I. INTRODUCTION This is a case of Patient X who was diagnosed with Uterine Myoma on the 6 th of March 2009.

Myomas or uterine fibroids are lumps that grow on your uterus. One can have fibroids on the inside, on the outside, or in the wall of your uterus. Doctors may call them fibroid tumors, or leiomyomas. But fibroids are not cancer. One does not need to do anything about them unless they are causing problems. Fibroids are very common in women in their 30s and 40s. By the time they are 50, about 80 women out of 100 have fibroids. But fibroids usually do not cause problems. Many women never even know they have them. Doctors are not sure what causes fibroids. But the female hormones estrogen and progesterone seem to make them grow. A female body makes the highest levels of these hormones during the years when she menstruates. Fibroids usually shrink after menopause and stops causing symptoms. Often fibroids do not cause symptoms. Or the symptoms may be mild, like periods that are a little heavier than normal. If the fibroids bleed or press on a patient’s organs, the symptoms may make it hard for her to enjoy life. Fibroids make some women have: Long, gushing periods and cramping. Fullness or pressure in their abdomen, Low back pain, dyspareunia or pain during sex, and an urgency to urinate often. Sometimes heavy bleeding during your periods can lead to anemia. Sometimes fibroids can make it harder to get pregnant. Or they may cause problems during pregnancy, such as going into early labor or losing the baby. As for Patient X, she was recently admitted at Xavier University Community Health Care Center (XUCHCC) or German Doctors Hospital on April 19, 2009. She was

1

admitted at the said hospital under the care of Dr. Boromeo for her scheduled surgery, Total Abdominal Hysterecomy-Unilateral Salphingo Oophorectomy (TAH-USO) which was performed last April 22, 2009. Furthermore, the patient has been on recovery until April 24, 2009. With the acquired information given by the patient, the group aims to present the case of Patient X comprehensively and discuss the ideal and actual management done to improve the condition of the client, including an individualized nursing care plan done to relieve the nursing problems identified by the team in the small span of time that we were able to care for the patient. In the process, we aim to enhance our knowledge, skills and attitude to further improve ourselves in our nursing practice.

2

A. GENERAL OBJECTIVE: At the end of 2 hours of case presentation, the group will be able to increase our knowledge pertaining to our patient’s case and other concepts most useful in the surgical ward, enhance our skills in making and conducting all parts of our case study, and develop a good attitude of cooperation and camaraderie among every member of the group. B. SPECIFIC OBJECTIVES: At the end of 2 hours of case presentation, we will be able to: 1. 2. 3. 4. 5. lay out our general and specific objectives to the panel of CI’s clearly. discuss our general assessment of the patient thouroughly. expound the pathophysiology of our patient’s case knowledgeably. present the medical and the nursing management carried out by the group to the patient. answer the questions thrown by the CI’s to the group correctly.

C. SCOPE AND LIMITATIONS This case presentation will attempt to cover and discuss the disease process and present condition of the patient as assessed in the five days of assessment and duty, at Xavier University Community Health Care Center. It will also present the nursing and medical care as provided during the 32 hours of duty (April 20-23, 2009). This case presentation will be limited only to the patient’s verbalizations, laboratory reports, signs and symptoms as evidenced by and observed from the patient within the engaged days and how the medical team (doctors, nurses, SN, etc.) has managed each of them.

3

II. ASSESSMENT A. ASSESSMENT TOOL I - GENERAL INFORMATION Name: Patient X Age: 42y.o. Birthday: December 25, 1966 Civil Status: M Sex: F Religion: R.C. Occupation: Housewife Informant: Patient X Relation: patient Admission Date: April 19, 2009 Time: 10 am Chief Complaint: hypogastric mass Reason for admission: for further evaluation and management: TAH- USO Attending Physician: Dr. Rico Borromeo Diagnosis/Impression: Uterine Myoma History of Present Illness: March 6, 2009- Patient sought consultation at German Doctor’s Hospital due to noticed palpable mass at right hypogastric region- (-) tender and (-) movable. (+) monthly menses lasting three days with increased blood flow volume. Patient experienced urinary frequency- about 15-20 times a day with an estimated amount of 200cc per urination. Undergone ultrasound and result showed enlarged uterus (11cm x 9cm) and isoechoic mass of anterior myometrium (9.7cm x 7.5cm) and was advised for admission on April 19, 2009. Patient frequently sought consultation and completed laboratory exams (CBC, U/A, CXR and ECG) and thus admitted and scheduled for surgery. Past Medical/Surgical History: Illness None Legend: Black – Day 1(April 19); Blue – Day 2(April 20); Green – Day 3(April 21); Violet – Day 4(April 22); Orange – Day 5(April 23) Vital Signs: HR = 75 bpm Temperature 36.8oC 36.7oC 37.2oC 37.3oC RR= 19 cpm BP = 120-80 mmHg Temp = 36.8°C Blood Pressure 120/80mmhg 130/80mmhg 120/80mmhg 130/90mmhg Date

Heart Rate 88 bpm 78 bpm 78 bpm 102 bpm

Respiratory 18cpm 16cpm 18cpm 16cpm

II - ACTIVITY/REST 4

Subjective Usual activities/hobbies: Doing household chores, vending snacks, working as a barangay health worker Leisure time activities: Watching TV Limitations imposed by condition: Cannot perform usual activities due to stay in hospital Sleep number of hours: 4-5 hours, not continuous Naps: None Aids: None Difficulty in sleeping: None Feeling on awakening: Most of the time, patient feels well rested but there were times when she feels heavy as if she never had a rest at all Others/Comments: “Bulog usahay akong ulo pagmata kay kulang tulog,” as verbalized by the patient. “Sige man gud og mata-mata kung gabii kay mangihi ko. as verbalized by the patient. “Dili pud ko kabawi ug tulog kay trabaho man nako sa hapon. Daghan ko ginabuhaton ba. ”as verbalized by the patient. Objective Observed response to activity: Cardiovascular: Increased PR- 81 bpm Respiratory: Increased RR-23 cpm Mental Status: Oriented Posture: Erect LOM: None Tremors: None Others/Comments: The patient responds normally to activities. III – CIRCULATION Subjective History of hypertension: None Heart trouble: None Ankle/leg edema: None Slow healing: None Claudication: None Cough/hemoptysis: None Extremities: Numbness: None Tingling: None Change in frequency/amount of urine: 15-20x a day 4-6x a day Others/Comments: Frequent urination has always been the patients problem. Patient reported that she voids 15-20x per day, about 200cc per urination before admission. “Ga sige ko og ihi-ihi, ika-kinse or ik-bente sa isa ka adlaw, adtong wala ko na admit. Pag-admit nako kay ika-napulo o ika-kinse nalang sa usa ka adlaw.” As verbalized by the patient. Objective

5

BP

R: Lying: 120-80 mmHg L: Lying: 120/80mmHg

Pulse Pressure: 40 mmHg Heart Sounds: Rate: 75 bpm Pulse: Carotid: 79 bpm Popliteal: 71 bpm Femoral: 79 bpm Vascular Bruit: None Jugular Vein Distention: None Extremities: Temperature: 36.8°C Color: Slightly pale Capillary Refill: Returns after 2 seconds Homan’s sign: none Varicosities: None Color/Cyanosis: Nail beds: Pale Lips: Brown Mucous membranes: Moist Sclera: Whitish Others/Comments: Patient’s lips are cracked and dry, palms are having some palmar pallor. IV - EGO INTEGRITY Subjective Report of Stress Factors: Second child’s behavior Ways of handling stress: Nagging Financial Concerns: Presently experienced Relationship Status: Strained relationship with second child Lifestyle: Active with no vices Recent changes: Patient can’t perform usual activities. Patient stays still in bed. Patient was on a clear liquid diet. Feelings of: Helplessness: None Hopelessness: None Powerlessness: None Other/Comments: “ Wala kay ko problema sa akong kinamagulangan og kinamanghuran na anak. Kato ra akong ikaduha kay sige’g kahubog,” as verbalized by the patient. “Usahay muabot man jud ng problema pang pinansyal. Labaw na karon nahospital pa jud ko,” as verbalized by the patient.

Sitting: 120/80mmHg Standing: 120/80mmHg Sitting: 120/80mmHg Standing: 120/80mmHg PMI: Apex of the heart Rhythm: Normal sinus rhythm Radial: 75 bpm Temporal: 78 bpm Dorsalis Pedis: 79 bpm Breath Sounds: Bronchovesicular

Objective

6

Emotional status (Check those that apply) (√) Calm ____Anxious ____ Withdrawn ____Fearful ____ Euphoric

____ Angry ____ Irritable

Observed physiologic response: Patient was able to establish good eye contact. Others/Comments: The patient is able to answer all the questions asked appropriately. V – ELIMINATION Subjective Usual Bowel Pattern: Irregular (3-4 days interval) before admission Character of Stool: Hard, formed, brown in color, and minimal in amount Last BM: April 19, 2009 – 4:30 pm April 20, 2009 – 6:00 am April 21, 2009 - 7:30 am April 23, 2009 – 9:00 am & 8:00 pm Laxative use: Dulcolax (April 22& 23) History of bleeding: None Hemorrhoids: None Constipation: None Diarrhea: None Usual voiding pattern: 15-20x per day Incontinence: None Urgency: (√) Retention: None Frequency: (√) (-) (-) Pain/Burning/Difficulty in voiding: None History of kidney/bladder disease: None Others/Comments: The patient has an abnormal voiding pattern at night with an amount of 200 cc urine per voiding, however, the patient does not drink much water about 2 – 3 glasses per day only. The patient also mentioned that she experienced straining upon defecation. “Dili na regular ako paglibang. Sukad tong niaging bulan kay mga tag-tulo o upat ka adlaw ko ayha malibang. Ginagmay nga gahi akong tahi. Usahay galisod pud ko ug libang” as verbalized by the patient. “Gasige ko ug ihi-ihi, ika-kinse o ika-bente sa isa ka adlaw, adtong wala pa ko na admit. Paadmit nako kay ik kinse o ika napulo na lag sa isa ka adlaw.”, as verbalized by the patient. “Karon dili na ko sige’g ihi-ihi. Mga kaupat o kaunom sa isa ka adlaw nalang,” as verbalized by the patient. Objective Abdomen:

