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  • IV. Laboratory Results
  • IX. Nursing Care Plans
  • XI. References

St. Paul University Manila (St.

Paul University System) College of Nursing and Allied Health Sciences Nursing Care Study (Application of Nursing Process)

I. ASSESSMENT A. General Information This is the case of L.L., a Filipino Citizen and a Roman Catholic, who was brought to the Emergency room of East Avenue Medical Center on August 10, 2010 at around 7:45 am. The client is a fifty-seven (57) year old female, widow; she has 4 children and resides at 6720 Libis Espina, Caloocan City. One year prior to admission, the client experienced general weakness, weight loss, abdominal pain, and pallor and was confined at Caloocan Local Hospital with findings of myoma. 3 days prior to confinement, the client experienced pallor, weakness, difficulty of breathing, diarrhea, vomiting and decreased sensorium. The client has a chief complaint of episodes of diarrhea with vomiting for 3 days. Her admitting vital signs were as follows: pulse rate of 105 beats per minute, respiratory rate of 48 cycles per minute, blood pressure of 120/80 mmHg, and temperature of 36.8oC. Upon assessment, the client has pale palpebral conjunctiva, globular abdomen, and abdominal girth of 79cm with a palpable mass of 24 x 10 x 14 cm. The gynaecological assessment stated the client uses 4-5 pad per day during her menstrual cycle and has normal external vagina, parous, and closed, soft cervix. She also has difficulty of breathing and orthopnea. The client¶s initial diagnosis was Ovarian New Growth, probably malignant. On August 11, 2010, the client underwent exploratory laparotomy, adhesiolysis, omentectomy, and biopsy of the mesenteric mass, and Left salphingo-oophorectomy. She was then inserted with a nasogastric tube for decompression, an indwelling catheter, tube drain to Jackson Pratt, Foley catheter to urine bag and central venous line. The client was with an endotracheal tube hooked to mechanical ventilator, size 7.5, Level 19, with the following settings: FiO2 of 40%, tidal volume of 400 mL, BUR of 12, PEEP of 4cm/H20, AC Mode. The client¶s final diagnosis is Abdomino-Pelvic Mass, Ovarian New Growth Probably Malignant (t/c mesenteric lymphoma). B. Nursing History (Based on the Functional Health Pattern by Gordon) During the time when the client was handled, the client was with endotracheal tube hooked to a mechanical ventilator which forbids the student nurse from obtaining relevant information from the client. The student nurse also was not able to interview the client¶s relative because they were not present during the time that the client was handled.

C. DEVELOPMENTAL TASKS Sigmund Freud¶s Psychosexual Theory The client falls under the Genital Stage of Freud¶s Psychosexual Theory. On this stage, the person¶s main focus of energy is towards full sexual maturity. She should be manifesting sexual maturity development and establishing satisfactory relationship with the opposite sex. The client was able to achieve this stage because at the age of 57, she was able to establish a family, although her husband was already dead. Erik Erikson¶s Eight Stages of Development According to Erikson¶s eight stages of development, the client is in the late adulthood stage therefore he is under the central task of Integrity versus Despair. The client can look back on good times with gladness, on hard times with self-respect, and on mistakes and regrets with forgiveness and finds a new sense of integrity and a readiness for whatever life or death may bring. Jean Piaget¶s Cognitive Theory In Jean Piaget¶s Cognitive Development theory, the client is in the Formal Operational stage of the Formal Operational Thought. She has the ability to think about problems she have, able to make decisions for herself and can also think logically in her mind. However, because of the client¶s hospitalization, her decision making skills had some changes. Currently, her children are the ones who decide and anticipate the needs of the family. Lawrence Kohlberg¶s Moral Development Theory In Lawrence Kohlberg¶s Moral Development Theory, the client is at the Principled Conscience under the Post-Conventional Stage. The client is concerned with maintaining the principles and law of the family and the society. In her confinement, she complies with the advice of the doctors because she believes that it would help her recover.

