Structural causes are separated from nonstructural ones by PALM-COEIN in this abnormal uterine bleeding workup example, NRNP 6559 Week 4, and every test is staged, endometrial sampling included. Searches like "nrnp 6559 week 4 assignment example", "nrnp6559 week 4 sample" and "nrnp 6559 week 4 example" land here.
The NRNP 6559 Week 4 example, in full
Abnormal Uterine Bleeding Workup: A 42-Year-Old With Heavy, Frequent Bleeding, an Irregular Uterus, and Years of Irregular Cycles
Student Name
College of Nursing, Walden University
NRNP 6559: Advanced Primary Care of Women and Diverse Populations
Instructor Name
Month Day, Year
Abnormal Uterine Bleeding Workup: A 42-Year-Old With Heavy, Frequent Bleeding, an Irregular Uterus, and Years of Irregular Cycles
Bleeding, Quantified
Composite case. A 42-year-old warehouse supervisor reports that her periods have changed over the past year. Cycle length now: every 20 to 24 days; a year ago: every 35 to 60 days, as it had been since her twenties. Days of flow: 9, up from 5. Products: on the heaviest 3 days, she changes an overnight pad every 1 to 2 hours during a 10-hour shift and wears two pads at night. Clots larger than a quarter on those days. Flooding through her clothes at night twice in the past 3 months. One episode of spotting for 3 days in the middle of a cycle, 6 weeks ago. No bleeding after intercourse. Gravida 2, para 2, both vaginal births; tubal ligation after her second child.
A Bleeding Disorder Screen
A structured screen for an inherited bleeding disorder was used, built on the questions that best identified women with menorrhagia who had a laboratory bleeding disorder in its development study (Philipp et al., 2008). Heavy bleeding since her first period: no. Family history of a diagnosed bleeding disorder: no. Prolonged bleeding after tooth extraction, surgery, or childbirth: no; no transfusion after either birth. Past treatment for anemia: no. Result: negative.
Consequences of the bleeding: fatigue that makes her sit down during her shift; lightheadedness when she stands up fast; and, for 2 months, an urge to crunch ice, a classic sign of iron deficiency.
Risk factors bearing on the endometrium: irregular, infrequent cycles for two decades, which means long stretches of estrogen exposure without regular progesterone; body mass index 37.
Examination
Blood pressure 128/80, heart rate 96 lying and 110 standing. Conjunctival pallor. Thyroid not enlarged. No hirsutism or acanthosis. Speculum: small amount of dark blood at the os, cervix appears normal. Bimanual: uterus enlarged to about 12 weeks' size, firm, with an irregular contour on the right fundus; no adnexal masses; nontender.
Sorted by PALM-COEIN
The FIGO classification sorts causes into structural (PALM) and nonstructural (COEIN) groups (Munro et al., 2018). Applied to her:
Polyp: possible; intermenstrual spotting fits.
Adenomyosis: possible; an enlarged uterus fits, but her exam is irregular rather than globular.
Leiomyoma: likely; an enlarged, irregular uterus is the classic finding.
Malignancy and hyperplasia: must be excluded; two decades of irregular ovulation and obesity are risk factors for endometrial hyperplasia.
Coagulopathy: screen negative; not pursued further unless other testing is unrevealing.
Ovulatory dysfunction: supported by her long history of irregular cycles, although her recent cycles are frequent rather than infrequent.
Endometrial: a diagnosis of exclusion.
Iatrogenic: none; no anticoagulants, hormones, or IUD.
Not otherwise classified: none suspected.
More than one category can apply at once, and in her case leiomyoma and ovulatory dysfunction may coexist, with hyperplasia still to be ruled out.
Three Stages of Testing
Stage 1, today: urine pregnancy test; complete blood count; ferritin; thyroid-stimulating hormone. Results that would change the next step: a hemoglobin below 8 g/dL or ongoing orthostatic symptoms would move her to same-day evaluation for transfusion or intravenous iron before any other testing; an abnormal TSH would be treated and the bleeding reassessed.
Stage 2, within 2 weeks: transvaginal pelvic ultrasound, ordered because the uterus is enlarged and irregular on exam. Results that would change the next step: a fibroid distorting the cavity or a suspected polyp would lead to saline infusion sonohysterography or hysteroscopy, and would rule out an IUD as her treatment; a thickened or irregular endometrium would make stage 3 urgent.
Stage 3, at the stage 2 visit: endometrial biopsy in the office. ACOG's practice bulletin places endometrial sampling as a first-line test in women older than 45 with abnormal bleeding and in younger women with a history of unopposed estrogen exposure, such as obesity or chronic anovulation, as well as when bleeding persists or medical management fails (American College of Obstetricians and Gynecologists, 2012). She is 42, but two decades of anovulatory cycles and a body mass index of 37 place her in the second group. The ultrasound does not cancel the biopsy, whatever it shows. A result showing hyperplasia with atypia would lead to gynecology referral for definitive management.
Her Route, Her Options
Her priorities: to stop flooding at work, to keep working, and to avoid surgery if she can. She does not need contraception after her tubal ligation. Options discussed in principle, to be chosen once the ultrasound and biopsy are back: a levonorgestrel IUD if the cavity is not distorted, which also protects the endometrium; tranexamic acid on heavy days, which does not affect the endometrium; a progestin taken by mouth; and, if fibroids are large or distorting, referral to discuss uterine artery embolization or surgery. Iron replacement started today regardless of route. She chose to start tranexamic acid on her heavy days now, while the workup proceeds, and to decide on a longer-term option once the results are back.