Tender: No Soft/Firm: Soft Palpable Mass: Palpable mass at right lower quadrant of the

7

abdomen Palpable mass at right lower quadrant of the abdomen absent Size/Girth: 40 inches 37 inches Bowel Sounds: Present ( Once in every 30 seconds) Bladder palpable: No Distended: No distention Others/Comments: Abdominal pains were felt after the surgery and even 2-3 hours after. VI - FOOD/FLUID Subjective Usual diet (type): DAT NPO PMN Clear Liquid Diet Number of meals daily: 3 meals a day which usually comprises of rice, fish or chicken but not much of vegetables. Last meal/intake: Lunch (12:00nn)(Apr. 19, 2009) Loss of appetite: None Nausea/Vomiting: None Dentures: none Allergy/Food intolerance: None Heartburn/Indigestion: None Mastication/swallowing problems: Difficulty masticating solid foods such as meat d/t lack of teeth Usual Weight: “65kg man tingali ko sa una” as verbalized. Changes in weight: 6 kg Diuretic use: None Others/Comments: “Isda, dili kayo ko gakaon anang gulay, Gana-gana ra. Dilli pud ko hinginom ug tubig. Mga 2-3 ra ka baso akong mainom sa isa ka adlaw” as verbalized by the patient. Objective Current Weight: 59 kg upon admission Height: 5’0” Body Build: Stout Skin Turgor: Good Mucous membranes: Dry Moist Hernia/Mass: Palpable mass at right lower quadrant of the abdomen Palpable mass at right lower quadrant of the abdomen Palpable mass at right lower quadrant of the abdomen Edema: General: None Dependent: None Periorbital: None Ascites: None Thyroid enlarged: Not enlarged Halitosis: Evident

8

Condition of teeth/gums: 1 tooth on upper jaw; 4 teeth on lower jaw; pinkish gums Appearance of tongue: Pinkish Others/Comments: Mass at right hypogastric region was removed. VII – HYGIENE Subjective Activities of Daily Living (Dependent/Independent) Pls. encircle Mobility: Hygiene: Toileting: Mobility: Hygiene: Toileting: Mobility: Hygiene: Toileting: D/I D/I D/I D/I D/I D/I D/I D/I D/I Feeding: Dressing: Feeding: Dressing: Feeding: Dressing: D/I D/I D/I D/I D/I D/I

Others: None Equipment/prosthetic devices required: None Assistance provided by: Husband if activity is too heavy for the patient brought about by her condition. Others/Comments: “Gapatabang pa kog bakod bakod og adto sa CR,” as verbalized by the patient. Objective General Appearance: Patient is a fair- skinned, stout woman with a black, short, and wavy hair. Her teeth are losing. And her nails are long and her feet are dusty. Manner of dress: Appropriate for age Personal Habits: Takes a bath once a day Body odor: Evident Condition of scalp: Dry Presence of vermin: None Others/Comments: Patient appears neat except for her untrimmed nails and some flakes on her hair. Horizontal incision in the hypogastric region of the abdomen with dressing and abdominal binder noted. Redness of surrounding skin is also noted.

9

“Dako akong samad. Ginabutangan pa gain ni ug binder para dili ma-ukab and tahi kay sakit man. Magsige na lang ko higda kay sakit musamot kung mulihok. Tuloy-tuloy iyang pagsakit. Ngut-ngot nga dili masabtan.”as verbalized. VIII – NEUROSENSORY Subjective Fainting Spells/dizziness: None Headache: Location: None Onset: Not applicable (N/A) Frequency: N/A Seizures: None Aura: N/A How controlled: N/A Eyes: Vision Loss: R: None L: None Last examination: Never been examined Glaucoma None Cataract: None Ears: Hearing Loss R: None L: None Last examination: Never been examined Sense of smell: No problem reported Epistaxis: None Others/Comments: Patient’s overall neurosensory state is normal. Objective Mental Status Oriented / Disoriented Time: (√) Place: (√) Person: (√) (√) Alert ____ Drowsy ____ Lethargic ____ Stuporous ____ Comatose (√) Cooperative ____ Combative Affect: Appropriate Delusions: None Hallucinations: None Memory: Recent: Good Remote: Good: Able to recall onset of signs and symptoms of existing disease Speech pattern: Spontaneous Congruence: Congruent Glasses: None Contacts: None Hearing Aids: None Pupil size/reaction: R: PERRLA – 2mm L: PERRLA – 2mm Facial droop: None Swallowing: Good: No problems with swallowing Handgrip/release: R: Strong L: Strong Posturing: Erect DTR: Not assessed Paralysis: None Others/Comments: Patient’s overall mental status is good.

IX – PAIN Subjective Onset: April 21, 2009 April 22, 2009 Duration: Continuous Continuous

10

Location: Epigastric region Hypogastric region

Intensity: Pain score of 4 with 10 as the highest Pain score of 6 with 10 as the highest Pain score of 3 with 10 as the highest

Frequency: 5 minutes Quality: Regular 5 minutes Irregular Description of Pain (check all that apply) ____Shooting ____Stabbing ____ Sharp ____ Dull ____ Numb (√) (√)_ Throbbing _(√)_ Burning ____ Unbearable Precipitating Factors: None Aggravating Factors: Frequent movements How relieved: Change in position Associated Symptoms: None

____Gnawing ____ Aching ____ Radiating

Others/Comments: “ Sakit akong kuto-kuto, hapdos siya. Gi gutom na gyud kaayo ko.” As verbalized by patient. “Dili lagi ko lugos kalihok kay tungod sa kasakit sa samad. Magsige na lang man ko ug higda. Musakit man ug samot pag maglihok-lihok ko” as verba;ized by the patient. “ Human pag opera kay sakit kaayo akong tahi. Mas musakit kung mag lihok ko mao nga ga puyo lang ko, unya gaka-irita pud ko kung nay gasaba-saba.” As verbalized by patient. Epigastric pain was related to NPO status. It was no longer present after the surgery. Objective (Check all that apply) (√) _Grimacing _(√) Being Irritable (√) _Moaning ____ Sitting Rigidly ____Sighing (√)(√) Moving very slowly ____Limping ____ Clenching Teeth (√) Avoiding Physical Activity ____ Narrowed focus (√)__Lying down during the day ____Requesting help with walking ____Walking with an abnormal gait ____Stopping frequently while walking _(√) Frequently shifting posture or position _(√) Moving in a guarded or protective manner ____Holding or supporting the painful body area ____ Asking to be relieved from tasks or activities ____ Asking such questions as “Why did this happen to me?” ____ Using a cane, cervical collar, or other prosthetic

11

Others/Comments: Patient is able to tolerate pain. Difficulty in turning to sides noted. X – RESPIRATION Subjective Dyspnea, related to: None Cough/sputum: None ____ Bronchitis ____ Asthma ____ Tuberculosis ____ Emphysema ____ Recurrent Pneumonia ____ Exposure to noxious fumes Smoker: No Pack/day: N/A Number of years: N/A Use of respiratory aids: None Oxygen: None Others/Comments: Patient has been experiencing second-hand smoke for four years now. Her second child started smoking at the age of 17. Objective Respiratory: Rate: 19 cpm Depth: Deep: unlabored Symmetry: Symmetrical Use of accessory muscle: None Nasal Flaring: None Fremitus: Present Breath sounds: Bronchovesicular Cyanosis: None Clubbing of fingers: None Sputum characteristics: N/A Mentation/restlessness: None Others/Comments: Patients had no observable signs of respiratory problems. Respiration rate and rhythm is within normal range. XI – SAFETY Subjective Allergies/sensitivity: None Reaction: N/A History of STD (date/type): None Blood transfusion/number: Never When: N/A History of Accidental injuries: None Fractures/dislocations: None Arthritis/unstable joints: None Back problems: Present Changes in moles: None Enlarged nodes: None Prosthesis: None Ambulatory devices: None Expression of ideation of violence (self/others): Patient is non violent to herself and others Others/ comments: “Usahay kay gasakit akong bat-ang, labaw na anang gikan kog panglimpyo,” as verbalized by the patient.

12

Objective: Temperature: 36.8°C Diaphoresis: None Skin integrity: Dry and intact Dry but no longer intact due to surgical incision; abdominal binder noted Scars: None Rashes: None Lacerations: None Ulcerations: None Ecchymosis: None Blisters: None Burns, degree/percent: None Drainage (note location): None General Strength: Patient is generally strong. She is able to do daily activities of daily living. Patient appears generally weak and has complains of pain. Patient has regained some of her strength. Muscle tone: Good Gait: Normal Others/Comments: XII – SEXUALITY Sexually active: Not much Sexual concerns/difficulties: None Recent change in frequency/interest: Still interested but seldom does it Subjective Age of menarche: 13y.o. Length of cycle: 26 – 30 days interval Duration: 3 days Last menstrual period: Mar. 10, 2009 Menopause: Early menopausal due to TAH-USO, April 22, 2009 Vaginal discharge: None Bleeding between periods: None Deliveries/Pregnancies: G 3 P 3 T 3 P 0 A 0 L 3 Episiotomy: None Lochia: None Complications of pregnancy: None Surgeries: For TAH-USO on April 22, 2009 Post TAH-USO on April 22, 2009 Hormonal therapy/calcium use: Used contraceptive pills for 13 years after 2nd child Practices self-breast examination: Yes Discharges: None Last Pap smear: 2007 Method of birth control: Artificial method: pills, and calendar method Paresthesia/Paralysis: None

