Introduction

A cyst is an abnormal growth that develops as a closed sac somewhere in the body. A dermoid cyst is a specialized type containing many different kinds of tissues including hair, teeth, nerves, bone or fat. It may be present at birth and can be found in the face, spinal cord or skull. It may also develop in the ovary in women during the childbearing years as an ovarian dermoid cyst.

There are two classifications of ovarian cyst; the functional that involves the normal physiology of ovary and non-functional that is independent from the functions of the ovary. Dermoid ovarian cyst is a non-functional cyst.
Dermoid ovarian cyst is considered a cystic teratoma, consisting of mixtures of tissues not normally found in ovary that contains mature skin that is complete with sweat glands, hair follicles, pockets of stale blood, fat, bone, cartilages, nails, teeth, and even traces of thyroid tissues.

 It is common among women in pre-menauposal age, those with unhealthy lifestyle like smokers and heavy drinkers, and women with irregular menstrual cycle. No statistical data available at DOH Region VII and the only available data is the Vicente Sotto Memorial Medical Center 2012 Statistics. Statistically, there were 153 case as of 2012.

Jan-Dec 2012 total cases of ovarian cysts: 153 Breakdown: Malignant = 42 (27%) Dermoid = 31 (20%) Other types= 80 (52%)

 DATA BASE AND SOCIAL HISTORY: Name Sex Age Civil Status Nationality Religion Address Occupation Date of Admission Time of Admission Height Weight Accompanied by Mode of Admission Vital signs : : : : : : : : : : : : : : : Maria Clara (fictional) Female 36 years old Married ( year of marriage - 2001 ) Filipino Roman Catholic Tuburan, Cawayan, Masbate Housewife February 13, 2013 12:15pm 5 feet 3inches 49kgs (107lbs) Cris Ybarra (Husband - fictional name ) Ambulatory T - 36.6C P - 95 bpm R - 20 cpm BP - 130/90mmHg

Has client received blood in the past Allergies Food Drug Admitting Diagnosis Attending Physician

: No : : No known food allergy : No known drug allergy : Ovarian cyst, bilateral : Dr. Melvin Justimbaste

 CHIEF COMPLAINT AND HISTORY OF PRESENT ILLNESS: Two weeks PTA, client complained of a 2-day, on and off, sharp abdominal pain, both lower quadrants, graded at 8/10 and was admitted for 4 days (February 1-4, 2013) at Masbate Provincial Hospital. Client was also treated for Urinary tract infection during her admission and was prescribed Ciprofloxacin, BID. Client unable to recall dose. Two days PTA, client complained of a 2-day sharp abdominal pain, both lower quadrants, graded at 6/10, and nausea and vomiting secondary to gastritis. Client did not take any pain medication. Vomited several times after every ingestion of food but could not recall exactly how many times. Characteristics of vomitus: watery, yellowish, unable to quantify the amount. Client was prescribed Omeprazole, 20mg, BID with very minimal relief. Client was diagnosed of Bilateral ovarian cysts in 2008. Her primary care physician told her that no surgery was needed at that time since the size was too small. Client made few follow-up visits regarding her condition but missed the succeeding follow-up visits because her doctor went out of town and eventually stopped going.

In November of 2012, client was admitted at Masbate Provincial Hospital for 6 days due to vaginal bleeding of two (2) week duration consuming one pad per day and UTI. Client unsure whether or not bleeding was medically managed during hospitalization. In December of 2012, client had another episode of Urinary Tract Infection with accompanying fever.

I. PERSONAL AND SOCIAL HISTORY A. Family History Father Mother Note Rank in the family Number of children Educational attainment Occupation of husband : alive : alive : Client is a biological daughter : youngest, has 6 other siblings : none (client had never been pregnant) : 1st year college : carpenter

B. Living Conditions Client and her husband owned a house - house is made of wood and metal roofing Number of rooms :2

Number of people staying in the house: 3 ( client, husband and 1 year old adopted daughter )

 Note: Client lived in a remote village in the barrio, away from the town proper where public transportation is poorly accessible.

