PERSONAL DATA

NAME: Mrs. M

ADDRESS: Caliat,Quizon, Nueva Vizcaya

AGE: 48 years old

BIRTHDAY: June 18, 1962

CIVIL STATUS: Married

NATIONALITY: Filipino

RELIGION: Roman Catholic

LANGUAGE: Iloco, tagalog

CHIEF COMPLAINTS: Vaginal bleeding

DATE OF ADMISSION: November 30, 2010

ATTENDING PHYSICIAN: Dr. Dela Cruz

PRICIPLE DIAGNOSIS: G3P2 (2-0-1-2)

Endometrial adenocarsinoma
HEALTH HISTORY

A. Past Medical History

Three months prior to admission, patient had vaginal bleeding for 7 days, 2 times
in one month with 1 week interval accompanied by hypogastric pain

Two months prior to admission, patient had another episode consult to the OB
Gyne when curettage done revealed Endometrial Adenocarsinoma referred hence
admitted for TAHBSO with BLND

B. Present Medical History

In regards to her current illness, Ms. M had noticed that she had begun having
vaginal bleeding for about a year. She asked neighbors and friends about this, and
because they had told her it was a normal occurrence which may happen as a result of
menopause, she sought no further treatment. The bleeding, she explained to student
nurses, was not painful, so she believed that it was not really a concern. After telling her
children about her condition, her daughter kept insisting that she seek medical advice,
however, she refused because of the high costs which comes from hospitalization. After
sometime, the bleeding began to increase, and the patient finally listened to the advice of
her children.
Brief Description of the Disease

A Myoma is a solid tumor made of fibrous tissue, hence it is often called a 'fibroid'
tumor. Myomas vary in size and number, are most often slow-growing and usually cause no
symptoms. Myomas that do not produce symptoms do not need to be treated. Approximately
25% of myomas will cause symptoms and need medical treatment.

Myomas may grow as a single nodule or in clusters and may range in size from 1 mm to
more than 20 cm in diameter. Myomas are the most frequently diagnosed tumor of the female
pelvis and the most common reason for a woman to have a hysterectomy. Although they are
often referred to as tumors, they are not cancerous.

The cause of myomas has not actually been determined, but most myomas develop in
women during their reproductive years. Myomas do not develop before the body begins
producing estrogen. Myomas tend to grow very quickly during pregnancy when the body is
producing extra estrogen. Once menopause has begun, myomas generally stop growing and can
begin to shrink due to the loss of estrogen.

Until recently, hysterectomy was the preferred option for treating symptomatic fibroids.
Now, however, there are a number of uterine fibroid treatments including the noninvasive,
outpatientMR guided Focused Ultrasound myoma treatment.

Clinical Manifestation

• Abnormal vaginal bleeding

• Pain
• Back ache
• Pressure bloating
• Constipation
• Urinary problem
• Menorrhagia
• Metrorrhagia
Surgical Management

• TAHBSO
• Hysterectomy
• Myomecomy
Anatomy and Physiology

The female reproductive system

consists of the ovaries, uterine
tubes (or fallopian tubes), uterus,
vagina, external genitalia, and
mammary glands. The internal
reproductive organs of the female
are located within the pelvis,
between the urinary bladder and
the rectum. The uterus and the
vagina are in the midline , with an
ovary to each side of the organ.
The internal reproductive organs
are held in place within the pelvis
with ligaments. The most
conspicuous is the brad ligament,
which spreads out on both sides
of the uterus and to which the ovaries and the uterine tubes attach.

Ovaries
The two ovaries are small organs suspended in the pelvic cavity by ligaments. The
suspensory ligament extends from each ovary to the lateral body wall, and the ovarian ligament
attaches the ovary to the superior margin of the uterus. In addition, the ovaries are attached to the
posterior surface of the broad ligament by folds of the peritoneum called the mesovarium. The
ovarian arteries, veins, and nerves transverse the suspensory ligament and enter the ovary
through the mesovarium.