13

Others/Comments: When menstruating patient consumes 4-5 sanitary pads per day. “Dili man daghan ang gagawas kung dug-on ko sa una, dili naman gain ko ganapkin ato. Katong naa na gitubo kay ganapkin nako. Kusog2x naman ang dugo. Ika upat o ika lima ko makapuli ug napkin sa isa ka adlaw.” As verbalized by patient Objective Breast Examination: No palpable mass, non-tender Vaginal warts/lesions: None Others/Comments: No discharges from the breast were noted. XIII - SOCIAL INTERACTIONS Subjective Marital status: Married Years in relationship: 24 years Living with: Husband and 3 sons, parents, and an adopted son Concerns/stresses: Second child’s behavior and financial concerns Extended family: Yes Other Support Persons: None Role within family structure: Co-bread winner Report of problems related to illness/condition: Inability to work and earn money for their needs Others/Comments: “Katong akong ikaduha ra jud og kwarta hilabi na karon nga nahospital ko. Dili ko makapamaligya,” as verbalized by the patient. Objective Speech: (√) Clear ____Slurred ____Unintelligible ____ Aphasic Others/Comments: Patient remained calm and attentive throughout the interview. XIV - TEACHING/LEARNING Subjective Dominant Language (specify): Cebuano Literate: (√) Educational Level: High school graduate Health beliefs/practices: Patient believes in hilot, panuhot,and bughat as well as the use of herbal medicines. Familial risk factors (check all that apply & indicate relationship): __ Diabetes ______ ____Tuberculosis _______ ____ Heart Disease _______ Stroke _______ __ High BP _______

14

____ Epilepsy ____ Kidney Disease Cancer ____ Mental Illness

_______ _______ _______ _______

Use of Alcohol (amount/frequency): No Others/Comments: Patient’s sister was also diagnosed of uterine myoma.

XV - Body Map: (Illustrate in the body map how your patient looks like, e.g. tubes inserted, bruises, surgical incisions, physical abnormalities, affected areas. Mark with a small “X” where it is located or draw it on the body map and then label it in the space provided.)

Dry scalp with some flakes

Epigastric pain 4/10 X Hypoactive bowel sounds Catheter Attached to urobag (4/22 – 4/23) Dirty Nails Scar xx X x

Palpable mass Suture line with dressing and binder hypogastric pain 6/10 4/10 IV line: D5LR 1000cc regulated @ 30 gtts/min

General weakness Dusty Feet

15

B. Laboratory/Diagnostic Results: Ultrasound 03/06/09 Sonography Report: The uterus is enlarged in size measuring 11cm x 9 cm. There is an isoechoic mass at the anterior myometrium 9.7cm x 7.5 cm. Both adnexa are unremarkable. No fluid in the posterior culdesac. Impression: Myoma uteri, intramural, anterior Interpretation: to consider uterine myoma Hematology 04/14/09 Complete Blood Count: Hematocrit: Hemoglobin: WBC: Segmenters: Lymphocytes: Eosinophils: Stabs: 40 F 37-47 vol. %

13.3 F 12-16 gms% 5,700 5000- 10,000/cumm 56 34 7 55-75% 20-35% 1-3%

Differential count:

5/100% 0-9%

Platelet count: 170,000 150,000-350,000/cumm Bleeding Time: 2’15” 1-3 mins Clotting time: 3’30” 2-6 mins.

16

Interpretation: possible parasitic infection or allergic reaction due increased eosinophils Urinalysis Color: Straw Transparency: Hazy Protein: Negative Sugar: Negative pH: 6.0 Specific Gravity: 1.010 Pus Cells: 2-5 Red Blood Cells: 1-3 Epithelial Cells: Squamous: Few Bacteria: Moderate Mucus Thread: Few Interpretation: possible bacterial infection ECG 4/14/09 WNL Chest PA 4/14/09 4/14/09

Radiological Findings: The heart is normal in size. The lungfields are clear. Hemi diaphragms and sulci are intact. The thoracic aorta is atheromatous. Impression: Atheromathous Thoracic Aorta Interpretation: possible presence of fats in the thoracic aorta

17

III. ANATOMY AND PHYSIOLOGY Anatomy of Female reproductive system

The internal reproductive organs

1) Vagina – a 3-4 inch long dilatable canal located between the bladder and the rectum;contains rugea (which permit considerable stretching without

tearing);organ of copulation; passageway of menstrual discharges and fetus. 2) Uterus – hollow pear-shaped fibromuscular organ 3 inches long, 2 inches

wide,1 inch thick and weighing 50-60 grams in non –pregnant woman. held in place by broad ligaments (from sides of the uterus to pelvic

walls;also hold fallopian tubes and ovaries in place) and round ligaments ) from sides of the uterus to mons pubis) abundant blood supply from uterine and ovarian arteries. Composed of 3 muscle layers :perimetrium,myometrium,endometrium. Consist of 3 parts: corpus(body) – upper portion with triangular part

called fundus ; isthmus-area between corpus and cervix which forms a part 18

of the lower uterine segment ; cervix- lower cylindrical portion. Organ of menstruation;site of implantation; retainment and nourishment of

the products of conception. 3) Fallopian tubes- 4 inch long from each side of the fundus; widest part called ampulla spread into finger like projections called fimbriae. -responsible for transport of mature ovum from ovary to uterus; fertilization takes place in its outer third or outer half. 4) Ovaries- almond-shaped,dull white sex glands near the fimbriae ,kept in place by ligaments. Produce mature and expel ova and manufacture estrogen and progesterone.

Hormones

1) estrogen • inhibits production of follicle stimulating hormone. • • • Causes hypertrophy of the myocardium. Stimulates growth of the ductile structure of the breast. Increases quantity and pH of cervical mucus,causing it to become thin

and watery and can be stretched to a distance of 10-13 cm. 2) progesterone • Inhibits production of leutenizing hormone. • Increases endometrial tortuosity. • Increases endometrial secretions.

19

• Inhibits uterine motility. • Decreases muscle tone of gastrointestinal and urinary tracts. • Increases musculoskeletal motility. • Facilitates transport of the fertilized ovum through the fallopian tubes . • Decreases renal threshold of lactose and dextrose. • Increases fibrinogen levels;decreases hemoglobin and hemtocrit. • Increase body temperature after ovulation.

The phases of menstrual cycle

1) First phase(proliferative)-immediately after the menstrual flow(which occurs during the first 4-5 days of a cycle),the endometrium ,or lining of the uterus,is very thin,approximately one cell layer in depth. as ovary begins to produce estrogen(in the follicular fluid,under the direction of the pituitary FSH),the endometrium begins to proliferate. this growth is very rapid and increases the thickness of the endometrium approximately eightfold. this increase continues for the first half of the menstrual cycle (from approximately day 5 to day 14).this half of a menstrual cycle is term interchangeably the proliferative, estrogenic ,follicular,or postmenstrual phase.

2) Second phase(secretory)-after ovulation,the formation of progesterone in the corpus luteum (under the direction of LH) causes the glands of the uterine endometrium to become corkscrew or twisted in appearance and dilated with quantities of glycogen (an elementary sugar) and mucin (a protein).the capillaries of

20

the endometrium increases in amount until the lining takes in the appearance of rich,spongy velvet. This second phase of menstrual cycle is termed the progestational , luteal,premenstrual,or secretory phase.

3) Third phase (ischemic)-if fertilization does not occur,the corpus luteum in the ovary begins to regress after 8-10 days. as it regresses,the production of estrogen and progesterone decreases. with the withdrawal of progesterone stimulation ,the endometrium of the uterus begins to degenerate (at approximately 24 or 25 day cycle).the capillaries rupture,with minute hemorrhages,and the endometrium sloughs off.

4) Final phase (menses)- the following products are discharges from the uterus as menstrual flow or menses: a. blood from the ruptured capillaries. b. mucin from the glands. c. fragments of endometrial tissue. d. the microscopic,atrophied, and unfertilized ovum. -menses is actually the end of an arbitrarily defined menstrual cycle. because it is the only external marker of the cycle,however,the first day of menstrual flow is used to mark the beginning day of a new menstrual cycle. - contrary to the common belief ,a menstrual flow contains only approximately 30-80 ml of blood; if it seems like more,it is because of accompanying mucus and endometrial shreds .the iron loss in a typical menstrual flow is approximately 11mg ,this

21

is enough loss that many women need to take a daily iron supplement to prevent iron depletion during their menstruating years. - in women who are going through menopause ,menses may typically consist of a few days of spotting before a heavy flow, or a heavy flow followed by a few days of spotting,because progesterone withdrawal is more sluggish or tends to “staircase” rather than withdraw smoothly.

22

IV. NARRATIVE PATHOPHYSIOLOGY

Leimyomas are the most common benign tumors of the female genital tract. The mass is mostly composed of muscles and fibrous connective tissue. It is hypothesized that its growth is related to estrogen stimulation. The incidence is higher on women during the reproductive years where estrogens and other hormones are actively produced by the body. Many women opt to use oral contraceptives as a birth control method. Oral contraceptives promote estrogen dominance and eventually influence the growth of the cells in the uterus. High-fat diet is also considered a source of estrogen where as diets rich in fiber and low in fat decreases estrogen reabsorption. Leimyoma formation is also possible because of hyperestrogenism due to progesterone deficiency that is caused by luteal insufficiency. Apart from estrogen stimulation, heredity is a factor in the occurrence of leimyomas. Fibroids formation is 4.2 times more common in first-degree relatives than with fibroids without genetic influence. Estrogen is vital in the regulation the menstrual cycle. Presence of this hormone during the first phase influences the proliferation of smooth muscle cells in the uterine walls. Overstimulation increases the size of the uterine lining and further develops into a fibroid. During menstruation, the excessively thickened endometrium does not desquamate (shed its lining) easily (or even completely) at the end of the cycle, resulting in prolonged and/or excessive menstrual bleedings. Following the degeneration of the interior part of the fibroid, are the degenerative changes that eventually replace smooth muscle cells by fibrous connective tissue. The fibroid continually grows and its size puts pressure on the adjacent organs, the bladder and rectosigmoid. Urinary frequency and constipation, respectively, are the results of the compression of these organs.