C. Nutrition Mealtimes : breakfast- 8am, lunch- 12nn, dinner- 7pm

Client had snacks in between meals Usual 24-hour diet Water intake : rice, fish, dried fish, egg, vegetables, pork, bread, banana, papaya : 4-6 glasses per da

very seldom drinks other beverages such as soft drinks, juice and coffee
Food likes and dislikes : None

D. Sleeping Patterns

Nap

2-3hours per day between 1pm and 4pm

Awaken at night as she had to tend to their adopted daughter Client snored

Comfortable sleeping position : varies ( supine and side-lying )

Used 2 pillows for comfortable sleeping

Denied any other sleeping abnormality

E. Elimination Patterns Frequency of bowel movements : once every 2-3days (2-3x/week) Usual time of defecation : morning Consistency : hard Color : brown Amount : 1/4 to 1/2 cup (50-100ml) Note : Frequently experienced constipation Frequency of urination : 7x per day Color : yellow Amount : 50ml

F. Physical Hygiene Frequency of Bathing : once a day Used "SAFEGUARD" brand : daily Used "HEAD AND SHOULDER" brand : as often as necessary : once to twice per day Used "CLOSE-UP" brand

Frequency of Shampooing

Frequency of handwashing Frequency of Toothbrushing

G.Environmental Sanitation Water source : deep well for laundry and bathing purified water for drinking (water is stored in a jar with cover) - as per client, they had their own water purifier

Mode of human waste disposal Garbage disposal

: toilet pit : they burned their garbage at the backyard on a daily basis

Note: Clients house is away from industrial factories

H. Social Activity Sports: None Hobby / Habits: Watching TV, vegetable gardening Vices: Denied engaging in any vices Denied smoking, drinking alcoholic beverages and gambling NOTE: Client's lifestyle is very laid back.

II. MEDICAL HISTORY A. Heredo-Familial Disease Diabetes Mellitus Hypertension - maternal side - paternal side

B. Communicable Diseases Client denied any communicable diseases occurring in the family.

C. Obstetrical and Gynecological Menstruation Onset Duration Cycle Character Discomforts OB score LMP

- 16 years old - 3-5days - abnormal since the last 10 years ( unable to determine variations ) - scanty - frequently experienced dysmenorrhea - client had never been pregnant - November 28, 2012

D. Previous Illness/Surgery Client denied any other illness not related to the current medical condition except for fever, cough and common cold.

SYSTEMS ASSESSMENT A. COMMUNICATION Subjective: " Wala ra koy problema sa akong panan-aw, pandungog ug pag-istorya" as verbalized by the client. Objective: - client did not wear eyeglasses / contact lenses - pupils equal in size (4mm) - (+) PERRLA - able to read fine prints without difficulty using magazines - had slight difficulty identifying letters at a distance more than 10feet - client did not wear hearing aides - able to hear normal voice tone clearly - able to hear whispered words without difficulty - responded to every question asked correctly - spoken without difficulty - spoken and understood Cebuano

B. OXYGENATION Subjective: " Okay lang ang akong pag-ginhawa; wala ra man ko giubo; dili man ko manigarilyo ug wala pud ko kasulay " as verbalized by the client.

Objective:

- face and lips evenly colored, no prominent discoloration - nailbeds have light pink tones - breathing is quiet, relaxed and effortless - RR- 20cpm, regular - capillary refill time normal (less than 2 sec) - (+) equal chest expansion - (+) resonance on percussion - no noise heard during normal breathing - no adventitious sound on auscultation - no cough

C. CIRCULATION Subjective: " Wala ra koy gipamati nga sakit ug pamanhod sa akong dughan ug tiil " as verbalized by the client.

Objective:

- no ankle edema - Radial pulse - 95bpm, Apical pulse- 98bpm, regular, strong - BP- 130/90 mmHg - capillary refill time normal (less than 2 secs) - lower extremity sensation intact on palpation

D. NUTRITION Subjective: " Hangtod karon, naa gihapon panahon nga kasukaon ko; mahadlok ko mokaon kay ako ra unya isuka; wala ra koy problema sa pagtulon; ninggamay akong timbang " as verbalized by the client. Objective: - no dentures - did not eat hospital food - ate 1/2 cup oatmeal prepared by her husband (5 times a day) - consumed 2 individual packs of skyflakes whole day - consumed 1/2 glass water after having oatmeal - body weight in Feb. 1, 2013 - 53kgs ( 116lbs ) - body weight in Feb 13, 2013- 49kgs ( 107lbs ) - always lying in bed - appeared tired and weak - on DAT (diet as tolerated) - D5 Normal saline solution - D5 normosol-M