A layer of visceral peritoneum covers the surface of the ovary. The outer part of the
ovary is made up of dense connective tissue and contains the ovarian follicles. Each of the
ovarian follicles contains an oocyte, the female sex cell. Loose connective tissue makes up the
inner part of the ovary, where blood vessels, lymphatic vessels, and nerves are located.

Uterine Tubes
A uterine tube, fallopian tube, or oviduct (named after the italian anatomist, Gabriele
Fallopio) is associated with each ovary. The uterine tubes extend from the area of the ovaries to
the uterus. The open directly into the peritoneal cavity near each ovary and receive an oocyte.
The opening of each uterine tube is surrounded by long, thin processes called fimbriae.
 The fimbriae nearly surround the surface of the ovary. As a result, as soon as the oocyte
is ovulated, it comes into contact with the surface of the fimbriae. Cilia on the fimbriae surface
sweep the oocyte into the uterine tube. Fertilization usually occurs in the part of the uterine tube
near the ovary known as the ampulla.

Uterus
The uterus is as big as the size of a medium-sized pear. It is oriented in the pelvic cavity
with the larger, rounded portion directed superiorly. The part of the uterus superior to the
entrance of the fallopian tubes is called the fundus. The main part of the uterus is called the body,
and the narrower part is termed the cervix and is directed inferiorly. Internally, the uterine cavity
in the fundus and uterine body continues through the cervix as the cervical canal, which opens
into the vagina. The cervical canal is lined by mucous glands.

The Uterine wall is composed of three layers: a serous layer or perimetrium of the uterus,
consists of smooth muscle is quite thick and accounts for the bulk of the uterine wall. The inner
most layer of the uterus is called the endometrium. The endometrium consists of simple
columnar epithelium tissues with an underlying connective tissue layer. Simple tubular glands,
called enometrial glands, are formed by folds of the endometrium. The superficial part os the
endometrium is sloughed off during menstruation.

The uterus is supported by the broad ligament and the round ligament. In addition to
these ligaments that support the uterus, much support is provided inferiourly to the uterus by
skeletal muscles of the pelvic floor. If ligaments that suppor the uterus or the muscles of the
pelvic floor are weakened such as in childbirth, the uterus can extend inferiorly into the vagina, a
condition termed as a prolapsed uterus. Severe cases require surgical correction.

Vagina
The vagina is the female organ of copulation and functions to receive the penis during
intercourse. It also allows menstrual flow and childbirth. The vagina extends from the uterus to
outside the body. The superior portion of the vagina is attached to the sides of the cervix so that a
part of the cervix extends into the vagina.

The wall of the vagina consists of an outer muscular layer and an inner mucous layer.
The muscular layer is smooth muscle and contains many elastic fibers. Thus the vagina can
increase in size to accommodate the penis during intercourse, and it can stretch greatly during
childbirth. The mucous membrane is moist stratified squamous epitheliam that forms a protective
surface layer. Lubricating fluid passes through the vaginal epithelium into the vagina.
In young females, the vaginal opening is covered by a thin mucous membrane known as the
hymen. The hymen can completely close the vaginal oriface in which case it must be removed to
allow menstrual flow. More commonly, the hymen is perforated by one or several holes. The
openings of the hymen are usually greatly enlarged during the first sexual intercourse. The
hymen can also be perforated during a variety of activities including strenuous exercise. The
condition of the hymen is therefore not a reliable indicator of virginity.

The External Genitalia

The external female genitalia, also called the vulva, or pudendum, consists of the
vestibule and its surrounding structures. The vestibule is the space into which the vagina and
urethra open. The urethra opens just anterior to the vagina. The vestibule is bordered by a pair of
thin, longitudinal skin folds called the labia minora. A small erectile structure called the clitoris
is located in the anterior margin of the vestibule. The two labia minora unite over the clitoris to
form a fold of skin known as the prepuce.

The clitoris consists of a shaft and a distal glans. Like the glans penis, the clitoris is well
supplied with sensory receptors, and it is made up of erectile tissue. An additional erectile tissue
is located on either side of the vaginal opening.
On each side of the vestibule, between the vaginal opening and the labia minora, are openings of
the greater vestibular glands. These glands produce a lubricating fluid that helps maintin the
moistness of the vestibule.