23

V. SCHEMATIC PATHOPHYSIOLOGY Uterine myomas also called “fibroids” are tumors that grow from the wall of the uterus. Predisposing Factors • Age- 42 y.o. • • • Gender Family History- sister Use of OCP- 13 years Increased hormonal production of estrogen Precipitating Factor • Luteal Insufficiency • High fat diet

Proliferation of smooth muscle

Overgrowth of uterine lining Development of uterine Increased blood flow volume (before: does not use sanitary pads; upon palpation of mass: 4-5 sanitary pads/day during menstruation)

Degeneration of interior part of the

Hyaline Degeneration

Red or carneous

Smooth muscle cells are replaced by fibrous connective tissue

24

Continued growth of fibroid

Increased abdominal girth (40 inches preop)

Palpable mass at right hypogastric region. (UTZ showed enlarged uterus and isoehoic mass at anterior uterus)

Endometrial distention

Pressure on bladder

Recto sigmoid pressure

Urinary frequency and urgency (preop: 10-15 times/ day)

Constipation ( Once every 3-4 days, minimal amount of hard formed stool, decreased bowel sounds- 1 in every 30 seconds)

Legend: Manifestations

Signs and Symptoms

25

VI. MEDICAL MANAGEMENT A. Ideal Management: Uterine Myoma There's no single best approach to uterine myoma or fibroid treatment. Many treatment options exist. In most cases, the best action to take after discovering fibroids is simply to be aware they are there. Because fibroids aren't cancerous and usually grow slowly, patients have time to gather information before making a decision about if and how to proceed with treatment. The option that's right for a patient depends on a number of factors, including the severity of the signs and symptoms, the plans for childbearing, how close one is to menopause, and ones feelings about surgery. Watchful waiting- If patient has no signs or symptoms, watchful waiting (expectant management) could be the best course. Fibroids aren't cancerous. They rarely interfere with pregnancy. They usually grow slowly and tend to shrink after menopause when levels of reproductive hormones drop. This is the best treatment option for a large majority of women with uterine fibroids. Medications- Medications for uterine fibroids target hormones that regulate menstrual cycle, treating symptoms such as heavy menstrual bleeding and pelvic pressure. They don't eliminate fibroids, but may shrink them. Medications include:

Gonadotropin-releasing hormone (Gn-RH) agonists. To trigger a new

menstrual cycle, a control center in the brain called the hypothalamus manufactures gonadotropin-releasing hormone (Gn-RH). The substance travels to the pituitary gland, a tiny gland also located at the base of the brain,

26

and sets in motion events that stimulate the ovaries to produce estrogen and progesterone. Medications called Gn-RH agonists (Lupron, Synarel, others) act at the same sites that Gn-RH does. But when taken as therapy, a Gn-RH agonist produces the opposite effect to that of the natural hormone. Estrogen and progesterone levels fall, menstruation stops, fibroids shrink and anemia often improves.

Androgens. Ovaries and adrenal glands, located above the kidneys,

produce androgens, the so-called male hormones. Given as medical therapy, androgens can relieve fibroid symptoms. Danazol, a synthetic drug similar to testosterone, has been shown to shrink fibroid tumors, reduce uterine size, stop menstruation and correct anemia. However, occasional unpleasant side effects such as weight gain, dysphoria (feeling depressed, anxious or uneasy), acne, headaches, unwanted hair growth and a deeper voice, make many women reluctant to take this drug.

Other medications. Oral contraceptives or progestins can help control

menstrual bleeding, but they don't reduce fibroid size. Nonsteroidal antiinflammatory drugs (NSAIDs), which are not hormonal medications, are effective for heavy vaginal bleeding unrelated to fibroids, but they don't reduce bleeding caused by fibroids. Hysterectomy- This operation — the removal of the uterus — remains the only proven permanent solution for uterine fibroids. But hysterectomy is major surgery. It ends ones ability to bear children, and if a patient elects to have her ovaries removed

27

also, it brings on menopause and the question of whether she'll take hormone replacement therapy. Myomectomy- In this surgical procedure, the surgeon removes the fibroids, leaving the uterus in place. If one wants to bear children, she might choose this option. With myomectomy, as opposed to a hysterectomy, there is a risk of fibroid recurrence. There are several ways a myomectomy can be done:

Abdominal myomectomy. If having multiple fibroids, very large or very

deep fibroids, the doctor may use an open abdominal surgical procedure to remove the fibroids.

Laparoscopic myomectomy. If the fibroids are small and few in number,

the patient and the doctor may opt for a laparoscopic procedure, which uses slender instruments inserted through small incisions in your abdomen to remove the fibroids from your uterus. The doctor views the abdominal area on a remote monitor via a small camera attached to one of the instruments.

Hysteroscopic myomectomy. This procedure may be an option if the

fibroids are contained inside the uterus (submucosal). A long, slender scope (hysteroscope) is passed through the vagina and cervix and into the uterus. The doctor can see and remove the fibroids through the scope. This procedure is best performed by a doctor experienced in this technique. Variations of myomectomy — in which uterine fibroids are destroyed without actually removing them — include:

Myolysis. In this laparoscopic procedure, an electric current destroys the

fibroids and shrinks the blood vessels that feed them.

28

Cryomyolysis. In a procedure similar to myolysis, cryomyolysis uses

liquid nitrogen to freeze the fibroids. The safety, effectiveness and associated risk of fibroid recurrence of myolysis and cryomyolysis have yet to be determined.

Endometrial ablation. This treatment, performed with a hysteroscope,

uses heat to destroy the lining of the uterus, either ending menstruation or reducing menstrual flow. Endometrial ablation is effective in stopping abnormal bleeding, but doesn't affect fibroids outside the interior lining of the uterus. Uterine artery embolization- Small particles injected into the arteries supplying the uterus cut off blood flow to fibroids, causing them to shrink. This technique is proving effective in shrinking fibroids and relieving the symptoms they can cause. Advantages over surgery include:
• •

No incision Shorter recovery time

Complications may occur if the blood supply to the ovaries or other organs is compromised. Focused ultrasound surgery- MRI-guided focused ultrasound surgery (FUS), approved by the Food and Drug Administration in October 2004, is a newer treatment option for women with fibroids. Unlike other fibroid treatment options, FUS is noninvasive and preserves the uterus. This procedure is performed while one is inside of a specially crafted MRI scanner that allows doctors to visualize ones anatomy, and then locate and destroy (ablate) fibroids inside the uterus without making an incision.

29

Focused high-frequency, high-energy sound waves are used to target and destroy the fibroids. A single treatment session is done in an on- and off-again fashion, sometimes spanning several hours. Initial results with this technology are promising, but its longterm effectiveness is not yet known. It is recommended that before making a decision, women must consider the pros and cons of all available treatment options in relation to their particular situation. Remember most women don't need any treatment for uterine fibroids.

B. Actual Management

In our patient’s case, she was scheduled and has undergone Total Abdominal Hysterecomy-Unilateral Salphingo Oophorectomy (TAH-USO) which includes the removal of the uterus and an ovary. This procedure lets our patient have an early menopausal and ends her ability to bear a child. She was not given any medications that may prevent the reoccurrence of fibroids; Instead, she was given medications that could prevent possible infections due to her surgery (such as antibiotics), could relieve pain from surgery and could improve her body’s immunity and functioning (such as multivitamins and ferrous sulfate).

30

31

Name of Patient: ______________Patient X _________________________ Diagnosis/Impression: ________Uterine myoma _________________________

Age: 42 Attending Physician: __Dr. Borromeo________

DRUG STUDY
Name of Drug (Generic & Brand) Ampicillin Date ordered Classification of Drug Dose/ Frequen cy 500 mg 1 tab qid Mechanism of Action Specific Indication Contraindicati on Side Effects/ Toxic Effects Nursing Precautions

04/19/0 9

antiinfective

Bacteria resist penicillins by producing penicillinases – enzymes that convert penicillins to inactive penicillin acid. Cloxacillin resist these enzymes.

• •

Skin structure infections Staphyloc occal infections

Sensitivity to penicillins

• • • •

Anaphylaxis Drug fever Rash Overgrowth of nonsusceptible organisms

Give on an empty stomach, at least 1h before or 2h after meal. Take medication around the clock, do not miss one dose, and continue taking medication until it is finished. Instruct patient to take each dose with a full glass of water and not with fruit juice or carbonated beverage because their acid will inactivate drug.

32

Name of Patient: ______________Patient X _________________________ Diagnosis/Impression: ________Uterine myoma _________________________

Age: 42 Attending Physician: __Dr. Borromeo________

DRUG STUDY
Name of Drug (Generic & Brand) Metronidazol e Date ordered Classification of Drug Dose/ Frequen cy 500 mg 1 tab tid Mechanism of Action Specific Indication Contraindicati on Side Effects/ Toxic Effects Nursing Precautions

04/19/0 9

Antibacterial

It enters the cell of microorganisms that contain nitroreductase unstable compounds are then formed that bind to DNA and inhibit synthesis, causing cell death

Prophylaxis in elective hysterectom y or vaginal repair

• • • •

Liver disease Alcoholism Blood dyscrasias Active CNS disease

• • • • •

Hypersensiti vity Irritability Drowsiness Dyspareunia Dryness of vagina and vulva

• • •

Give oral form with meals to minimize GI upset. Instruct patient in proper hygiene. Tell patient that metallic taste and dark or red-brown colored urine may occur. Tell patient to avoid alcohol or alcohol-containing drugs during therapy and for at least 3 days after therapy is completed.