E. ELIMINATION Subjective: " Sukad sa akong pagka-admit, kausa pa lang ko nakalibang, ganinang alas 830 sa buntag; gahi man gihapon akong ta-e; magsige gihapon ko ug ihi-ihi ika-7 sa usa ka adlaw; wala ray sakit inig pangihi nako" as verbalized by the client. Objective: - stool characteristics: hard, yellow, aromatic, 50ml in amount - urine: yellow in color, 50ml - (+) tenderness on both lower quadrants on palpation - (+) dullness on percussion - hypoactive bowel sound on auscultation - Dulcolax suppository given on Feb. 14, 2013

F. MANAGEMENT OF HEALTH AND ILLNESS Subjective: " Namaligya na lang mi ug yuta para ibayad sa hospital ug sa operasyon; nabalaka gyud ko sa resulta sa operasyon; wala man gyud ko kasulay anang pap smear ug eksaminasyon sa totoy" as verbalized by the client. Objective: - compliant with medications during hospital stay - preoccupied - weakness - diminished productivity - client always lying in bed - expressed concerns - decreased appetite

G. SKIN INTEGRITY Subjective: " Wala ra man koy problema sa akong panit; wala ra koy mga katol-katol " as verbalized by the client.

Objective:

- presence of IV line on the right wrist - no rashes/lesions - skin turgor normal - skin was dry and warm to touch

H. ACTIVITY AND SAFETY Subjective: " Dili ra man ko malipong kung mobangon ug mobarog ko; kapoy ug luya lang gyud akong pamati sa akong lawas " as verbalized by the client. Objective: - V/S : BP-130/90mmHg, RR- 20cpm, PR- 95bpm - observed client always lying in bed - though client hesitant to get up and move around, was able to use toilet with supervision for safety - alert, awake and oriented (time, place and person) - able to walk without assistive device but slow paced, decreased cadence - slow, steady gait with supervision for safety - no joint limitation of movement on active-range-ofmotion - minimal guarded movements - exhibited decreased endurance during activity

I. COMFORT / SLEEP / AWAKE Subjective: " Sakit pa gihapon akong tiyan pero madala ra man ( 4/10), magwala-wala lang ang sakit; panagsa makamata ko inig ka gabii para mangihi " as verbalized by the client. Objective: - V/S : BP - 130/90mmHg, RR - 20cpm, PR - 95bpm - observed minimal facial grimaces during movements/activities - exhibited minimal guarded movements during activities - observed client always lying in bed - client hesitant to smile during interview - facial expression looked tired

J. COPING Subjective: " Nag-guol ko sa akong kahimtang; gusto man ko magpa-opera, wala pa lang schedule" as verbalized by the client.

Objective :

- client frequently demonstrated attention-seeking behavior from the husband - client open to questions regarding her medical condition - observed client dependent on the husband and hesitant to perform ADLs - observed client not smiling during interview/assessment

HEAD TO TOE ASSESSMENT A. HEAD AND FACE HAIR: - hair color was black - shoulder length - scalp was clean and oily - no dandruff and head lice noted - no lesions HEAD: - symmetrical, round, erect and in the midline - no visible lesions noted - no involuntary movements noted - consistency was hard and smooth without lesion on palpation

FACE: - symmetrical with an elongated appearance - no abnormal movements noted - temporal artery non-tender on palpation and pulsation is palpable - Temporo Mandibular Joints no swelling, non-tender and no crepitation during movement - mouth opened and closed fully - lower jaw moved laterally both sides B. NECK - symmetrical with the head at the center and without bulging masses - the thyroid cartilage, cricoid cartilage and thyroid gland moved upward symmetrically during swallowing - neck movements Within Normal Limits during active range of motion (flexion, extension, lateral flexion and rotation) - trachea located at the midline

C. LYMPH NODES OF THE HEAD AND NECK - no swelling, no enlargement and no tenderness on palpation ( preauricular, post-auricular, occipital, tonsillar, submandibular, submental, superficial cervical, posterior cervical, deep cervical and supra-clavicular nodes) D. EYES - the upper and lower eyelids closed easily and met completely when closed - eyelashes were evenly distributed - eyelids no redness, no swelling, no lesions - sclera is white - pupils equal in size (4mm), round and centered in the iris - iris round and evenly colored (black) - pupils equally round, reactive to light and accommodation (PERRLA)