Lateral to the labia minor are two prominent rounded folds of skin called the labia
majora. The two labia majora unite anteriorly at the elevation of tissue over thepubic symphysis
calle dthe mons pubis. The lateral surfaces of the labia majora and the surface of the mons pubis
are covered with coarse hair. The medial surfaces of the labia minora are covered with numerous
sebaceous and sweat glands. The space between the labia minor is called the pudendal cleft.
Most of the time, the labia minora are in contact with each other across the midline , closing the
pudendal cleft and covering the deeper structures within the vestibule.

The region between the vagina and the anus is the clinical perineum. The skin and muscle
of this region can tear during childbirth. To preven such tearing, an incision called an episiotomy
is sometimes made in the clinical perineum. Traditionally, this clean, straight incision is thought
to result in less injury, and less trouble in healing, and less pain. However, many studies indicate
that there is less injury and pain when no episiotomy is performed.
PATHOPHYSIOLOGY
Precipitating Factors:
-High fat diet
Predisposing -Obesity
Factors: -Anxiety/Stress
-Age -Oral Contraceptives or
Etiology:
-Gender Unknow
-Heredity -Hormone replacement
-Early therapy
Menarche -Luteal Insufficiency
Estrogen Dominance or
increase in Estrogen -Coffee/ Caffeine intake
production

Proliferation of
cells in uterus* S/sx:
-Swelling of breasts
-Depression
-Loss of sex Drive
Overgrowth the -Dysmenorrhea
endometrial lining

Myoma:
Development of
uterine fibroid

Uterine Cavity S/sx:

begins to stretch or -Pain
increase in size -Increased pelvic Pressure

Interference in the
vascular supply

Degeneration of
the interior part of S/sx:
-hypermenorrhea
fibroid -Abnormal bleeding
PHYSICAL ASSESSMENT
BODY PARTS TECHNIQUE FINDINGS INTERPRET
ATION
HEAD
• Hair Inspection Black in color Normal
No lice

• Scalp Inspection No presence of Normal

Palpation dandruff Normal
No masses
No tenderness

• Ears Inspection With normal Normal

hearing
• Earlobes Inspection Bean-shaped Normal
• Ear Canacl Inspection No abnormal Normal
discharges
• Eyes Inspection PERRLA Normal
(Conjunctiv With pale Due to present
a) conjunctiva condition
• Lips Inspection Pale in color Due to present
(white) condition
• Teeth Inspection With presence of Due to poor hygiene
dental carries

• Gums Inspection Pinkish in color Normal

• Tongue Inspection Moist Normal

FACE Inspection Pale in color Due to present
Palpation No masses condition
Normal
NECK Inspection Symmetrical and Normal
pale in color
Due to present
condition
UPPER Inspection No lesion and pale Due to present
EXTREMITIE Palpation in color condition
S Symmetrical, no
bones dislocated