33

Name of Patient: ______________Patient X _________________________ Diagnosis/Impression: ________Uterine myoma _________________________

Age: 42 Attending Physician: __Dr. Borromeo________

DRUG STUDY
Name of Patient: ______________Patient X _________________________ Age: 42 Name of Drug Date Classification Dose/ Mechanism of Specific Contraindicati (Generic & ordered of Drug Frequen Action Indication on Brand) cy Diclofenac Na 04/24/0 9 NSAIDs 250 mg 1 tab tid Potent inhibitor of cyclooxygenase, thereby decreasing the synthesis of prostaglandins • • Postoperative inflammation Mild to moderate pain • • • • • Hypersens itivity to diclofenac Urticaria Angioede ma Bronchosp asm Other sensitivity reaction precipitate by aspirin or other NSAIDs bleeding or blood clotting disorder • Side Effects/ Toxic Effects Nursing Precautions

• • • • • •

Prolonged bleeding time Inhibit platelet aggregation Skin itching or rash Dizziness Headache Stomach upset Flatulence

Do not crush, chew, or break an extended-release tablet. Swallow the pill whole. Do not drink alcohol while taking diclofenac. Alcohol can increase the risk of stomach bleeding caused by diclofenac. Avoid prolonged exposure to sunlight. Diclofenac may increase the sensitivity of the skin to sunlight. Instruct patient to use a sunscreen and wear protective clothing when exposure to the sun is unavoidable.

34

Diagnosis/Impression: ________Uterine myoma _________________________

Attending Physician: __Dr. Borromeo________

DRUG STUDY
Name of Drug (Generic & Brand) Multivitamins Date ordered Classification of Drug Dose/ Frequen cy 1 tab OD Mechanism of Action Specific Indication Contraindicati on Side Effects/ Toxic Effects Nursing Precautions

04/24/0 9

supplement

Treat vitamin deficiencies (lack of vitamins) caused by illness, pregnancy, poor nutrition, digestive disorders, and many other conditions.

Vitamin deficiences

If patient takes more than the prescribed dose

• • •

Stomach upset Headache Unusual or unpleasant taste

• •

Take your multivitamin with a full glass of water. Never take more than the recommended dose of a multivitamin. Avoid taking more than one multivitamin product at the same time unless your doctor tells you to.

Name of Patient: ______________Patient X

_________________________

Age: 42

35

Diagnosis/Impression: ________Uterine myoma _________________________

Attending Physician: __Dr. Borromeo________

DRUG STUDY
Name of Drug (Generic & Brand) Ferrous Sulfate + folic acid Date ordered Classification of Drug Dose/ Frequen cy 1 tab OD Mechanism of Action Specific Indication Contraindicati on Side Effects/ Toxic Effects Nursing Precautions

04/24/0 9

Iron preparation

Corrects erythropietic abnormalities induced by iron deficiency but does not stimulate erythropoiesis. Folic acid helps your body produce and maintain new cells, and also helps prevent changes to DNA that may lead to cancer.

May be used prophylactic ally during periods of increased iron needs Iron deficiency anemia

• • • •

Peptic ulcer Hemolytic anemia Regional enteritis Ulcerative colitis

• • • • • •

• •

Nausea Heartburn Diarrhea Constipation Black stool Yellow brown discoloration of eyes and teeth Lethargy Drowsiness

• • •

Give on empty stomach if possible because oral iron preparations are best absorbed then. Do not crush tablet or empty contents of capsule. Do not give tablets within 1h of bedtime. Avoid taking antacids or antibiotics within 2 hours before or after taking ferrous sulfate. Do not use discolored tablets.

36

Name of Patient: ______________Patient X _________________________ Diagnosis/Impression: ________Uterine myoma _________________________

Age: 42 Attending Physician: __Dr. Borromeo________

DRUG STUDY
Name of Drug (Generic & Brand) Ranitidine Date ordered Classification of Drug Dose/ Frequen cy 1 tab q8 hours PO Mechanism of Action Specific Indication Contraindicati on Side Effects/ Toxic Effects Nursing Precautions

04/19/0 9

Anti-ulcer Drugs (H2 Antagonist)

Inhibits action of histamine on the H2 receptor sites of parietal cells decreasing gastric acid secretions

Upper GI bleeding

• •

Hypersen sitivity to drug Diminishe d renal function

• • • • • • •

Vertigo Malaise Dizziness Headache Mild transient diarrhea Muscle pain Blurred vision

Assess patient for abdominal pain. Note presence of blood in emesis, stool, or gastric aspirate. Instruct patient to take the drug without regard to meals because absorption is not affected by food.

37

Name of Patient: ______________Patient X _________________________ Diagnosis/Impression: ________Uterine myoma _________________________

Age: 42 Attending Physician: __Dr. Borromeo________

DRUG STUDY
Name of Drug (Generic & Brand) Tramadol Date ordered Classification of Drug Dose/ Frequen cy Mechanism of Action Specific Indication Contraindicati on Side Effects/ Toxic Effects Nursing Precautions

04/18/0 9

Narcotic and 75 mg Opioid IVTT q 6 analgesics hours

It is thought to bind to opioid receptors and inhibit reuptake of norephinephrine and serotonin.

Moderate pain

• • • •

Hypersen sitivity to drug Kidney disease Liver disease History of alcohol or drug dependen ce

• • • • • • •

Dizziness Headache Nausea Constipation Vomiting Dry mouth Diarrhea

Monitor CV and respiratory status. Withhold dose and notify physician if respirations decrease or rate is below 12 cpm. Monitor bowel and bladder function. Anticipate need for laxative.

.

38

Name of Patient: ______________Patient X _________________________ Diagnosis/Impression: ________Uterine myoma _________________________

Age: 42 Attending Physician: __Dr. Borromeo________

DRUG STUDY
Name of Drug (Generic & Brand) Amoxicillin Date ordered Classification of Drug Dose/ Frequen cy 500 mg 1 tab qid Mechanism of Action Specific Indication Contraindicati on Side Effects/ Toxic Effects Nursing Precautions

04/19/0 9

antiinfective

Bacteria resist penicillins by producing penicillinases – enzymes that convert penicillins to inactive penicillin acid. Cloxacillin resist these enzymes.

• •

Skin structure infections Staphyloc occal infections

Sensitivity to penicillins

• • • •

Anaphylaxis Drug fever Rash Overgrowth of nonsusceptible organisms

Give on an empty stomach, at least 1h before or 2h after meal. Take medication around the clock, do not miss one dose, and continue taking medication until it is finished. Instruct patient to take each dose with a full glass of water and not with fruit juice or carbonated beverage because their acid will inactivate drug.

39

PREOPERATIVE NCPS Name of Patient: Patient X Diagnosis: Uterine Myoma NURSING CARE PLAN NO. 1 CUES NURSING DIAGNOSIS Subjective: Impaired Urinary “Gasige ko ug Elimination related ihi-ihi, ika-kinse o to anatomical ika-bente sa isa compression of k adlaw, adtong the urinary bladder wala pa ko na admit. Paadmit nako kay ik kinse o ika napulo na lag sa isa ka adlaw.”, as verbalized by the patient. Objective: -urinary frequency= 1520x per day at about 200cc per voiding -sonography report: The uterus is OBJECTIVE Short term: At the end of 2 hours of nursing intervention, patient will be able to: a) verbalize understanding of her condition and the need undergo surgical removal of the uterus and ovary b) participate and demonstrate measures such as proper perineal hygiene to prevent any further complications such as infections and INTERVENTION Independent 1) Encourage gradual increase in fluid intake of 8-10 glasses per day from her usual 2-3 glasses. 2) Restrict fluid intake 2-3 hours before bedtime. 3) Measure and record patient’s intake and output. Document urine color and characteristics 4) Assist in developing toileting routines as appropriate and RATIONALE - to help maintain renal function and prevent dehydration. EVALUATION Age: 42 Physician: Dr Borromeo

Short Term: At the end of 2 hours nursing intervention, objectives were fully met. Patient was able to verbalize - to reduce voiding understanding of during the night. uterine myoma and the surgery it required. Patient - accurate intake also willingly and output participated and measurements are demonstrated use essential for of water and mild correct fluid soap in perineal replacement care. Wiping of therapy perineal area after urination from - to provide the front to back was patient ease in also demonstrated coping with the correctly. condition

40

enlarged in size measuring 11cm x 9 cm. There is an isoechoic mass at the anterior myometrium 9.7cm x 7.5 cm.

other urinary problems. Long Term: At the end of 3 days of nursing intervention, patient will be able to: a) verbalize increased comfort and achieve her elimination pattern before of 5-6x per day in moderate amount b)maintain fluid balance, intake equals output

provide necessary equipment such as bedpans. 5) Give appropriate preoperative and postoperative instruction and care. Stress the pros and cons of total abdominal hysterectomy and unilateral salpingo oophorectomy 6) Instruct on proper and frequent perineal hygiene. -accurate information allows patient to understand the procedure and the benefits of undergoing such.

- cleanliness prevents bacterial growth and promotes comfort. -this food are known as bladder irritant and can increase the number of urinary elimination

Long Term: At the end of 3 days of nursing intervention, objectives were partially met. Patient was able to verbalize increased comfort with her an elimination pattern of (amount?, frequency?). Fluid balance? No further complications noted.

7) Discuss possible c) have no further dietary restrictions complications ( coffee, due to condition chocolate, carbonated drinks, citrus, tomatoes)

41

Name of Patient: Patient X Diagnosis: Uterine Myoma NURSING CARE PLAN NO. 2 Cues Subjective “Dili na regular ako paglibang. Sukad tong niaging bulan kay mga tagtulo o upat ka adlaw ko ayha malibang. Ginagmay nga gahi akong tahi. Usahay galisod pud ko ug libang.” “Dili man ko gakaon kaayo ug gulay. Gana-gana ra. Dilli pud ko hing-inom ug tubig. Mga 2-3 ra ka baso akong mainom Nursing Diagnosis Constipation related to anatomical obstruction of the rectum and inadequate intake of fluids and bulk Objectives Short term: At the end of 4 hours nursing intervention, patient will be able to : a) verbalize understanding of etiology and appropriate interventions for individual situation. b) verbalize the need to participate in a bowel program as indicated. c) verbalize the need to increase consumption of high fiber foods such as fruits and vegetables and the need to increase intake of fluids to 8-10 glasses per day. Intervention Independent 1) Determine patients fluid intake 2) Note color, odor. consistency, amount, and frequency of stool 3) Instruct on a diet of balanced fiber and bulk and fiber supplements. 4) Promote adequate fluid intake, including high-fiber fruit juices; suggest drinking warm stimulating fluids.