E. EARS - the auricles aligned with the corner of each eye, equal in size - skin is smooth - color consistent with facial color - no lesions, lumps or nodules - no discharges noted - no tenderness on palpation F. MOUTH - lips are smooth, dry and without lesions/swelling - lip color- light pink - complete set of teeth noted - no repaired or decayed areas - gum color- light pink , no lesions/masses - tongue- light pink, dry and no lesions

G. NOSE - nasal color is consistent with facial color - nasal structure is smooth and symmetrical - no lesions/tenderness - no swelling/flaring - no discharges - presence of nasal hairs noted H. THORAX AND LUNG GENERAL ASSESSMENT - lips and face evenly colored and no prominent discoloration - nail beds light pink in color - no cough noted - no pain/discomfort during respiration - breathing is relaxed, effortless and quiet - no noise heard during respiration -breathing pattern is normal ( no abnormality in the rate, rhythm and depth ) - RR 20cpm

POSTERIOR THORAX: - scapulae are symmetrical and non-protruding - no kyphosis noted - no tenderness/pain or unusual sensations - no masses noted - symmetrical chest expansion noted -normal tones elicited on percussion (resonance over lung tissue and flatness over the scapula) - no adventitious sounds noted on auscultation

ANTERIOR THORAX: - anteroposterior diameter is less than the transverse diameter - sternum is straight and positioned at midline - no sternal retractions noted - ribs sloped downward with symmetrical intercostal spaces - no retractions/bulging of intercostal spaces during respirations - chest color is fairer compared to the rest of the body and without lesions/masses - expansion of the abdomen and lower ribs noted on inspiration and return to resting position on expiration - no tenderness/pain on palpation - no masses/lesions - symmetrical chest expansion noted - normal tones elicited on percussion ( resonance over lung tissue and intercostal spaces ) - no adventitious sounds noted on auscultation

I. HEART - apical impulse not visible on inspection - heart sound audible with the use of a stethoscope - apical pulse - 98bpm J. ABDOMEN - skin is fairer compared to the rest of the body - smooth and without lesions/rashes - no scars noted - umbilical skin tone similar to the surrounding abdominal skin tones - umbilicus is located at midline, inverted (recessed) -abdominal contour- distended, protuberant due to the cysts - abdominal asymmetry noted; left side is bigger than the right side - abdominal girth- 28 inches (measurement taken at the level of the umbilicus) - hypoactive bowel sounds noted - dullness elicited on percussion on both lower quadrants - palpable masses noted on both lower quadrants - tenderness elicited on palpation

K. UPPER EXTREMITIES ( Shoulders, Elbows, Wrists, Hands and Fingers ) - skin color is brown - no redness - no swelling - no lesions, masses, nodules - no tenderness - no numbness, sensation is intact - no joint limitation on AROM except the right wrist due to presence of IV line

L. LOWER EXTREMITIES ( Hips, Knees and Ankles ) - skin color-brown - no redness - no swelling - no lesions, masses and nodules - joints are stable, no tenderness, no crepitus - sensation is intact, no numbness no joint limitation on AROM against resistance

NEURO-SENSORY ASSESSMENT Fainting spells / Dizziness : Denied experiencing dizziness; no fainting spells Headache : Denied occurrence of headache History of Stroke : Denied history of stroke Seizure : Denied occurrence of seizures Mental Status : Oriented x 3 (time, place and person) Memory : Intact both recent and remote memory Client was able to recall both recent and remote events Speech Pattern : Normal Speech pattern No slurring of speech Words are clear and comprehensible Deep Tendon Reflexes : Triceps, Biceps and Patellar Reflexes : 2+ (Normal)

CRANIAL NERVES 1) OLFACTORY NERVE (CN 1) Remarks : Intact. Client was able to identify scent correctly (bath soap).

2) OPTIC NERVE (CN II) Note : Snellen chart not available Remarks : Client was able to read fine prints without difficulty using magazines. Exhibited difficulty identifying letters at a distance of more than 10feet. Peripheral vision intact.
3) OCULOMOTOR NERVE (CN III) Remarks : PERRLA ( Pupils Equally Round, Reactive to Light and Accommodation )

4) TROCHLEAR AND ABDUCENS NERVES (CN IV AND VI) Remarks : Intact cardinal gaze Client able to move each eye upward, downward, diagonally and laterally. 5) TRIGEMINAL NERVE (CN V) Remarks : Intact motor function Positive contraction of the temporal and masseter muscles when client clenched her teeth Positive corneal reflex. Client's eyelids blinked bilaterally when cornea was lightly touched with a fine wisp of cotton. Intact sensory function Client was able to correctly identify sharp and dull stimuli and light touch to the forehead, cheeks and chin.