Normal
 11GORDON
• Fingernails BEFORE
Inspection DURING
Clean and ANALYSI INTERPRETATION
Normal
PATTERN properly cut S
1.Health Health is PalpationI am not Slightly poorHealth is Due Theto patient
present is not
Perception important, capillary
knowledgeable refill
a condition
knowledgeable
because this is about my disease condition about her condition
the only one that all I know is that of but she is willing to
I have to function this operation will physical, undergo all the
• Shoulder as well to giveInspection
my help me symmetrical
to live and
mental Normal
procedures for her
family comfort longer pale in color.
and betterment
and away from social Due to present
illness. A good well condition
• Heart health canAuscultation
take 90 bpm being and Normal
me away from the
illness because absence
• Palpation
Thorax and hospitalization
lungs is No tendernessof Normal
expensive to No wheezingdisease
avoid for itAuscultation
I keep sound Normal
myself health.
2.Nutritional He eats 3 times a He eat 3 times a Hepersen The pts.
Metabolic Pattern day, having snack day with snack sitivy to Nutritional
in the afternoon in the afternoon aquatic metabolic
• Abdomen Inspection and has
with his family.
Flat, Symmetrical
a food foods
Duepatterns
to present
in
He has food slightly
allergies to fish. pale in condition
general is all good
allergies to fish, He is in soft color
diet because she eats
as of his food diet Normoactive
and he drink 3-4 the minimum
consists ofAuscultation
meat sound
glasses of water req’ts of food that
more than 3 in a day,No tenderness
vitamin Normal
is essential to
Palpation B complexResonant
times in a week as survival
and vegetables ordered. Normal
sometimes. He
drink 7-8 glasses Normal
of water in a day
and sometimes
soft drinks.
Percussion
LOWER Inspection Symmetrical Normal
EXTREMITIES
3.Elimination Pattern He voids 6 times He voids Pale in color Before:6
5 times There are no
in a day and in a day and in During:5 Duesignificant
to present
yellowish inPalpation
color normal color no alteration on her
condition
have no foul odor. foul odor. He elimination
His bowel bowel 1 times a pattern
movement 2 day in normal
• Legs times in a day,
Inspection color andslightly pale. Due to present
normal in color. consistent. condition

4.Activity/exercise He has physical He just ambulate ROM

Pattern activity every day, over the hospital given by
 he walks for aisle in male the help
almost 2hours to ward corner. of the
go to his farm and NOD
do all work load of
a farmer.

5.Sleep rest Pattern He sleeps 6-7 He sleeps 7-8

hours in a day hours in a day
and has sleeping and he takes
problem related naps at day
to bad dreams at time. He has
night. He never sleeping
takes pills to problem at night
promote good due to
sleeping pattern. environment.

6.Cognitive - he is not wearing eye glasses and No significant

Perceptual Pattern hearing aid, she answers all our alteration in
questions accordingly cognitive
perceptual pattern
7.Self-
perception
8.Role relationship According to the patient he has a good Upon her
pattern relationship with his family and operation
sharing emotional bond with his
upspring.
9.Sexuality -menarche at 12 years old with
Reproductive Pattern moderate flow within 3-4 days of
duration

10.Copping stress He spends his time to his family and internali Pt. M uses
Management relatives to coping up from stressed. zation internalization as
her overall stress
mgtter
11.Values belief He is active member of Pentecost and She Religious in nature
pattern they go to church every Sunday. keeps
praying
to god
even
she’s not
attendin
g
Sunday
mass
Course in the Ward

12/06/10
Doctor’s order Rationale
Please admit under Dr. Melchor dela For regal purposes
Cruz secure consent for admission and
management
Monitor BP, TPR for 4o For baseine data
Clear liquid then NPO In preparation for operation
Diagnostic: For baseline data
fbs
IVF D5LRS 1Lx8o on call medication To maintain electrolytes
Cefazolin 1 gram IV ANST
For TAHBSO with BLND on Nov7, Removal of the anomaly
2010
Secure consent For regal purposes
12/06/2010
8:50PM
anesthesia note preparation of the operation

Patient evaluated To prepare for the operation

NPO post midnight In preparation for the operation
For CBC prior to admission For baseline data
Follow up availability of blood for OR Preparation for the operation
use
Refer accordingly For medical purposes
12/07/2010
5:30PM
flat on bed to prevent intracranial pressure

On going To maintain fluids and electrolytes

IVF1: D5LRS 1lx30 gtts/min
IVF2: PNSS x KVO
Keep thermoregulation To prevent hyperthermia
Refer accordingly For further management
12/08/2010
5:00AM
Back to ward for further management

