or hormonal therapies for any underlying conditions or previous AUB episodes.

Comprehensive Menstrual History

• Menarche and Cycle Regularity: Record the age of menarche (first menstruation) and the typical regularity of menstrual cycles before the onset of AUB.
• Menstrual Cycle Characteristics: Detail the usual length of menstrual cycles, duration of menstrual flow, and typical flow volume before AUB.
• Recent Changes in Menstrual Patterns: Document any recent alterations in menstrual patterns, such as increased frequency (polymenorrhea), prolonged bleeding (menorrhagia), heavy flow (heavy menstrual bleeding – HMB), or bleeding between periods (metrorrhagia).
• Impact on Daily Life: Assess the impact of AUB on the patient’s daily activities, work, social life, sexual activity, and overall quality of life. Quantify the impact using validated tools if available.
• Emotional Well-being: Evaluate the emotional and psychological impact of AUB, including feelings of anxiety, frustration, embarrassment, or depression related to the bleeding.

Detailed Bleeding Assessment

• Characteristics of Bleeding: Thoroughly document the characteristics of the bleeding. Quantify blood loss using both objective (e.g., number of pads or tampons used per hour/day, presence of clots larger than a quarter) and subjective descriptions (“soaking through pads in an hour,” “needing to change protection every few hours”).
• Blood Color and Clots: Note the color of the blood (e.g., bright red, dark red, brown) and the presence and size of blood clots.
• Associated Symptoms: Inquire about pain (dysmenorrhea, pelvic pain), cramping, bloating, fatigue, dizziness, lightheadedness, or shortness of breath associated with the bleeding episodes.
• Signs of Blood Loss: Assess for clinical signs of significant blood loss, such as pallor, dizziness, lightheadedness, weakness, fatigue, and syncope.
• History of Anemia: Determine if the patient has a prior history of anemia or iron deficiency.

Assessment of Associated Symptoms

• Pelvic Pain and Dyspareunia: Explore the presence, location, duration, and severity of pelvic pain. Specifically inquire about dyspareunia (painful sexual intercourse), which may indicate underlying gynecological conditions.
• Urinary and Bowel Disturbances: Assess for urinary symptoms (frequency, urgency, dysuria) and bowel symptoms (constipation, diarrhea, pain with bowel movements), which can be related to pelvic pathology.
• Systemic Symptoms: Inquire about systemic symptoms such as unexplained fatigue, weight changes (gain or loss), changes in appetite, fever, night sweats, or mood disturbances.
• Hormonal Imbalance Symptoms: Assess for symptoms suggestive of hormonal imbalances, such as hot flashes, night sweats, vaginal dryness, sleep disturbances, acne, or hirsutism.

Medication and Allergy Review

• Current Medications: Document all current medications, dosages, routes, and frequency. Reiterate the importance of including over-the-counter medications, herbal supplements, and hormone-based therapies.
• Allergies: Thoroughly document any known allergies to medications, food, latex, or other substances. Record the type of reaction experienced (e.g., rash, anaphylaxis).

Psychosocial Assessment

• Emotional and Psychological Well-being: Assess the patient’s emotional state, coping mechanisms, stress levels, anxiety, and mood. Use standardized screening tools for anxiety and depression if indicated.
• Support System: Evaluate the patient’s social support network, including family, friends, and community resources.
• Coping Mechanisms: Explore the patient’s usual coping strategies for stress and difficult situations.
• Impact on Self-Esteem and Body Image: Assess the impact of AUB on the patient’s self-esteem, body image, and feelings about femininity and sexuality.
• Sexual Relationships: Inquire about the impact of AUB on sexual relationships, including changes in libido, dyspareunia, and avoidance of intimacy due to bleeding concerns.

Physical Examination

• General Physical Exam: Perform a complete physical examination, including vital signs (blood pressure, heart rate, temperature, respiratory rate), height, weight, and body mass index (BMI). Assess general appearance and nutritional status, noting any pallor, fatigue, or signs of distress.
• Abdominal Examination: Perform an abdominal examination to assess for tenderness, distension, or masses.
• Pelvic Examination: Conduct a thorough pelvic examination to visualize the external genitalia, vagina, and cervix. Perform a bimanual examination to assess the uterus and adnexa for size, shape, consistency, mobility, and tenderness. Note any cervical lesions, discharge, or uterine enlargement.