7) ACOUSTIC NERVE (CN VIII) Remarks : Intact cochlear component. Client was able to hear whispered words at a distance of 2feet. Note : Weber and Rinne Tests not done. Tuning fork not available. Intact Vestibular component. Balance was intact. (-) Romberg test. Client was able maintain standing position for 20secs with minimal swaying with feet together and arms on the sides and eyes open and then closed. 8) GLOSSOPHARYNGEAL NERVE (CN IX) Remarks : Motor function intact. Gag reflex elicited upon touching the posterior pharynx with a tongue depressor. Sensory function intact. Client was able to correctly identify coffee and table salt.

9) VAGUS NERVE (CN X) Remarks : Motor and Sensory functions intact. Client was able to swallow without difficulty by drinking a glass of water. 10) ACCESSORY NERVE (CN XI) Remarks : Intact Client was able to do shoulder shrugs against resistance.

11) HYPOGLOSSAL NERVE (CN XII) Remarks : Intact Client was able to protrude the tongue, put it back in the mouth and move it side to side against resistance.

Laboratory tests and Diagnostic Tests

Hematology Laboratory Patients Result Feb 13 11:40pm 9.5 Significance Patients Result Feb 14 1:55pm 12 Significance Reference Value

Hgb mass conc.

Decreased due to history of blood loss

There shows F: 12.0 an 16.0 gm/dL improvement in the value. Based on reference values its within normal limit There shows F: 0.37 an 0.47 % improvement in the value. But based on reference value its below normal limit

Hct (RBC vol. fraction)

0.3

Decreased due to history of blood loss

0.36

Laboratory

Patients Result Feb 13 11:40pm

Significance

Patients Result Feb 14 1:55pm

Significance

Reference Value

WBC

9.25

Within normal limit

10.38

Within normal limit

5-10.8 x 109cells/L

RBC

3.76

Decreased due to history of blood loss

4.06

There shows F: 4.0 - 5.5 x an 1012 cells/L improvement in the value. Based on reference values, its within normal limit

Laboratory

Patients Result Feb 13 11:40pm

Significance

Patients Result Feb 14 1:55pm

Significance

Reference Value

Thrombocytes (Platelets)

469

Increased due to history of blood loss

410

There shows an improveme nt in the value. Based on reference value, its within normal limit

140-440 x 109/L

Differential Counts Neutrophils 0.55 Within normal limit Within normal limit 0.63 Within normal limit Within normal limit 0.51 0.67

Lymphocyt es

0.38

0.31

0.25 0.40

Monocytes

0.05

Within normal limit

Within normal limit

0.06

Within normal limit

No data available

0.02-0.08

Eosinophils 0.02

0.01-0.06

Feb. 13, 2013 2:45 PM Laboratory

Urinalysis Reference Value Significance

Patients Result

Macroscopic:
Color Transparency Specific gravity Protein Glucose Yellow Clear 1.02 Negative Negative Yellow Clear 1.003 1.03 Negative Negative Normal Normal Within normal limit Normal Normal

Microscopic RBC/HPF 0-2 1-2 Within normal limit Increased in UTI Increased in UTI Increased in UTI

WBC/HPF

3-6

2-4

Epithelial cells

Moderate

None

Bacteria

Abundant

None

Feb. 13, 2013 Laboratory

Creatinine Patients Result Reference Value Significance

Creatinine Priority: routine Fluid : serum

0.7 mg/dL

0.7-1.5

Within normal limit

Feb. 13, 2013 Laboratory

1:00 PM Patients Result

Chemistry Reference Value Significance

Glucose (RBS)

119

70 130 mg/dL

Within normal limit

Feb. 13, 2013 1:07 AM

Blood Typing

Laboratory or Diagnostic Testing

Patients Result

Significance

ABO

A To anticipate Blood Transfusion, should the patient need one

RH

Feb. 13, 2013

Radiology Report
Name : Maria Clara Address: Tuburan, Cawayan Masbate Age : 36 years old Gender: Female

DOB: 12/19/1976

Conclusion: Negative Chest

Favorable

Feb. 13, 2013 Laboratory

8:39 AM Patients Result

Immunology Reference Value Significance

CA-125

46.9

< 35 U/mL, the generally accepted upper limit

Elevated

Feb. 123, 2013

4:05 PM

Ultrasound Report
Name : Maria Clara Address: Tuburan, Cawayan Masbate Age : 36 years old Gender: Female DOB : 12/19/1976