Age: 42 Physician: Dr Borromeo

Rationale -To evaluate clients hydration status. -Provides a baseline for comparison, promotes recognition of changes. -To improve consistency of stool and facilitate passage through colon. -To promote passage of soft stool

Evaluation Short Term: At the end of 4 hours, objectives were fully met. The patient was able to verbalize her understanding of the etiology and appropriate interventions; participate in bowel program as and verbalized the relation of her diet to her constipation. She also verbalized the significance of increasing consumption of high-fiber foods

42

sa isa ka adlaw.” Objective: -bowel sounds hypoactive= 1 in every 30seconds -straining with defacation -hard dry and formed stool in minimal amount noted upon defecation

Long term: After 4 days of nursing intervention, the patient will: a) regain normal pattern of bowel functioning which was defecation of soft formed stool in moderate amount each day. b) demonstrate and incorporate the changes in intake of high fiber foods and increase in fluids effectively in daily living.

5) Encourage activity/exercise within limits of individual’s ability. -To stimulate contractions of Dependent: intestines. 6) Administer Bisacodyl 1 adult suppository stat -To help in softening stool to facilitate elimination.

such as fruits and vegetables and increasing intake of fluids to 8-10 glasses. Long Term After 4 days of intervention, the objectives were partially met. She was observed to effectively follow the advised dietary regimen including an increase in both fiber and fluids. Her normal pattern of bowel functioning was not regained.

43

Name of Patient: Patient X Diagnosis: Uterine Myoma NURSING CARE PLAN NO. 3

Age: 42 Physician: Dr Borromeo

44

Cues Subjective: “Sige man gud og matamata kung gabii kay mangihi ko,”as verbalized by the patient. “Dili pud ko kabawi ug tulog kay trabaho man nako sa hapon. Daghan ko ginabuhaton ba. ” “Bulog usahay akong ulo pagmata kay kulang tulog,” as verbalized by the patient. Objective: -urinary frequency=15 -20x per day -Decreased number of hours of sleep = 4-5 hours -

Diagnosis Sleep pattern disturbance related to frequency of urine as manifested by reduced number of hours of sleep.

Objectives Short term: At the end of 20 minutes of nursing intervention, patient will be able to identify methods on how to improve quality of sleep. Long term: At the end of 16 hours of nursing intervention, patient will be able to increase in the number of hours of sleep and feeling rested on awakening.

Intervention Independent: 1. Minimize the environmental noise by closing the door properly always and maintain comfortable temperature and proper ventilation as much as possible. 2. Assist in wearing comfortable clothes and washing her face 3. Assist patient in performing bedtime rituals and provide sleeping aids such as pillows. 4. Provide comfort measures by doing back rub and placing patient flat on bed with head elevated by a pillow. 5. Organize nursing care.

Rationale Independent: 1. To provide an environment conducive for sleeping.

Evaluation Short term: At the end of 20 minutes of nursing intervention, objectives were fully met. The patient was able to verbalize ways to increase quality of sleep and to limit fluids during bedtime to decrease urinary frequency. Long term: At the end of 16 hours of nursing intervention, patient was be able to improve sleep pattern as evidenced by increase in the number of hours of sleep and feeling rested on awakening.

2. To provide comfort and freshness 3. To promote relaxation.

4. To promote rest and relaxation.

6. Limit fluids before bedtime.

5. To promote minimal interruption in sleep/rest. 6. To reduce need for voiding during the night.

45

POSTOPERATIVE NCPS Name of Patient: Patient X Diagnosis: Uterine Myoma NURSING CARE PLAN NO. 1 CUES Subjective: “Dako akong samad. Ginabutangan pa gain ni ug binder para dili ma-ukab and tahi kay sakit man. Magsige na lang ko higda kay sakit musamot kung mulihok. Tuloy-tuloy iyang NURSING DIAGNOSIS Acute pain related to surgical incision in the abdomen OBJECTIVES Short Term: After 4 hours of nursing intervention, the patient will: a) verbalize a pain scale of 4-5 and increased comfort b) verbalize and demonstrate nonpharmacologi c methods to manage pain such as deep INTERVENTIONS Independent: 1) Perform comfort measures such as massage, bathing and repositioning. RATIONALE EVALUATION Short Term: Objectives were fully met. Patient verbalized a pain scale of 4, increased relief and comfort. Patient also demonstrated breathing techniques splinting to minimize pain. She also participated in conversations Age: 42 Physician: Dr Borromeo

2) Help patient into a comfortable position and use pillows to splint or support the incision area

-these measures reduce muscle tension or spasm; redistribute pressure on body parts and help patient focus on non-pain related subjects -to reduce tension and thus reduce pain

46

pagsakit. Ngut-ngot nga dili masabtan.”

Objective: -verbalized a pain scale of 6, in a scale of 1-10 with 10 as the most painful -sighing and moaning noted -slowed movement -guarding behavior -positioning to avoid pain

breathing and splinting during cough c) participate in the use of diversional activities such as engaging in conversation s to minimize pain

3) Manipulate the environment to provide uninterrupted rest 4) Provide diversional activities such as such as encouraging visits of family members and engaging in conversations 5) Encourage use of relaxation techniques such as focused breathing and imaging. Dependent 1) Administer D5LR 1 liter with Tramadol 50mg at 30gtts/min

done to distract her from pain. - this promotes health, well-being and increased energy level important to pain relief. -to help patient focus on non-pain related matters Long Term: At the end of 2 days of intervention, objectives were fully met. The patient verbalized a pain scale of 2 and increased comfort. Whenever mild pain occurred, patient was observed to do deep breathing on her own.

Long Term: After 4 days of intervention, the patient will: a) verbalize a pain scale of 0-2 b) readily integrate nonpharmacologi c methods in daily activities whenever pain occurs

- to distract attention and reduce tension

-to effectively reduce or eradicate pain

47

Name of Patient: Patient X Diagnosis: Uterine Myoma NURSING CARE PLAN NO. 2 CUES NURSING DIAGNOSIS OBJECTIVES INTERVENTIONS

Age: 42 Physician: Dr Borromeo

RATIONALE

EVALUATION

48

Subjective: “Dako akong samad. Ginabutangan pa gain ni ug binder para dili ma-ukab and tahi kay sakit man.” Objective: -horizontal incision in the hypogastric region of the abdomen with dressing and abdominal binder noted -redness of surrounding skin noted

Impaired skin integrity related to surgical incision in the hypogastric region of the abdomen

Short Term: At the end of 1 hour of nursing intervention, the patient will: a) verbalize and demonstrate appropriate wound dressing procedure b) demonstrate the use splinting and support to protect the wound c) verbalize the need to increase intake of protein and carbohydrates for faster wound healing. Long Term: At the end of 4 days of nursing intervention, the patient will: a) display timely healing of wound without any signs of infection such as erythema,

Independent 1) Inspect skin on a daily basis, describing wound characteristics and changes observed.

Short Term: - To monitor At the end of 1 progress of hour of nursing wound healing. intervention, objectives were fully met. Patient demonstrated 2) Instruct the - To assist body’s wound dressing patient and natural process appropriately. significant others to of repair. Patient also keep the area clean demonstrated the and dry. use of pillow as splint or support 3) Teach patient of - this involves the during cough. proper wound patient in her Patient also dressing techniques care and verbalized the promotes need to increase empowerment protein and over her carbohydrate condition. This intake such as also prevents foods as meat, infection. fish, beans and 4) Instruct patient to -To provide bread. apply splint using a support over the pillow when patient incision area. Long Term: coughs or moves. At the end of 4 days of nursing 5) Position patient -these measures intervention, the for comfort and promote objectives were minimal pressure on circulation, fully met. No signs bony prominences. reduce pressure of further infection Turn to sides at least and avoid skin were noted. No every 2 hours. breakdown signs of erythema

49

hyperthermia and pus formation. 6) Encourage early ambulation or mobilization. -Promotes circulation And reduces risks associated with immobility such as thrombus formation and skin ulcers. -To aid in wound healing.

and pus formation were noted.

7) Provide optimum nutrition, and increased protein and carbohydrate intake such as meat, fish and bread. DEPENDENT: 1. Administer Cloxacillin 500mg 1 tab QID, Diclofenac 200mg 1 tab TID, Metronidazole 500 1 tab TID Name of Patient: Patient X Diagnosis: Uterine Myoma NURSING CARE PLAN NO. 3 Cues Nursing Diagnosis Objectives Intervention

-to aid in faster healing process and in preventing infection. Age: 42 Physician: Dr Borromeo

Rationale

Evaluation

50

Subjective “Dili lagi ko lugos kalihok kay tungod sa kasakit sa samad. Magsige na lang man ko ug higda. Musakit man ug samot pag maglihok-lihok ko” Objective: -difficulty turning to sides noted -slowed movement noted -moaning and sighing noted upon movement

Impaired physical mobility related to pain/discomfort

Short term: At the end of 4 hours of nursing intervention, patient will be able to : a) Verbalize understanding of situation and individual treatment regimen and safety measures. b) Demonstrate techniques that enable resumption of activities such as splinting, early ambulation and engaging in selfcare activities. Long term: After 2 days of nursing intervention, the patient will: a)Regain mobility at the highest possible level with minimal discomfort.

Independent 1) Instruct patient to splint the wound with a pillow if patient attempts to move. 2) Assist with self care activities.