Diagnostic Tests and Laboratory Investigations

• Transvaginal Ultrasound (TVUS): Prepare the patient for and explain the purpose of TVUS, which is often the first-line imaging study to evaluate the uterus, endometrium, and ovaries for structural abnormalities like fibroids, polyps, adenomyosis, or ovarian cysts.
• Endometrial Biopsy: Explain the procedure for endometrial biopsy, which is used to obtain a tissue sample from the uterine lining to rule out endometrial hyperplasia or cancer, especially in women over 35 or with risk factors.
• Hysteroscopy: Prepare the patient for hysteroscopy, a procedure that allows direct visualization of the uterine cavity using a thin, lighted scope. It can be diagnostic and therapeutic, allowing for biopsy or removal of polyps or fibroids.
• Complete Blood Count (CBC): Obtain a CBC to assess hemoglobin and hematocrit levels to evaluate for anemia secondary to blood loss.
• Coagulation Studies: Consider coagulation studies (PT, PTT, INR) if a bleeding disorder is suspected based on history or clinical presentation.
• Hormonal Assays: Order hormonal assays, such as thyroid-stimulating hormone (TSH), prolactin, follicle-stimulating hormone (FSH), luteinizing hormone (LH), and estradiol levels, to evaluate for hormonal imbalances, especially in cases of irregular bleeding or suspected PCOS.
• Infectious Disease Screening: Consider testing for sexually transmitted infections (STIs) like chlamydia and gonorrhea if pelvic inflammatory disease (PID) is suspected as a cause of AUB.
• Pregnancy Test (hCG): Perform a pregnancy test (serum or urine hCG) to rule out pregnancy as a cause of uterine bleeding, especially in women of reproductive age.

Common Nursing Diagnoses for Abnormal Uterine Bleeding

Based on the comprehensive assessment, several nursing diagnoses may be appropriate for patients with abnormal uterine bleeding. These diagnoses guide the development of a patient-centered care plan.

• Deficient Fluid Volume related to excessive uterine bleeding

  • Rationale: Prolonged or heavy uterine bleeding can lead to a significant loss of blood volume, resulting in hypovolemia and potential hemodynamic instability.
  • Supporting Evidence: Reported heavy menstrual bleeding, orthostatic hypotension, tachycardia, decreased hemoglobin and hematocrit levels, patient reports of dizziness and weakness.

• Risk for Anemia related to chronic blood loss secondary to abnormal uterine bleeding

  • Rationale: Chronic or recurrent abnormal uterine bleeding can lead to iron deficiency and anemia, impacting oxygen-carrying capacity and overall health.
  • Risk Factors: History of heavy menstrual bleeding, prolonged bleeding episodes, inadequate dietary iron intake, fatigue, pallor.

• Pain related to uterine cramping and/or underlying gynecological conditions associated with abnormal uterine bleeding

  • Rationale: Uterine contractions and underlying conditions like endometriosis or fibroids can cause significant pelvic pain and discomfort.
  • Supporting Evidence: Patient reports of pelvic pain, dysmenorrhea, cramping, pain rated on a pain scale, guarding behavior.

• Anxiety related to unpredictable bleeding episodes, impact on lifestyle, and potential underlying medical conditions

  • Rationale: The unpredictable nature of AUB, its impact on daily life, and concerns about potential underlying causes can lead to significant anxiety and emotional distress.
  • Supporting Evidence: Patient expresses worry about bleeding episodes, fear of social embarrassment, difficulty coping with symptoms, restlessness, irritability, verbalization of concerns.

• Disturbed Body Image related to changes in menstrual patterns and perceived loss of control over bodily functions

  • Rationale: Abnormal uterine bleeding can disrupt a woman’s sense of normalcy and control over her body, leading to negative feelings about body image and self-perception.
  • Supporting Evidence: Negative feelings about changes in menstrual patterns, expressions of self-consciousness, avoidance of social activities, concerns about femininity and sexuality.

• Deficient Knowledge related to causes, management, and treatment options for abnormal uterine bleeding

  • Rationale: Patients may lack adequate information about AUB, its potential causes, available treatment options, self-care measures, and when to seek medical attention.
  • Supporting Evidence: Patient questions about AUB, requests for information, misunderstanding of treatment plan, inaccurate follow-through of instructions.