Case # : 13-033 Date : 2/13/13

16:05:27

Examination: Whole abdomen LMP : November 28, 2012 Remarks: The right kidney measures 9.6 cm x 4.3 cm. The right renal cortex measures 1.2 cm. Mild hydro-nephrosis The left kidney measures 9.2 cm x 5.4 cm. The left renal cortex measures 1.7 cm Conclusion: Normal liver, Pancreas, GB, Spleen, Left Kidney, Ureters, Urinary Bladder, and Uterus

Mild hydro-nephrosis in the right kidney probably due to infections.

Not favorable

Feb. 14, 2013

12:33 PM Ultrasound Report Gender: Female DOB : 12/19/1976

Name : Maria Clara Address : Tuburan, Cawayan Masbate Age : 36 years old Case # : 035 Date : 2/14/13

12:33:08

Examination: Transvaginal Ultrasound LMP : November 28, 2012 Remarks: Posterior to the uterus and within the right adnexa is a cystic structure measuring 59. x 6.9 x 4.4 cm, thick-walled, unilocular, containing hyperechoic lines and dots. Posterior to the uterus and within the left adnexa is a cystic structure measuring 8.2 x 5.3 x 6.2 cm, thick-walled, multilocular, also containing hyperechoic lines and dots

Impression: Normal-size anteverted uterus with intact trilaminar endometrium Bilateral ovarian cyst, probably dermoid No culdesac fluid

Favorable Not favorable Favorable

Human Anatomy and Physiology

Ovaries: - Ovaries are located close to and on both sides of the uterus in the lower abdomen. It is difficult to locate them by abdominal palpation because they are situated so low in the abdomen. - the ovaries are approximately 4 cm long by 2 cm in diameter and approximately 1.5 cm thick, or the size and shape of almonds. - they are grayish white and appear pitted, or with minute indentations on the surface. - the ovaries are held suspended and in close contact with the ends of the Fallopian tubes by three strong supporting ligaments attached to the uterus or the pelvic wall. - the function of the two ovaries is to produce, mature and discharge ova - in the process, the ovaries produce estrogen and progesterone and initiate and regulate menstrual cycles.

 Pituitary Gland - Pituitary Gland is a small, bean-sized organ that is located at the base of the brain and is connected to the hypothalamus by a stalk. The pituitary gland secretes many essential hormones for growth and sexual maturation. - produces two hormones; follicle stimulating hormone and luteinizing hormone

- the second pituitary hormone, luteinizing hormone continues to rise in amount and acts on the follicle cells of the ovary. It influences the follicle cells to produce lutein, a brightyellow fluid. - lutein is high in progesterone and contains some estrogen. This yellow fluids fill the empty follicle , which is termed a corpus luteum -If fertilization does not occur, the corpus luteum in the ovary begins to regress after 8 to 10 days. As it regresses, the production of progesterone and estrogen decreases.

- every month during fertile period of a women's life, one of the ovary's primordial follicles is activated by follicle stimulating hormone to begin to grow and mature - as it grows, it's cells produce a clear fluid that contains a high degree of estrogen and some progesterone. - as the follicle reaches its maximum size, it is propelled toward the surface of the ovary. A full maturation the small ovum with its surrounding follicle membrane and fluid, is termed a graafian follicle. - when the graafian follicle is mature,the pituitary gland releases luteinizing hormone that increases the prostaglandin so the graafian follicle ruptures - the ovum is set free from the surface of the ovary, a process termed ovulation

Pathophysiology

Medical-Surgical Management

IDEAL DIAGNOSTICS: Urinalysis -To identify presence of infection. Transvaginal Ultrasonography -To define cysts morphologic characteristics. Abdominal Ultrasonography -Allows assessment of other intraabdominal structure. CT Scan -Best in imaging the ovarian cysts and distinguish other intra abdominal causes.

ACTUAL

-Done (Feb. 13, 2013)

-Done (Feb.14,2013)

-Done (Feb.13, 2013)

-Not done.

IDEAL

ACTUAL

DIAGNOSTICS: MRI - To identify fat and blood products and provide idea of the organ of origin for gynecological masses. Hormone Test - Evaluates hormonal balance in both pre- and post menopausal women, using a single blood sample. Pregnancy Test -To detect pregnancy

-Not done.