II. PHYSICAL ASSESSMENT Date performed: August 16, 2010 Time performed: 3:00 PM Client¶s Initial: L.L. Client¶s Admitting Diagnosis: Ovarian New Growth, Probably Malignant Appearance and mental status The client is fairly kempt, awake, appears weak, and on semi-fowler¶s position. The client is on shallow labored breathing with the use of accessory muscles. The client is cooperative as much as she can with the student nurse. The client was with an endotracheal tube hooked to mechanical ventilator, size 7.5, Level 19, with the following settings: FiO2 of 40%, tidal volume of 400 mL, BUR of 12, PEEP of 4cm/H20, AC Mode. The client has a Glasgow Coma Scale (GCS) of (eye opening-4; verbal response-X; motor response-4). The client has no body odor, but foul breath was noted. The client¶s posture while standing and walking were not assessed because of her inability to perform the said activities. The client has an IVF of PNSS 1 L for 8 hours inserted at Right Central venous pressure at 100 cc level and D5NR 1 L for 10 hours inserted at Right cephalic vein at full level. The client also has a nasogastric tube to bed side bottle draining bilious output inserted in the right nostril for decompression, with tube drain to Jackson Pratt with dark reddish output, moderate in amount, and with an Indwelling Foley Catheter attached to urine bag and hooked at bedside with urine output of 100 milliliters, dark yellowish in color. The client¶s post operation dressing is dry and intact. The client also has an abdominal binder and elastic bandage on both legs. Vital Signs: The client has the following vital signs during the physical assessment: Temperature: 36°C ; Pulse Rate: 72 cycles per minute; Respiratory Rate: 20 breaths per minute and; Blood Pressure: 110/70 mmhg.

presence of Oval. movements. Symmetric nasolobial mood and situation. hair distribution and consistency) Scalp & Hair HEAD Face Inspection (Shape. facial expressions. no involuntary involuntary movements. No deformities. square or round in shape.AREAS TO BE ASSESSED METHODS OFASSESSMENT Inspection (Size. nasolobial folds. and occipital inches. grayish-white hair lesions. Smooth. smooth skull contour. texture. Normal temporal arteries. no contour. with A normal deviation of white dandruff flakes white in color. symmetrical facial movements. and wrinkles. wrinkles on forehead and outer symmetrical facial movements. deformities Smooth. lesions. nodules or masses. Normal findings on palpation depression. No signs of edema and hollowness. Temporal arteries Inspection/Palpation . lumps. nodules or masses. shiny. Temporal arteries are not protruding but are palpable. no lice. uniform consistency. Rounded and smooth skull Normal skull on inspection prominences). tenderness and tenderness and lesions. hair evenly distributed.5 with frontal. lumps. lesions. no hair due to the client¶s age. canthus of the eyes. thick. lesions. symmetry of movements. uniform consistency. free from split ends Round in shape. parietal. White scalp. dry. no lice. Head Circumference of 22. no Normal face deviations of free from wrinkles. thin. no White scalp. symmetry and deformities) Skull Palpation (Palpate for lumps. Symmetric folds. free from split ends dandruff flakes on the scalp. edema and hollowness) NORMAL FINDINGS ACTUAL FINDINGS INTERPRETATION Rounded (normocephalic and symmetric. tenderness and lesions) Inspection (Color. depression. depression. No signs of edema and hollowness. shape. shiny. Abnormal findings of unevenly distributed. absence of absence of masses. Temporal arteries are palpable but are not protruding during inspection and palpation. smooth. and facial expression facial expression depends on depends on mood. no dandruff.