• Sexual Dysfunction related to pain, fear of bleeding, and psychological impact of abnormal uterine bleeding

  • Rationale: Pain associated with AUB, fear of bleeding during intercourse, and the psychological impact of the condition can contribute to sexual dysfunction.
  • Supporting Evidence: Reports of dyspareunia, decreased libido, avoidance of sexual activity, expression of concerns about sexual intimacy, changes in sexual patterns.

Nursing Planning and Goals for AUB

Nursing care planning for AUB is crucial for establishing individualized goals and outcomes. Planning should be patient-centered and aim to alleviate symptoms, address underlying causes, and improve the patient’s quality of life.

• Maintain Fluid Volume Balance: Patient will maintain adequate fluid volume, evidenced by stable vital signs, urine output within normal limits, and absence of signs of dehydration.
• Achieve and Maintain Acceptable Hemoglobin Levels: Patient will demonstrate improvement or maintenance of hemoglobin and hematocrit levels within acceptable ranges as appropriate for age and condition.
• Manage Pain Effectively: Patient will report pain is managed to a tolerable level using pharmacological and non-pharmacological methods.
• Reduce Anxiety and Enhance Coping: Patient will demonstrate reduced anxiety and improved coping mechanisms related to AUB, evidenced by verbalization of decreased worry, engagement in stress-reduction techniques, and utilization of support systems.
• Improve Body Image and Self-Esteem: Patient will express improved body image and self-esteem, evidenced by increased participation in social activities and positive self-statements.
• Increase Knowledge about AUB: Patient will verbalize understanding of AUB, its causes, management strategies, treatment options, and self-care measures.
• Improve Sexual Function: Patient will report improved sexual function and satisfaction, if applicable, and address any concerns related to sexual activity with healthcare provider.

Nursing Interventions for Abnormal Uterine Bleeding

Nursing interventions for AUB are multifaceted and should be tailored to the patient’s specific needs and nursing diagnoses.

1. Manage and Monitor Fluid Volume Status:

   • Monitor Vital Signs: Regularly assess blood pressure, heart rate, and orthostatic blood pressure to detect signs of hypovolemia.
   • Assess for Dehydration: Monitor for signs and symptoms of dehydration, including dry mucous membranes, poor skin turgor, decreased urine output, and concentrated urine.
   • Fluid Replacement: Administer intravenous fluids as prescribed to restore fluid volume in cases of significant blood loss and dehydration.
   • Accurate Intake and Output: Monitor and record fluid intake and output to assess fluid balance.

2. Address Anemia and Promote Iron Replacement:

   • Monitor Hemoglobin and Hematocrit: Regularly monitor CBC results to assess for anemia and response to treatment.
   • Administer Iron Supplements: Administer oral or intravenous iron supplements as prescribed. Educate the patient on proper administration, potential side effects (e.g., constipation, GI upset), and dietary sources of iron.
   • Dietary Education: Educate the patient on iron-rich foods (lean meats, leafy green vegetables, fortified cereals) and strategies to enhance iron absorption (e.g., consuming vitamin C-rich foods with iron).

3. Pain Management:

   • Pain Assessment: Regularly assess pain using a pain scale (numeric rating scale, visual analog scale), noting location, intensity, duration, and alleviating/aggravating factors.
   • Pharmacological Interventions: Administer prescribed analgesics, such as NSAIDs or hormonal therapies, to manage pain. Educate the patient on medication use, dosage, and potential side effects.
   • Non-Pharmacological Pain Relief: Implement non-pharmacological pain relief measures, such as heat application, warm baths, relaxation techniques (deep breathing, guided imagery), massage, and acupuncture, as appropriate.

4. Reduce Anxiety and Provide Emotional Support:

   • Therapeutic Communication: Establish a trusting and empathetic relationship with the patient. Provide a safe space for her to express her concerns, fears, and feelings about AUB.
   • Active Listening and Reassurance: Actively listen to the patient’s concerns, validate her feelings, and provide reassurance and emotional support.
   • Education and Information: Provide clear, accurate, and understandable information about AUB, its causes, diagnostic procedures, treatment options, and prognosis. Address misconceptions and anxieties.
   • Referral to Support Services: Offer referrals to counseling services, support groups, or mental health professionals if the patient is experiencing significant anxiety, depression, or difficulty coping.