-Not done.

-Not done. Chest X-Ray -Use ionizing radiation to create pictures of structures inside the chest such as heart, lungs and blood vessels. -Done (Feb.13, 2013) Laparascopy - for visualization.

IDEAL LABORATORY: Complete Blood Count -To detect any blood dyscrasias. Creatinine Test -Measures kidney function. Blood Typing -To identify blood group to anticipate blood transfusion should the patient requires.

ACTUAL

Done (Feb. 13, 2013 and Feb.14, 2013)

Done (Feb. 14, 2013)

Done ( Feb.13, 2013)

IDEAL MEDICATIONS: Nonsteroidal Anti-inflammatory Drugs (NSAIDS) -Pain reliever, mild to moderate pain Narcotic Analgesics -Pain reliever, moderate to severe pain. D5 NSS -Hypertonic solution, for replacement or maintenance of fluid and electrolyte. D5 NM -Hypertonic solution, parenteral maintenance of routine daily fluid and electrolyte requirement w/ minimal carbohydrate calories from dextrose.

ACTUAL

Not ordered.

Not ordered.

Ordered (Feb. 13, 2013)

Done (Feb.14, 2013)

IDEAL MEDICATIONS:

ACTUAL Ranitidine -Anti- reflux agent -Ordered (Feb. 14, 2013) Dulcolax Suppository -Laxative -Ordered (Feb. 14,2013) once only Omeprazole -Gastric Anti-secretory agent -Ordered (Feb.14,2013)

IDEAL MEDICATIONS:

ACTUAL Metoclopramide -Anti-emetic agent -Ordered (Feb. 14, 2013) STAT Metronidazole -antibiotic -Ordered (Feb. 14, 2013) Ciprofloxacin -Antibiotic -Ordered (Feb. 14, 2013)

IDEAL TREATMENT: Blood Transfusion used to replace blood lost. DIET : Increase fluid intake -fluid and electrolyte replenishing Foods rich in Protein -to promote tissue repair and healing Foods rich in Carbohydrates -provide energy for the body

ACTUAL

Ordered (feb.14,2013)

DAT ( DIET AS TOLERATED)

IDEAL DIET : Foods rich in Iron -Manage and prevent anemia Foods rich in Vitamin C -To boost immune system Foods rich in Vitamin E -antioxidant that protects body tissue from damage caused by substances called free radicals D5 NM -Hypertonic solution, parenteral maintenance of routine daily fluid and electrolyte requirement w/ minimal carbohydrate calories from dextrose. D5 NSS -Hypertonic solution, for replacement or maintenance of fluid and electrolyte.

ACTUAL

Done (Feb.14, 2013)

Done (Feb.13,2013)

IDEAL

ACTUAL

SURGICAL: Laparatomy -to remove cyst in a large incision. Laparascopy - for visualization. TAHBSO ( Total Abdominal Hysterectomy Bilateral Salpingo Oophorectomy) -surgical removal of the affected ovaries and uterus Not done. Colostomy - provides an alternative channel for feces to leave the body.

11 KEY AREAS OF RESPONSIBILITY

A.

Safe and Quality Nursing Care Assisted patient during ambulation, upon getting up and in lying down, and in going to the comfort room. Obtained consent from the patient when taking vital signs. Explained to patient the purpose and/or significance of the procedure done to her present condition like monitoring of vital signs, intake/output and administration of medications. Given patient enough time to rest in between procedures. Minimized noise to promote comforting/relaxing environment. Made sure nothing was cluttered on the floor especially where patient is walking around.

A. Safe and Quality Nursing Care Made sure the floor was not wet and/or slippery. Evaluated patients response to medication after 30 minutes of administration. Taught patient and significant other regarding proper hygiene especially stressing on the importance of hand washing to prevent spread of microorganisms that may cause infection. Stressed on patient and significant other regarding food intake especially foods rich in protein which promotes tissue repair and vitamin C to boost immune system as well as high in fiber to manage constipation. Avoid gas-forming foods like potatoes and sweet potatoes and carcinogenic foods like grilled and char-broiled foods. - Discussed patients medical condition only among healthcare providers involved in the patients healthcare management.

B. Management of Resources and Environment Took patients vital signs as scheduled. Accompanied patient to the comfort room. Encouraged patient to reposition every 2 hours to prevent respiratory complications. Checked IVF patency regularly. Discarded used needles at the sharp box/receptacles as delegated by the nurse.