Pale palpebral conjunctiva Normal finding on lacrimal gland. grayish white ring around the margin called arcus serilis is evident in older people. and smooth. equal movement. no discoloration. and smooth. edema. INTERPRETATION Normal eyebrows. lesions and edema. Normal deviation of Arcus serilis finding on the client¶s cornea due to the clients aging process. skin is intact without lesions. Normal findings on eyelids. capillaries evident. Sclera appears white and without Sclera is white. shiny. Transparent in color. discharge and scaling. texture.) Inspection and Palpation (Edema and tenderness) Inspection (Clarity. No discoloration and discharge was noted. and pale in color.) Inspection (Color and lesions) Inspection (Color. Without lesions and edema. curled slightly outward.AREAS TO BE ASSESSED Eyebrows EYES AND VISION Eyelashes Eyelids Sclera Bulbar conjuctiva Palpebral conjunctiva Lacrimal gland EYES AND VISION METHODS OFASSESSMENT Inspection (hair distribution. No evident. and skin quality and movement) Inspection (Evenness of distribution and direction of curl) Inspection (Surface characteristics. Lids close symmetrically and bilaterally blinking. Lids close symmetrically. Eyelids have intact skin. smooth. abrasions and elevations) NORMAL FINDINGS Hair evenly distributed. no discharge. skin intact. texture. and pink or red in Shiny. Evident arcus serilis. alignment. Equally distributed. Absences of edema and edema and lesions. texture. Eyebrows symmetrically aligned. No edema and scaling. A thin. Skin intact. Details of the iris are visible. shiny. ACTUAL FINDINGS Evenly distributed hair. edema and lesions. No lesions and edema. ability. and lesions. Cornea Transparent. Shiny. No edema or tenderness over the lacrimal gland Transparent. lesions. moves equally Eyelashes are equally distributed and are curled slightly outward. No abrasions. Normal eyelashes. bilaterally blinking. No edema or tenderness Normal findings on sclera Normal bulbar conjunctiva. No abrasions were seen. Absence of edema and scaling. details of the iris is visible. position in relation to the cornea.) Inspection (Color. . smooth. color. Eyebrows symmetrically aligned. Capillaries are Transparent. Without lesions and edema. frequency of blinking.

. round. PERRLA (pupil is equal. about 3 mm in diameter When looking straight ahead. ACTUAL FINDINGS Client blinked when the cornea was touched. constricts when light is pointed to eyes and dilates when light is removed. The client was not able to read print due to the presence of Endo tracheal tube and just nodded when asked if she couldn¶t see the print. Visual Acuity Inspection (Near vision) Able to read print. Black in color. reaction to light and accommodation) Inspection (Function of the retina and neurological function of the retina and neuronal visual pathways to the brain and second (optic) cranial nerve Inspection (Assess for the six ocular movement to determine eye alignment and coordination) Black in color. Normal extraocular muscle. reacts to light and accommodation). round. EYES AND VISION Extraocular muscle test Both eyes coordinated. move in unison. Both eyes coordinated. shape. The size of the pupils are equal on both eyes. Inspection (Color. Normal pupils. The client was not able to read print with font style of Times New Roman and size of 12 without eyeglass with a distance of 14 inches. Normal visual fields. the client agreed and nodded that she can still see objects in the periphery. indicating that the th function of the 5 cranial nerve) trigeminal nerve is intact. symmetry of size.AREAS TO BE ASSESSED Cornea EYES AND VISION Pupils METHODS OFASSESSMENT NORMAL FINDINGS Client blinks when the cornea is Inspection (Corneal sensitivity to determine touched. with parallel alignment when the test was done on the client¶s extraocular muscle. pupil is equal. move in unison. reacts to light and accommodation. INTERPRETATION Normal cornea. client can see objects in the periphery. with parallel alignment. Visual fields When looking straight ahead. constricts when light is pointed to eyes and dilates when light is removed.

and blood) Normal auricles on palpation. about 10 O from vertical. Not done because otoscope is not available during the physical examination. skin lesions. or sticky. Pinna recoils after it is folded.AREAS TO BE ASSESSED METHODS OFASSESSMENT Inspection (Color. pinna recoils after it is folded. Auricle aligned with outer canthus of eye. pus and swelling. ACTUAL FINDINGS Uniform in color. Client is not able to hear normal voice tones clearly Client was not able to hear the ticking of the watch. semitransparent. and not tender. elasticity. Symmetrical. Not done because of the unavailability of tuning fork. No blood. Student nurse needs to increase volume of voice or repeat the question twice for her to hear. pus. Auricle aligned with the outer canthus of eye. Grayish-tan in color. Tymphanic membrane Inspection (Color and gloss) Inspection (Response to normal voice) Not done. Dry cerumen which is golden brown in color. Symmetrical. Distal third contains hair follicles. Normal voice tones audible. Not able to hear ticking on both ears. Auricles EARS AND HEARING Palpation (Texture. Mobile and firm. symmetry of size. External ear canal Normal external ear canal. Sound is heard in both ears or is localized at the center of the head (weber negative) Tuning Fork Test . firm. EARS AND HEARING Gross hearing and acuity tests Watch Tick Test Able to hear ticking on both ears. wet cerumen in various shades of brown. INTERPRETATION Normal auricles upon inspection. No tenderness was noted Presence of hair follicles. pus and swelling. and position) NORMAL FINDINGS Color same as facial skin. Pearly gray in color. Not done. and areas of tenderness) Inspection (Cerumen. Dry cerumen. Mobile. Absence of blood.