Continue monitoring For baseline data

Refer accordingly For further management
9:00AM
repeat hgb +hct for medical purposes
Monitor v/s q4o For monitoring purposes
Monitor I&O To know if the output and input are
properly working
Diagnostic Exam
Complete Blood Count
Analysis and
Diagnostic Indications or Normal
Results interpretatio
Procedure Purpose Values
n
HGB (g/dL) To measure the 140 120-160 Normal.
hemoglobin g/dl Patient was
able to
compensate
with
decreased of
oxygen
carrying
capacity and
availability of
oxygen
increased.
HCT (%) To aid 43.1 36.0 – Normal. The
diagnosis of 47.0 ratio of solid
abnormal states particles in
of hydration, the blood of
polycythemia the patient is
and anemia and in proportion
aids in to the liquid
calculation of part of the
erythrocyte blood
indices signifying
that the blood
is neither too
diluted nor
too
concentrated.
Platelet Count To evaluate 246 150 – 400 Normal. It
(x10 9/L) platelet means that
production the
coagulation
capacity and
clotting factor
of the patient
is functioning
well.

WBC (x10 To determine 9.1 4.8 – 10.8 Normal

9/L) for presence of count. It
for further tests means the
such as WBC patient’s
 differential immune
infection and function is
also for intact and
determination functioning in
count its optimum.
Proximity of
the WBC
count to the
high limit
score means
the body is
trying to fight
present
developing
infection or
there is
presence of
bleeding in
some parts of
the body.
Differential To provide a 40 55-65% The result is
Count: numeric below normal
Segmenters (%) estimate of the range
client’s indicating the
immune status. possible
presence of a
viral
infection.
Lymphocytes To check for 48 25-35% The result is
(%) immune above normal
responses range
indicating
infection.
Eosinophils To determine 05 2-4% The result is
(%) presence of above normal
multicellular range
parasites and indicating the
certain presence of a
infections parasitic
infection.

Monocytes (%) To determine 07 2-6% The result is

presence of above normal
Chronic range. It
inflammatory means
 disease, macrophages
Parasitic are activated.
infection, Viral
infection

Blood Chemistry
Diagnostic Indications or Normal Analysis and
Results
Procedure Purpose Values interpretation
Glucose ; RBS To measure the 101 <140 Normal count.
amount of mg/dl It means the
glucose in the amount of
blood right at glucose in the
the time of blood is
sample sufficient for
collection energy
production and
also not
excessive to
cause
hyperglycemia.
Indicated
insulin
(pancreatic)
function is
functioning to
its optimum.
Creatinine To evaluate 0.8 0.4-1.4 Normal. It
kidney mg/dl means toxic
function. substances in
the body are
maintained in
normal amount
and signifies
the kidneys are
functioning
normally with
accordance to
its filtration
and excretion
of toxic
substances.
Result also
indicate
normal pH of
blood is
 maintained.

Potassium To detect 3.82 3.4 - 5.3 Normal /

concentrations mmol/l within normal
that are too range. It means
high electrolyte
(hyperkalemia) supply in the
or too low body is
(hypokalemia). sufficient to
meet hydration
needs.

Diagnostic Curettage Examination

Procedure: Diagnostic Curettage

Clinical Dx: AUB, Myomauteri; t/c endometrial malignacy ; t/c leiomyosarcoma

Final Pathologic Diagnosis :

ENDOMETRIAL ADENOCARCINOMA
Drug Study
Side Effect/
Generic Name
Classification Indication Action Adverse Nursing Consideration
(Brand Name)
Reaction
Brand Name: urinary tract First generation • Assess patient for infection (vital
Ancef Therapeutic: infections cephalosporin Seizures (high signs; appearance of surgical site,
Anti-infectives anti-infective doses), diarrhea, urine; WBC) at beginning and
Generic Name: drug that inhibits during therapy.
Cefazolin cell-wall nausea, • Before initiating therapy, obtain a
Sodium synthesis, history to determine previous use of
Pharmacologic: promoting vomiting, and reactions to penicillins or
osmotic cephalosphorins. Persons with a
First generation cramps,
instability; negative history of penicillin
cephalosphorins usually Rashes, urticaria sensitivity may still have an allergic
bactericidal. response.
Allergic • Obtain specimens for culture and
sensitivity before initiating therapy.
reactions • Observe patient for signs and
including symptoms of anaphylaxis (rash,
pruritis, laryngeal edema,
Anaphylaxis and wheezing). Discontinue drug and
notify physician or other health care
Serum sickness, professional immediately if these
superinfection problems occur. Keep epinephrine,
an antihistamine, and resuscitation
equipment close by in case of
anaphylactic reaction.
Brand Name: 10 mg / amp Opioid Itching, burning,
Nubain Narcotic agonist- PRN analgesics. Binds urticaria,
antagonist with opiate Nausea,
Generic Name: analgesic Receptors in the vomiting,
Nalbuphine CNS, altering cramps,
Hydrochloride perception of dyspepsia, bitter
 and emotional taste, dry mouth
response to pain.