C.

Health Education
Taught patient and significant other regarding proper hygiene especially the importance of hand washing to avoid spread of microorganisms that may cause infection. Reinforced to patient and significant other that patient should eat foods that are rich in protein to promote tissue repair, vitamin C to boost immune system and those rich in fiber to manage constipation. (At least small frequent feedings.) Avoid gas-forming foods like potatoes and sweet potatoes. Monitored family/clients response by letting them verbalize what they understood about the procedures done to her. Documented patients vital signs and referred to patients baseline data at the patients chart for any abnormalities.

D.

Legal Responsibility
Carefully identified the right patient and rechecked data before administering medications. Documented every intervention/procedure done to patient like taking of vital signs and administration of medication carefully and correctly in the patients chart with the clinical instructors supervision and had it countersigned. Referred to patients chart to check for interventions/procedures ordered by the physician, and done every intervention with the consent and supervision of the clinical instructor.

E. Ethico-Moral Responsibility
Provided confidentiality by discussing patients medical condition only among healthcare providers involved in the healthcare team. Respected patients religious practices.

F. Personal and Professional Development

Done every nursing interventions/procedures especially the administration of medications always with the supervision of the clinical instructor. Discussed with the healthcare team involved in the patient care relevant data regarding patients condition and suggested ideas which may be helpful to the patient care. Addressed patients needs and set them to priorities based on clinical judgment. Involved patient as well as her significant other in the plan of care management for the patient.

G. Quality Improvement
Referred to patients chart for data regarding patients health status to know whether she has improved with all the interventions/procedures done. Monitored patients response after every intervention/procedure done. Documented carefully all data gathered after every interventions done like taking of vital signs and administration of medications. Reported to the nurse-in-charge any deviances noted with the patient like her increase in blood pressure after she took one of her medication. Took vital signs when patient reported that she felt dizzy after she took one of her medications, reported the data to the nurse-in-charge and documented it accurately on the patients chart.

H. Research
Discussed among healthcare team regarding priority needs and problems of the patient. Consulted with the clinical instructor/ nurse on duty regularly to discuss patients health status as well as data gathered from the patient.

I. Records Management
Documented accurately relevant data of interventions done like taking of vital signs and administration of medication on the patients chart with the supervision of the clinical instructor. Asked permission when using the chart. Returned the chart after using.

 J. Communication
Provided open communication with the patient and significant other to allow them to express feelings, needs and problems with regards to the patients condition. Readily addressed patients concerns and needs right away. Allowed patient to verbalize feelings and concerns after every intervention/procedure done to her. Stayed and listened to patient, given her time to talk to establish rapport and confidence. Reported/relayed patients concerns regarding her condition/care to the appropriate member of the healthcare team. (Clinical Instructor/Nurse-in-charge)

 K. Collaboration and Teamwork

Reported to nurse-in-charge/clinical instructor any deviances noted with the patient especially when taking vital signs and administration of medications. Assisted nurse-in-charge whenever she performed certain interventions/procedures to the patient like administration of medication. Coordinated with the nurse-in-charge and clinical instructor whatever interventions/procedures to be done like monitoring of vital signs every 4 hours and administration of medications, and reported and documented accurately data gathered especially any deviations noted. Referred patient to social welfare services for financial support.

Discharge Planning

MEDICATIONS

-Advise patient to : -take medications with right dose, frequency and route as prescribed. -complete full course of medications as ordered. -properly and safely store medications -report/ call physician for any signs of adverse/anaphylactic reactions.

EXERCISE

- Encourage patient to perform progressive ambulation exercises by gradually increasing distance and/or duration.

-Advise patient to comply with all laboratory examinations as ordered.

TREATMENT

HEALTH TEACHING

-Advise patient to : -practice proper hygiene especially hand washing and mouth care. -take enough rest/sleep at least 8 hours -observe proper perineal care, front to back -Avoid interacting with people having infections -have small frequent feeding

OUT- PATIENT

-Advise patient to comply with scheduled follow up visits with her primary care physician. -Advise patient to: -increase fluid intake at least 2,500ml daily -Encourage patient to eat foods rich in Vitamin C, Vitamin E, protein, Iron and carbohydrates. -Avoid fatty/oily and spicy foods -Encourage patient to include high fiber in the diet. -Respect patient religious practices.

DIET

SPIRITUAL