Air moves freely as the client breathes through the nares. Normal facial sinuses. yellowish in color Teeth and Gums 32 adult teeth. Abnormal findings of teeth.) Assessment (Patency of both nasal cavities) Inspection (position and integrity) Palpation (Tenderness) Inspection/Palpation (Color. Normal findings on left nostril. face. glistening. No lesions noted. Not tender and no lesions.AREAS TO BE ASSESSED METHODS OFASSESSMENT Inspection (Shape. Proportional positioned at the lateral center of the to face. Air moves freely on her left nostril as the client breathes. Not tender on palpation The lips are symmetrical. Not tender. Intact and positioned in the middle. Nose is proportionate to the face Uniform in color. Uniform pink color. or color and flaring or discharge from the nose) Palpation (Tenderness. Pink gums. masses. texture and presence of lesions) Inspection (number of teeth. shiny Upper and lower teeth are yellowish in tooth enamel. It is Symmetric and straight. No retraction of on inspection. dry. Abnormal findings of pale colored and dry and peeling lips. gums. and uniform in color. smooth. No discharge or flaring. and peeling. moist. Gums are also pink and moist texture to gums. texture. smooth. moisture. Not tender on palpation. size. and displacements of bone and cartilage. Nasal septum intact and in the middle. and elastic texture. Nose NOSE AND SINUSES Normal nose on palpation. NORMAL FINDINGS INTERPRETATION Client¶s nose is normal. Right nostril was not assessed due to the presence of Nasogastric tube. Nasal Septum Facial Sinuses Lips and Buccal Mucosa MOUTH AND OROPHARYNX Normal nasal septum. firm color. Moist. pale in color. white. color) ACTUAL FINDINGS Symmetric and straight. . Nasogastric tube inserted at the right nostril.

without discharge noted. and mobility) Inspection (Color. Normal lymph nodes NECK Thyroid gland Palpation (Smoothness) Auscultation (a soft rushing sound created by turbulent blood flow) Carotid artery Palpation Normal findings No bruits auscultated. movement) Inspection (Position. and no swelling or masses noted. Muscles equal in size. head centered. No lesions noted. texture. Normal positioning and mobility of the uvula. slightly rough. & size) Inspection (Abnormal swellings or masses) Inspection (Head movement) Palpation (Enlarged lymph nodes) Inspection (swelling and visibility) NORMAL FINDINGS NORMAL FINDINGS Central position. color. Client¶s is not able to move her head by herself. discharge. Coordinated. smooth. Abnormal head movement. Lymph nodes are not palpable. Normal carotid artery pulsation. lobes are small. color. Carotid arteries on both sides are palpable but not protruding. Uvula is positioned in the middle of the soft palate. painless. smooth with no discomfort. thin whitish coating. Are not protruding but palpable. No swelling and masses. No lesions. Absence of bruits. of normal size or not visible. no discharge.AREAS TO BE ASSESSED AREAS TO BE ASSESSED Tongue MOUTH AND OROPHARYNX METHODS OFASSESSMENT METHODS OFASSESSMENT Inspection (Position. Tonsils¶ size is Grade I. Neck muscles are equal in size. centrally located. Gland ascends during swallowing but is not visible. Lobes of the thyroid gland are not palpable. and with raised papillae (taste buds) Positioned in middle of soft palate. Not palpable. Thyroid gland is neither visible nor swelling. and rise freely on swallowing. Not visible on inspection. If palpated. ACTUAL FINDINGS ACTUAL FINDINGS The client¶s tongue is centered and pink in color with whitish coating and raised papillae. Client¶s tonsils are pink in color. smooth. Head is located in the center. Neck Muscles Neck Muscles Lymph Nodes Normal findings. moist. . movements Normal finding. Lobes may be palpated. pink color. texture and movement of the tongue. INTERPRETATION INTERPRETATION Normal position. Uvula Tonsils Pink and smooth.