Brand Name: Antianginals. The patient verbalizes understanding

Amlodipine Inhibits calcium of taking this medication
Besylate ion influx acriss
5 mg / tab OD cardiac and
smooth- muscle
Generic Name: cells, dilates
coronary arteries
Norvasc and arterioles,
and decreases
blood pressure
and myocardial
oxygen demand.
Assessmen Nursing Scientific Nursing
Planning Rationale Evaluation
t Diagnosis Explanation Interventions
Decreased A surgery is a type After 4 hours Monitored and - To establish a base line data After 4 hours of
Cardiac Output of stress upon the of nursing recorded vital nursing
O: with a related to body. After a interventions, signs interventions,
BP of increased surgery, the patient the patient BP the BP of the
- To promote healing of the
140/80 afterload as is left with a scar will decrease Promote adequate patient and to lower heart rate. patient lowered
evidenced by a from the incision, to less than rest to 120/80
BP of 140/80 which pay cause 140/80 but not
pain. This pain lower than Encourage -To lessen anxiety from pain
may cause an 100/70 relaxation which may cause an increase
increase in the techniques such as in BP
blood pressure of listening to music
the client. This
prolonged increase Provide -To lessen anxiety
in blood pressure psychological
in time decreases support
the tissue perfusion
-To promote proper perfusion
and the blood out Encourage of blood to tissues to promote
put of the heart. ambulation as healing.
tolerated
- To prevent orthostatic
Encourage hypotension which may result
changing position from prolonged
immobilization.
slowly
 Nursing Scientific Nursing
Assessment Planning Rationale Evaluation
Diagnosis Explanation Interventions
S: “Di pa Activity Because stress After 2 hours Provide positive -To Enhance
masyadong intolerance and pain is an of nursing atmosphere learning After 2 hours
makagalaw,ang related to inevitable factor interventions, of NPI, the
hirap.” generalized post most surgical the patient Promote comfort -To promote a patient and SO
weakness as procedures, the and SO will measures like fixing positive atmosphere identified
manifested by client avoids identify the bedside conducive to techniques to
O: with discomforts, movement in order techniques to learning. enhance
grimace, weakness and to lessen the enhance Provide adequate rest
activity
appears weak, facial grimace. aggravation of this activity periods -To promote healing. tolerance
with verbal pain. They become tolerance of Instructed SO to -To promote adequate
reports of immobile, not the patient. reposition the patient tissue perfusion all
discomforts wanting to move every 2 hours with throughout the body.
proper assistance
as a result of this
pain. Because of Instructed SO to use -To provide safety
this, the side rails, overhead
immobilization and pillows in
can cause changing the position
of the patient
complications,
such as thrombus
formation.
Assessmen Nursing Scientific Nursing
Planning Rationale Evaluation
t Diagnosis Explanation Interventions
Goal met as
S: Altered comfort After 4 hours Monitor vital For baseline data evidence by
“masakit related to pain of nursing signs for base line pain of 2/10
ang puson intervention, data
ko” as the patient
verbalized sensation of Provide comfort To relieve pain
by the pain will be measures
patient with reduce from
pain scale 9/10 to 2/10 Encourage use of To relax aches and
of 9/10 relaxation pain
technique
O:
-restless Administered pain Drug to relieve pain
-Irritable reliever
-moaning
-crying
-
diaphoresis