-Splinting supports the wound and minimizes the discomfort and pain felt. - improves muscle strength and circulation, enhances patient control in the situation and promotes self directed wellness. -early mobility reduces complications of bed rest. Promotes healing and normalization of organ function. - postural hypotension is common to patients on bed rest and may require interventions like elevation of bed.

3)Provide assistance with mobility

Short Term At the end of 4 hours of nursing intervention, the objectives were fully met. The patient verbalized understanding of having myoma and the treatment regimen especially a change in diet to counter the problem. Patient also demonstrated the use of splinting during movement correctly. Patient also performed self-care activities such as dressing, tooth brushing and with assistance Long term: After 2days of nursing intervention, the objectives were fully met. Patient achieved full

4) Monitor BP with resumption of activity. Note reports of dizziness.

51

. Dependent 1) administer Tramadol 50mg IVTT every 6 hours -to perit maximal effort and involvement in activity

mobility status little complaints of discomfort.

Name of Patient: Patient X Diagnosis: Uterine Myoma NURSING CARE PLAN NO. 4

Age: 42 Physician: Dr Borromeo

Cues

Nursing Diagnosis

Objectives

Intervention

Rationale

Evaluation

52

Subjective: “Dako akong samad. Ginabutangan pa gain ni ug binder para dili ma-ukab and tahi kay sakit man.” Objective: -horizontal incision in the hypogastric region of the abdomen with dressing and abdominal binder noted -redness of surrounding skin noted

Risk for infection related to surgical incision:

Short term: At the end of 30 minutes of nursing intervention a) identify interventions to prevent/risk for infection b) identify the importance of the following the medication regimen. Long term: After 2 days of intervention, the client will be able to: a)demonstrate behaviors showing appropriate adaptation to present condition. b)achieve timely

Independent 1)Observe for localized signs of -To check for any infection at signs of infection sutures or surgical incision wound 2)Note signs and symptoms of sepsis; fever, chills, diaphoresis 3)Teach patient and SO how to cleanse incision site daily and remind the.m to change dressings as needed -To give necessary interventions -To facilitate wound healing and prevent infection by minimizing growth and spread of microorganisms

Short Term After 30 minutes of nursing intervention, the objectives were fully met. Patient mentioned the importance of hygiene, medication compliance, proper wound dressing and early ambulation to prevent infection.

Long Term After 2 days of nursing intervention, objectives were 4)Encourage early -Ambulation fully met. The ambulation and stimulates patient was able deep breathing lower extremity to integrate ,coughing and circulation interventions in position change after her daily activities caesarean such as wound birth dressing, coughing and position changes. Dependent: Patient also 1) 1. Administer -Premature complied with the Cloxacillin 500mg discontinuation of medication

53

wound healing; be free of purulent drainage or erythema; be afebrile c)comply to medication regimen accordingly

1 tab QID, Diclofenac 200mg 1 tab TID, Metronidazole 500 1 tab TID

treatment when client begins to feel well may result in return of infection this is also to avoid parasitic infection -To avoid cross contamination of microorganisms

regimen.

Collaborative: 1)Stress aseptic or proper handwashing technique by all caregivers

54

VIII. DISCAHRGE PLANNING

Medications

o Encourage strict adherence to the medication regimen to attain therapeutic effects. o Instruct patient to strictly follow orders for take home medications upon discharge as prescribed by physician. o Instruct patient to take medications as prescribed such as: 1. Cloxacillin 500mg i tab 4xday (8am12nn-4pm-8pm) x 7 2. Metronidazole 500mg i tab 3x/day (8am-12nn-6pm) x7 3. Diclofenac Na 25mg i tab 3x/day (8am-12nn-6pm) x10 4. Multivitamins i tab once a day (8am) x 30 5. FeSo4 + FA i tab once a day (8am) x30 o Instruct patient to follow right dose and timing of medications, and not to stop taking them abruptly without physician’s order. o Report any adverse effects and drugdrug interactions/drug-food interactions of the medications to the physician.

Inform patient that level of activity will be limited:

Exercise/Activity

Stair Climbing : Keep to a minimum the first week, try to limit to one time, every eight hours. Exercise - Take it easy and slowly increase your activity over the next three to four days. While you will progressively feel better, you can anticipate a lack of energy and you

55

should rest when you are tired. Instruct patient to do weight bearing exercises to strengthen the muscle tone and pelvic bone, such as: walking and aerobic exercises.

Shower - You may shower only for the next 7 to 10 days, and until groin puncture sites are completely healed. Sexual Relations: You may have unrestricted activity, including sexual relations and exercise , seven days after the procedure. Date to return to work: You will need about one week off from work. Other Limitations: No heavy lifting, pushing or pulling for 4 weeks.

Treatment/Therapy

o Instruct the client in the prescribed medication regimen. o Encourage routine and reminders to facilitate adherence. o Family Therapy- The family members must provide the patient with adequate emotional support, care, and may pray for the patient. Wellness hints:
o

Instruct patient to eat a variety of healthy foods every day to help you feel better and have more energy. Diet should include fruits, vegetables, breads, chicken, fish, and beans. Try to buy organic foods (grown without the use of pesticides or herbicides). Growing your own food when possible and washing food before using it may also be helpful. Suggest limiting how much meat fat, fish, dairy products, and egg yolks you eat. Eating too much of these foods

o

Health Teachings
o

56

o

can cause an increased estrogen level in the body. Maintain a healthy weight: instruct patient to talk to caregiver about ideal weight. Encourage an exercise program. It is best to start slowly and do more as patient get stronger. Instruct patient to try to exercise at least 30 minutes everyday.

o Encourage patient to have adequate rest periods.

Out-patient/Follow-up

Instruct patient to seek medical help IF: o You have a fever (increased body temperature). o You are vomiting (throwing up) and cannot keep food or liquids down. o You have a very bad headache, or you feel dizzy. o Your pain is worse or does not go away after taking your pain medicine. o You have questions or concerns about uterine fibroids, their treatment, or your medicine. Instruct patient to do self care IF: o You become pregnant while having treatment. o You have pain in your abdomen or lower back that does not go away after taking your pain medicines. o You have heavy or unusual vaginal bleeding. o You have pain during sex. o You have trouble urinating or emptying your bladder completely. o Your symptoms are getting worse or coming back.

57

Tips for preventing anemia o Increase the amount of iron in your diet. Your body needs iron to make new blood cells, and your diet is the best source. Get 18mg to 20mg of iron per day. Red meats, shellfish, eggs, beans, leafy green vegetables, and iron-enriched breads and cereals are the best sources of iron. o Eat a well-balanced diet. If you are not able to meet your need for iron through diet alone, consider taking a nonprescription iron supplement (such as ferrous sulfate) or a multivitamin. You may become constipated when you are taking an iron supplement. To avoid constipation, eat more fiber, eat plenty of fruits and vegetables, and drink at least 2 to 4 extra glasses of water per day. o Be sure your diet includes 250mg of vitamin C per day. Vitamin C helps your body absorb iron more effectively. o No Restrictions - Increase your fluids and fiber. Prune juice or mild laxative may be helpful to keep your bowels soft.

Diet

Spirituality

o Encourage the patient to hear masses regularly to strengthen her spiritual life. o Encourage patient to pray constantly and surrender all her worries to God especially her present condition to lessen anxiety and to promote presence of mind. o Have her join in prayer groups and meeting offered by the church or community.

58

IX. PROGNOSIS

The prognosis for patient X is good. Uterine myomas/fibroids are not cancerous and usually shrink after menopause. Her myoma mass found at the anterior portion of the uterus, her uterus and her one ovary have been removed which had all led to the elimination of the signs and symptoms she has experienced prior to surgery. Throughout her stay in the hospital, she has been responding well to the medical regimen given to her and has showed no signs and symptoms of possible complications or infections. However, patient X may not be able to bear a child due to her surgery. Nevertheless, the procedure she has undergone eradicates the possibility of another growth of a myoma mass.

59

X. RECOMMENDATION Recommendations are necessary for patient X to be able to improve health and prevent further complications as possible. This, in turn, will consider having a better health status – be it physically, emotionally, mentally, and spiritually. For Patient X, recommendations would include but not limited to the following: First, patient X should be able to develop an optimistic attitude towards the situation in order to promote a positive inclination of mental and emotional dimension of health. Second, she should strictly comply with the medication regimen since personal adherence is a determinant of willingness and eagerness to recover. Third, she should also be able to verbalize feelings to her husband to take emotional care and actions. She should also be able to express any discomfort in order for the health care provider to carry out certain measures. Patient X should be able to establish a direct open communication with her husband and health care practitioner to link care and needs. Thus, the proponents of this case study are able to understand the significance of a good health seeking behavior and medical treatment. Fourth, she should be able to strengthen or maintain strong faith since spiritual health is an important factor to be considered in achieving a healthy status. Patient X should eat foods rich in fiber, vitamins and minerals, such as pineapple, mango, orange, green leafy vegetables, lean meat, dairy products and fish. Patient X’s husband and support persons can prove functional when they are able to provide comfort, care measures, and assistance. They can encourage patient X to follow care provider’s instruction particularly on medication adherence. As health care providers, we should be able to provide quality health care services to patient X. As nurses and physicians, individualized care should be carried out. Open and welcome approach should be initiated to the patient, and most especially by showing empathy and recognizing that there is no enough words to overrule her feelings of heaviness and despondency. Sensitivity to the patient X has verbalized is also necessary for us to

60

consider in planning care. Physical, social, spiritual, emotional, and mental feedbacks and motivations can also be considered in imparting to the client.