Flexion of the elbow after sticking of the reflex hammer. crepitation Brachial and radial pulse is weak. Muscle Muscle strength test Inspection Bones Palpation (Edema and tenderness) UPPER EXTREMITIES Joints Inspection (swelling) Palpation (tenderness. Normal bones upon inspection. Client exhibited equal strength on both sides. No tenderness. Equal strength on each body side. Deep tendon reflex Elicit reflex Not done. or nodules. Normal radial pulse count is 60-100 beats per minute for adult people. Clients pulse has a normal rate. INTERPRETATION Abnormal muscle atrophy on the upper extremities. No contractures and tremors noted. swelling. No (Size and symmetry. No presence of tenderness. crepitation. Muscles are smooth with coordinated movements. and presence of nodules Palpation No deformities. No deformities. No swelling was noted Joints move smoothly. No tenderness or swelling No swelling No tenderness. crepitation. PR=72 bpm Not done because reflex hammer is not available. and tremors) Palpation (muscle tonicity) Normally firm with smooth coordinated movements. . swelling. Responses are symmetrical on both arms Normal findings on joints on the upper extremities. Normal muscle tonicity Upper extremities¶ muscles also have 75 percent of strength (grade IV) but still on normal range. swelling noted on palpation. Muscle Inspection Equal size on both sides of body. Abnormal swelling on the upper extremities. Joints move smoothly. Muscles of the client were tested through extension of extremities. contractures contractures and tremors.AREAS TO BE ASSESSED UPPER EXTREMITIES METHODS OFASSESSMENT NORMAL FINDINGS ACTUAL FINDINGS Client¶s muscles on both upper extremities are thin and inappropriate on his body built. Brachial and radial arteries Weak brachial and radial pulses. Pulse rate palpated over the brachial and radial pulse. smoothness of movement. swelling.

color. may be similar to the shape of the female. soft and smooth. Inversion of one or both nipples that is present from puberty. smooth and intact. symmetry. Skin is uniform in color. masses. No tenderness. dark brown in color. Breasts are of normal size and symmetric. shape. or dimpling. surface. Normal breast. Finger pads are yellowish Breast Inspection (size. Round. long and dirty. Capillary refill of 2-3 seconds. color. bilateral and dark brown in color with few small growing hair. Males: breast even with the chest wall. retraction. striae. characteristics. No discharge except from pregnant or breast-feeding. Breast BREAST AND AXILLAE Areola There are no presences of masses. symmetry. discharge) Both nipples are round. Nipples Inspection (size. Skin smooth and intact. moles and nevi. No swelling or lesions. No discharge was noted Normal nipples. and equal in size. Finger pads are yellowish. Skin uniform in color (same in appearance as skin of abdomen and back). from light to dark pink. swelling or edema) Palpation (masses. Diffuse symmetry horizontal or vertical vascular pattern in light-skinned people. Irregular placement of sebaceous glands on the surface of the areola (Montgomery¶s tubercles). Localized discoloration or hyperpigmentation. position. Round or oval and bilaterally the same. both nipples point in the same direction. Color varies widely. No striaes. Nails are thick. similar in color. ACTUAL FINDINGS Nails are thick. Skin is uniform in color. and any discharge from the nipples) Inspection (size. No lesions and masses were noted. . nodules or nipple discharge. untrimmed and dirty. overted. No tenderness was noted Areola in both breast is round. shape. nodules. Normal areola. tenderness. moles and nevi were noted Normal breast. if obese.AREAS TO BE ASSESSED UPPER EXTREMITIES METHODS OFASSESSMENT NORMAL FINDINGS Nails are trimmed and clean. soft and smooth. localized hypervascular areas. and contour/shape. equal in size. or nipple discharge. Absence of masses or lesions. and any masses or lesions. overted. No swelling and lesions was noted Capillary refill = 4 seconds Nails and skin Inspection INTERPRETATION Abnormal capillary refill of 4 seconds.

