Perpetual Help College of Manila 1240 V. Concepcion St.

, Sampaloc, Manila

A Case Study On

UTERINE MYOMA
Presented to: Mrs. Loren Herminigildo, RN, MAN Clinical instructor In Partial Fulfillment of the Requirements In Related Learning Experience (RLE)

By: Catabui, Reaflor Del Pilar, Czarina Aika F. Esteleydes, Eunice Kristia A. Ferrer, Julius U.

Introduction Uterine myoma is the most common tumors of female genitalia tract. Myoma commonly called fibroid. It is the benign tumor of the smooth muscle in the wall of the uterus. Hysterectomy has been common therapy in patients who have completed reproduction. Total abdominal Hysterectomy plus bilateral Salphingo OOpherectomy TAHBSO- this procedure removes the uterus, cervix, one ovary and one fallopian tube, while one ovary and one fallopian tube are left in places. Fibroids can be present and be apparent. However, they are clinically apparent in up to 25% of the women. Although myoma is generally considered to be the slowly growing tumor in 20-40% o the women at the age of 35 and more uterine fibroids of significant sizes with severe clinicical symptoms. Moreover myoma can be replase in 7-28% of patient after surgical treatment and in certain cases it may even turn to malignant tumor, this could causes significant morbidity including prolongrd or heavy menstrual bleeding, pelvic pleasure, and pain in rare cases reproductive dysfunction. Myoma affects one of every woman. of the woman with this condition, however experienced on symptoms. Abortions, long term use of inadequate contraceptive pills, chronic sub acute and acute inflammation of the uterus and its appendices , stress, ultraviolent radiation, cystic formation of avary are the following causes.

Objectives General: After this case study, students will be able to extend and improve their knowledge and understanding with regards to the causes, effects, complications, signs and symptoms and nursing implications for Cerebrovascular Infarction for them to be able to attain a comprehensive and thorough learning experience with regards to their study that would benefit not only them but also the readers and for the patients that they will be catering in the future with such kind of disease.

Specific: Study the patients history of past and present illness Conduct physical assessment Be able to review the anatomy and physiology of the affected organs and system Trace and analyze the pathophysiology of the disease. Classify the ordered drugs and associate its action and effects to the patient. Construct nursing care plan for the patient. Evaluate the clients condition from the time of the admission up to the present.

Course in the ward Day 1 A 46 years old female admitted @ OB ward and following orders are given: Admit to ward, secure consent for TAHBSO, give cefuroxime IV 1 hour prior to admission. At 4am, ss enema was given and vital signs monitored every shift. Day2 May 4, 2010 patient was brought to the operating room and the following post operative orders were given: patrint to the recovery room after procedure. Monitor vital signs every 15 minutes with O2 inhalation of 4 lpm. Run present IVF @ 30 gtts/min. after IVF consume D5LR, D5NM to follow for the next 8 hours. Cefuroxime 750 mg q 12o IV, tramadol HCL 100 mg q 8o IV for 3 doses to start. Input and output hourly and record. At 4 pm the patient was transfer to ward. Day3 Patient may have clear liquid diet once with flatus and full diet once with bowel movement. Last ordered IVF to complete if the patient is stable. At 1pm, foley catheter removed c oral medications of cefuroxime 500 mg BID, mefenamin=c acid q6, FeSO4 tab once a day and vitamin C 599 g I tab once a day. Day 4 There is no objection for discharge. Home medications instructed and patient may go home. Patient was discharged accompanied by sister.

Evaluation

After few days of conducting thorough study about the case of Patent J, we were able to trace the history of her disease. We have come up with the assessment of the patient biological data and physical assessment as well as the medical information with regards to the clients condition. Apart from that, we were also able to have a clearer view on how the disease the disease affects the patients body by tracing the pathophysiology of the disease. By understanding fully the mechanism and affects of the disease to the patient, we have identified and trace some medications and how these drugs affect the patients physiological functioning. Appropriate therapeutic care well planned and provided to the client and lastly, we have come up with a discharge plan pertaining to the patients recovery. Discharge Plan M E T Mefenamic Acid must be given TID O.D for pain. Instruct the relative to follow medication regimen. Encourage the patient to have some exercise. Educate and instruct the family of the patient of the proper taking of medications on time and the proper wound care to avoid contamination and infection at the surgical site. Encourage ambulation for her early recovery. Inform the patient the importance of proper hygiene from head to toe. Inform the family of the patient to have her checkup 2 weeks after discharge for the continuity of treatment. Instruct the family of the patient to monitor if there is any sudden change to the patient and report immediately. In order to attain proper diet, the patient should be guided to the prescribed foods as advised by her physician. Her meals should incluce Vitamin C rich foods for wound healing. D