5. Enhance Body Image and Self-Esteem:

   • Promote Positive Self-Perception: Encourage the patient to focus on her strengths and positive qualities. Help her to reframe negative thoughts about her body and menstrual changes.
   • Facilitate Coping Strategies: Help the patient develop coping strategies to manage feelings of embarrassment or self-consciousness related to bleeding episodes.
   • Encourage Social Engagement: Encourage the patient to maintain social connections and activities, addressing any barriers related to AUB management.

6. Patient Education and Knowledge Enhancement:

   • Explain AUB and Causes: Provide comprehensive education about AUB, including potential underlying causes (hormonal imbalances, structural abnormalities, systemic diseases).
   • Medication Education: Educate the patient about prescribed medications, including purpose, dosage, administration, expected effects, and potential side effects. Emphasize adherence to the treatment plan.
   • Menstrual Hygiene: Provide guidance on menstrual hygiene practices, including proper use of sanitary products, frequency of changes, and hygiene measures to prevent infection.
   • Self-Care Measures: Educate the patient on self-care measures to manage AUB symptoms, such as rest, stress reduction techniques, balanced nutrition, and regular exercise.
   • When to Seek Medical Attention: Instruct the patient on when to seek medical attention, such as for heavy bleeding that soaks through pads or tampons hourly, dizziness, severe pain, fever, or any new or worsening symptoms.

7. Address Sexual Dysfunction:

   • Open Communication: Create a safe and non-judgmental environment for the patient to discuss concerns about sexual function and intimacy.
   • Pain Management Strategies: Address pain management strategies to alleviate dyspareunia.
   • Counseling and Support: Offer counseling and support to address psychological factors contributing to sexual dysfunction, such as fear of bleeding or negative body image.
   • Referral to Specialist: Refer to a sex therapist or counselor specializing in sexual dysfunction if needed.

8. Collaboration and Referral:

   • Interdisciplinary Team: Collaborate with the healthcare team, including physicians, gynecologists, hematologists, and other specialists, to ensure coordinated and comprehensive care.
   • Referral to Specialists: Facilitate timely referrals to specialists as needed based on the underlying cause of AUB or complexity of the patient’s condition.
   • Community Resources: Connect patients with relevant community resources, such as support groups, women’s health organizations, or financial assistance programs if needed.

Nursing Evaluation of Care for AUB

Nursing evaluation is an ongoing process to assess the effectiveness of the care plan and patient progress toward achieving desired outcomes.

1. Evaluate Symptom Management: Assess the patient’s report of bleeding patterns, pain levels, and other symptoms. Monitor for improvement in bleeding frequency, duration, and volume.
2. Assess Fluid Volume Status and Hemoglobin Levels: Evaluate vital signs, hydration status, and repeat CBC results to assess fluid volume balance and improvement in hemoglobin and hematocrit levels.
3. Evaluate Pain Control: Assess the patient’s pain levels using a pain scale and evaluate the effectiveness of pain management interventions.
4. Assess Anxiety and Coping Mechanisms: Evaluate the patient’s emotional state, anxiety levels, and coping mechanisms through observation, patient reports, and standardized anxiety scales if used.
5. Evaluate Knowledge and Understanding: Assess the patient’s understanding of AUB, treatment plan, self-care measures, and when to seek medical attention through verbal questioning and observation of self-care practices.
6. Evaluate Body Image and Self-Esteem: Assess the patient’s self-perception, body image, and engagement in social activities to evaluate improvement in these areas.
7. Evaluate Sexual Function: If applicable, assess the patient’s report of sexual function, satisfaction, and resolution of any concerns related to sexual activity.

Conclusion

Providing nursing care for women with abnormal uterine bleeding requires a comprehensive and compassionate approach. By conducting thorough assessments, formulating accurate nursing diagnoses, implementing targeted interventions, and continuously evaluating patient outcomes, nurses play a critical role in managing AUB, alleviating symptoms, addressing underlying causes, and improving the overall well-being and quality of life for affected women. This nursing diagnosis guide provides a framework for nurses to deliver evidence-based, patient-centered care and empower women to effectively manage abnormal uterine bleeding.