XI. CONCLUSION In conclusion, the group was able to come up with a comprehensive case presentation on uterine myoma, especially concerning our client, Patient X. Information presented here were factual, basing on our actual assessments by interview and by using available secondary sources, such as her chart. The group was able to work together to surface this case study in the best way that we can, using every resource we can find useful in making every part of this write up. In the process, we were able to enhance our knowledge about uterine myoma, its signs and symptoms and treatment modalities, as well as on how we, future nurses, can care for patients similar to Patient X. Moreover, we have taken our grand case presentation enactment to the next level, owing this to our extensive learning from our experiences this semester as well as our previous wisdom acquired in the classroom and hospital settings. Lastly, the group has developed a better working relationship with one another, especially through this challenging and demanding stretch of our student life.

61

BIBLIOGRAPHY Book Sources: • .Bullock, B. & Henze, R. (2000). Focus on Pathophysiology. Lippincott Williams & Wilkins. • • Doenges, M. (2006). Nursing Pocket Guide. 10th ed. Igroup Press Co., Ltd. (2007). Nursing 2007 Drug Handbook. 27th ed. Lippincott Williams & Wilkins

Internet Sources: • Advance Fertility Center of Chicago . Uterine Fibroids and Fertility

Potential.<http://www.advancedfertility.com/uterinefibroid.htm> • • • • • Elizabeth Smith, M.D. Uterine Fibroid.<http://www.fibroid101.com/index.htm> http://encyclopedia.thefreedictionary.com/uterine+fibroids http://www.amazingpregnancy.com/pregnancy-articles/513.html http://www.anticancer.net/resan/myoma.html Uterine Fibroids Health Center. Uterine Fibroids - Treatment Overview <http://women.webmd.com/uterine-fibroids/uterine-fibroids-treatment-overview>

62

APPENDIX A April 20,2009 3:00 pm

NURSES NOTES 3 -11  Received awake on bed c ongoing IVF of D5LR 1L@ 330 ml level regulated @ 30 gtss/min infusing well on L arm  conscious and coherent  dry lips noted  c complaints of pain at the epigastric region of the abdomen with a pain scale of 4/10, with 10 as the most painful  initial vital signs taken: T:36.8oC; PR:88 bpm; RR: 18 cpm; BP: 120/80 mmHg  for TAH-USO tomorrow  afternoon care done  wet cottonballs applied on lips  encouraged to take adequate oral fluid intake  encouraged deep breathing exercised to minimize pain

63

 adequate rest provided  health teaching imparted with emphasis on: a) adequate fluid intake 6 – 8 glasses a day b) strict medication compliance c) compliance to clear liquid diet  all needs attended 11:00 pm  kept watched for any unusualities  endorsed with latest vital signs: T: 36.8 oC; PR: 86 bpm; RR: 16 cpm; BP: 120/80 mmHg Jayson Pauig XUSN3 April 21, 2009 3:00 pm 3 – 11  Received awake on bed c on going IVF of D5LR 1L @ 930 cc level regulated @ 30 gtts/min infusing well @ L arm  c foley bag catheter attached to urobag draining well c straw colored urine @ 750 cc level  appears weak  dry lips noted  c complaints of radiating pain @ incision site c a pain scale of 6/10, 10 as the most painful

64

 initial vital signs taken: T:36.7 oC; PR:78bpm; RR:16 cpm: BP: 130/80mmHg  wet lips c wet cotton balls  encouraged deep breathing exercises for 2 5:00 pm NPO minutes to minimized pain  turned to sides q2  maintained  health teachings reinforced with emphasis on: 1) Proper wound care and dressing 2) Strict medication compliance 3) Adequate intake of food rich in vitamins and minerals such as green leafy vegetables; vitamin c for faster wound healing 1100 pm  kept watched for any unusualities  intake and output monitored & recorded  endorsed with latest vital: T:37.4 oC; PR: 90 bpm; RR: 16 cpm; BP: 130/90mmHg. Jayson Pauig XUSN 3 April 22, 2009 3:00 pm 3 – 11  Received awake lying on bed with ongoing

65

IVF of D5LR 1L @ 180 cc level regulated @ 30 gtts/min infusing well @ L arm  with foley catheter attached to urobag draining well with straw colored urine @ 80 cc level  initial vital signs taken : PR: 78 bpm; RR: 18 cpm; BP: 120/80 mmHg; T: 37.5 oC – febrile  tepid sponge bath done  temperature rechecked: 37.2 oC NPO  encouraged to ambulate  maintained  health teachings reinforced with emphasis on: 1) proper wound care and dressing 2) strict medication compliance 3) eating nutritious food rich in vitamins and minerals such as 11:00 pm green leafy vegetables  I & O monitored and recorded  endorsed with latest vital signs: T: 37.4 oC; PR:80 bpm; RR: 18 cpm; BP: 130/90 mmHg Jayson Pauig XUSN 3

66

April 23, 2009 3:00 pm  Received awake lying on bed with on going IVF of D5LR 1L @ 400 cc level regulated @ 30 gtts/min infusing well @ L arm  with foley bag catheter attached to urobag draining well @ 10 cc level with straw colored urine  with complaints of bearable pain @ incision site with a painscale of 3/10, 10 as the most painful  initial v/s taken: Bp: 130/90mmHg; RR: 16cpm; PR:102 bpm: T: 37.8 oC – febrile  tepid sponge bath done  temperature rechecked: 37.3 oC  encouraged deep breathing exercise for 1 -2 mins to minimize pain Clear liquid 6:30 pm Soft diet  encouraged to ambulate  maintained until pm  consumed 1 cup of porridge with good appetite  health teachings reinforced with emphasis on:

67

1) proper wound care and dressing 2) strict medication compliance 11:00 pm 3) eating nutritious foods rich in vitamins and minerals such as green leafy vegetables  intake and output monitored and recorded  endorsed with latest v/s: T: 37.3 oC; PR:100 bpm; RR: 20cpm: BP: 120/80mmHg Jayson Pauig XUSN 3

68

APPENDIX B

DOCTOR’S ORDER

Date 04/19/09

Doctor’s Order - Please admit under the service of Dr. Borromeo - Consent to care - TPR every shift - For TAHUSO - Attach all labs - CP clearance - Please inform surgeon/anaestheologist/ Dr. Luminarias/OR of this admission - Refer for any unusualities - Refer accordingly

Rationale - Admitting the patient in the agency provides a chance for the medical personnel’s to monitor the health status of the patient.

- SOP before any surgical procedures to anticipate/ prevent possible complications.

04/20/09

- NPO for midnight - Full oral and body hygiene - Insert IVF with D5LR 1L at 30 gtts/min - Ranitidine 1tab every 8 hours PO

- Needed for surgery - Preparation for surgey - Acts as fluid replacement

- To decrease gastric acid secretions

- Pre Op meds given @ AM 69

- Secure one unit FWB for possible OR use in properly typed and crossmatched

- For blood replacement during surgery

04/21/09 11:30 AM

Post-Op orders -Flat in bed until 5:00pm then turn to sides every 2 hours - Safety precautions to prevent falls, thrombus formation and skin -vital signs every 15 minutes until stable breakdown. - For monitoring patient’s status. -MPD until further orders -IVF @ 30gtts/min ; follow up with D5 LR 3L at same rate -Ampicillin 1gm IVTT every 6 hrs ANST (-) -Metronidazole 500mg by IV drip for 30 mins every 8 hours -Tramadol 50 mgs IVTT every 6 hours - Prophylaxis against GI infections - Prophylaxis against bacterial infections - To decrease pain - IVF follow-up

04/22/09

-Insert Bisacodyl 1 adult suppository

-To soften stools

70

per rectum now -May have clear liquid diet once able to pass flatus -Encourage ambulation -Cont IVF and IVT meds -I&O every shift -no dressing till ordered -To monitor fluid balance -To promote circulation -To monitor GI function

04/23/09

8:00 AM (-) flatus -Insert another Bisacodyl adult suppository per rectum now -may have clear liquid diet at lunch time -Continue IVF -Pls. inform once with flatus -for full ambulation - GI function has not restored - To soften stool

1:30 PM (+) flatus -may have clear liquid this lunch Then general liquid tonight

- GI functioning restored - To have the stomach adjust

71

(+) defecation -May have general liquid now then soft diet tonight

Dr. Luminarias

04/24/09

8:00 AM (+) BM -May have DAT now -IVF to consume -Shift IVT meds to PO once IVF is consumed 1) Amoxicillin 500mg QID #28 - For prophylaxis and/or treatment of infection 2) Metronidazole 500mg TID PO p.c. #26 3) Diclofenac Na 25 mg TID PO p.c. #30 -Start: MV 1-0-0 #30 FeSO4 + FA 1-0-0 #30 PO p.c. -For dressing today - To increase body’s immunity - Acts as Iron supplementation - To promote wound healing - For prophylaxis and/or treatment of infection - For pain

72

-Remove FBC now – refer if unable to void 4 hrs. after -Please prepare above meds for possible home meds -For D/C tomorrow

and prevent infection - To prevent infection

- To continue prescribed medications at home - May continue recovery outside hospital premises

APPENDIX C

URINE AND STOOL

4/19

4/20

4/21

4/22

4/23

73

U S

7-3 3-11 11-7 7-3 3-11 11-7

AM 3 2 0

PM 2

AM 2 2 1

PM 2

AM C C 0

PM C

AM C C 0

PM C

AM C C 1

PM C 1

1 1 1

0 0

0 0

0 0

APPENDIX D INTAKE AND OUTPUT SHEET DAYS DATE 4/21 1 Shif t 7-3 311 117 24 4/22 2 H 7-3 311 74 NPO NPO 720 960 Oral NPO NPO NPO INTAKE Tuba Parente l ral 250 920 1000 Total 250 920 1000 2170 720 960 250 250 Urin e 100 300 800 0 OUTPUT Suctio Oth n ers Total 100 300 800 1200 250 250

Precipitatin g Factor 1. Lut eal Insu

117 24 4/23 H 7-3

NPO

750

750 2430

500 0 100

500 1000 100

Clea r liquid Clea r liquid 200

640

640

3

311 117 24 H

960

960

150

150

850

1050 2650

500

500 750

75

Sign up to vote on this title
UsefulNot useful