References
American College of Obstetricians and Gynecologists. (2012). Practice bulletin no. 128: Diagnosis of abnormal uterine bleeding in reproductive-aged women. Obstetrics & Gynecology, 120(1), 197-206. https://doi.org/10.1097/AOG.0b013e318262e320
Munro, M. G., Critchley, H. O. D., Fraser, I. S., & FIGO Menstrual Disorders Committee. (2018). The two FIGO systems for normal and abnormal uterine bleeding symptoms and classification of causes of abnormal uterine bleeding in the reproductive years: 2018 revisions. International Journal of Gynecology & Obstetrics, 143(3), 393-408. https://doi.org/10.1002/ijgo.12666
Philipp, C. S., Faiz, A., Dowling, N. F., Beckman, M., Owens, S., Ayers, C., & Bachmann, G. (2008). Development of a screening tool for identifying women with menorrhagia for hemostatic evaluation. American Journal of Obstetrics and Gynecology, 198(2), 163.e1-163.e8. https://doi.org/10.1016/j.ajog.2007.08.070
What a finished NRNP 6559 Week 4 abnormal uterine bleeding workup looks like
A bleeding history comes first and is specific: cycle length now and a year ago, days of flow, products changed per shift, clots, flooding at night, and one episode of bleeding between cycles. A structured screen for an inherited bleeding disorder follows, along with fatigue, lightheadedness on standing, and a craving for ice. Her history of irregular cycles since her twenties and her weight are noted as risk factors bearing on the endometrium. Exam findings include an enlarged, irregular uterus on bimanual exam. Then the workup, in stages. Stage one holds a pregnancy test, blood count, iron studies, and thyroid function. Stage two is transvaginal ultrasound, ordered because the uterus was irregular. Stage three, endometrial sampling, is argued from her risk factors and ACOG guidance. Each stage names the result that would change the next.
How a NRNP 6559 Week 4 example is structured
Two organizing systems shape the document. PALM-COEIN organizes the differential into structural causes, polyp, adenomyosis, leiomyoma, malignancy and hyperplasia, and nonstructural ones, coagulopathy, ovulatory dysfunction, endometrial, iatrogenic, and not otherwise classified, so the assessment arrives as a sorted list rather than a guess. Staging organizes the plan. Tests are grouped by what they can answer and ordered so that a normal early result makes a later test unnecessary or a positive one makes it urgent. That structure answers the rubric's interest in cost-conscious, reasoned investigation. Life stage runs through both: the perimenopausal transition makes ovulatory dysfunction likely and simultaneously raises the stakes of missing hyperplasia, a tension the note states in plain words. Context gets a closing paragraph, since heavy bleeding on a delivery route shapes which management options she can realistically use.
Bleeding, quantified
Cycle length, flow days, products per shift, clots, and intermenstrual bleeding are recorded as numbers or events, not adjectives, so the pattern can be classified.
A bleeding disorder screen
A short structured screen for inherited coagulopathy sits in the history, since the C in PALM-COEIN cannot be ruled out without asking the questions.
Sorted by PALM-COEIN
Structural and nonstructural causes are listed in separate groups, with the irregular uterus pointing toward leiomyoma and her cycle history toward ovulatory dysfunction.
Three stages of testing
Laboratory tests, then imaging, then endometrial sampling, each stage justified by the one before it and by ACOG guidance on who needs tissue.
Her route, her options
Management choices are discussed against a job with limited bathroom access. The context paragraph explains why a method that reduces flow quickly suits her better.
Where marks go in NRNP 6559 Week 4
Classification and sequencing do most of the scoring in a bleeding workup. A document that lists fibroids, polyps, and hormones in no particular order has named causes without the framework the course teaches, and PALM-COEIN applied visibly is where the credit is won here. Sequencing is marked next: ordering every test on day one reads as indiscriminate, while staged testing with stated triggers shows reasoning a grader can follow. Safety carries weight in a woman in the perimenopausal years, and a plan silent on endometrial sampling, or one that dismisses it without reasoning, loses points even if the likeliest cause is benign. Anemia screening is expected given her fatigue and ice craving. A pregnancy test missing from stage one draws a standard deduction, and context left out of the plan costs credit in this course specifically.
Get a NRNP 6559 Week 4 example written to your instructions
Send what your Week 4 prompt supplies, the menstrual complaint, the history, and the rubric. A workup is drafted that classifies the bleeding with PALM-COEIN, stages investigations with a trigger for each step, and carries her context into the plan. No cost attaches to a first custom sample; turnaround is 24-48 hours.
NRNP 6559 Week 4 questions, answered
What is PALM-COEIN?
A classification system from FIGO, the International Federation of Gynecology and Obstetrics, for abnormal uterine bleeding in nonpregnant women of reproductive age. PALM groups structural causes that imaging or tissue can show; COEIN groups nonstructural causes. The example uses it to organize the differential, so each candidate cause sits in a recognized category and the workup can target structural and nonstructural questions separately.
Why is endometrial sampling argued rather than simply ordered?
Because it is invasive and not every woman with heavy bleeding needs it, yet missing hyperplasia or cancer in a woman at risk is a serious error. ACOG guidance identifies who should have tissue sampled, based on age and risk factors such as long-standing anovulation and obesity. The example applies that guidance to her history and states why she qualifies.
Why does her job appear in a gynecology workup?
Because this course asks for plans that fit the person. A carrier who cannot reach a bathroom for hours experiences heavy bleeding as a work problem, and that changes which management options are realistic and how quickly relief matters. The example records the detail in the history and returns to it in the plan, which is the visible adjustment rubrics here look for.