Normal findings upon auscultation of the aortic. Carotid Artery Palpation (for pulses. turns head and changes position. louder at base of the heart S3: in children and young adults S4: older adults Symmetric pulse volume. No tenderness. Quality remains same when client breathes. No lifts and heaves. elasticity. Pulmonic. nodules or nipple discharge INTERPRETATION Normal nipples. and nodules) discharge. masses. Elastic arterial wall. masses. Tricuspid. nodules. Inspection and palpation (note for presence or absence of pulsations) Aortic and Pulmonic area No pulsation No pulsation Normal findings on the aortic and pulmonic area Tricuspid area Inspection and palpation (note for presence of apical pulsation and location) Pulsation palpable in fifth left intercostal space at or medial to midclavicular line. Palpable pulse in the fifth left intercostals space. Pulmonic. and quality) S1: heard at all sites. tricuspid and Apical area. Full palpation and thrusting quality. turns head and changes from sitting to supine position. louder at apical area S2: heard at all sites. tenderness. No lifts and heaves was noted Normal findings on the tricuspid area of the heart HEART AND CENTRAL VESSELS Epigastric area Inspection and palpation (note for presence of abdominal aortic pulsation) Aortic pulsation Presence of aortic pulsation Normal findings on the epigastric area Aortic. or nipple Palpation (masses.AREAS TO BE ASSESSED BREAST AND AXILLAE Nipples METHODS OFASSESSMENT NORMAL FINDINGS ACTUAL FINDINGS There is no noted tenderness. Normal findings upon palpating the carotid artery . Apical Auscultation S1: heard at all sites. louder at apical area S2: heard at all sites and louder at the base of the heart S3: not heard S4: not heard Pulse volume is symmetric and with thrusting quality which remains the same when client breathes.

symmetry. Dull on the heart and muscle and bone. Trachea has bronchial and tubular breath sounds. . Chest is symmetric. dull on areas over the liver areas. and effortless respirations. Tympanic over the heart and the liver. Normal findings of the anterior chest. Presence of crackles on both lungs.AREAS TO BE ASSESSED Carotid Artery METHODS OFASSESSMENT Ausculatation (note for presence of bruits) Inspection (note for distention) NORMAL FINDINGS No sound heard upon auscultation ACTUAL FINDINGS No sound was noted. Inspection (Breathing pattern) Quiet. THORAX Auscultation (trachea and anterior chest) Crackles heard at the mid base right of the lung and crackles heard at basal lower lung. and tympanic over the stomach. INTERPRETATION Normal findings upon auscultation of the carotid artery Normal findings upon inspection of the jugular veins Shallow labored breathing with use of accessory muscles. underlying stomach. Time of expiration is longer than the expiration. Inspection (Shape. HEART AND CENTRAL VESSELS Jugular veins Veins not visible Veins are not visible and there are of signs of distention There is the use of accessory muscles and shallow labored breathing. Time of expiration is twice longer than the inspiration. Bronchovesicular and vesicular breath sounds beginning over the bronchi between the sternum and the clavicles. deformities) Anterior Thorax Anteroposterior to transverse diameter in ratio of 1:2. Dullness was noted over the lung tissue. rhythm. Percussion Percussion notes resonate down to the sixth rib at the level of the diaphragm but Percussion notes dullness over the are flat once over the areas of heavy lung tissue. Chest symmetric.

Crackles are heard on the midbase of the right lung field and basal crackles over the left lung field. Palpation (vocal (tactile) fremitus) THORAX Auscultation (trachea and posterior chest) The vocal fremitus is symmetric. Bilateral symmetry of vocal fremitus. uniform in temperature. Normal anterior thorax upon palpation. Anteroposterior to transverse diameter in ratio of 1:2. Lowest point of resonance is at the diaphragm. except over scapula. Spinal column is straight. Normal findings . Costal angle is less than 90 O. no masses. ACTUAL FINDINGS INTERPRETATION Palpation (Lesions. except over scapula. and the ribs insert into the spine at approximately a 45 O angle. Fremitus is normally decreased over the heart and breast tissue Trachea has bronchial and tubular breath sounds. liquid or material) Spine is vertically aligned and straight.AREAS TO BE ASSESSED METHODS OFASSESSMENT NORMAL FINDINGS Skin intact. Full symmetric chest expansion. Anterior Thorax Palpation (Respiratory excursion) 2 cm chest expansion w/ the use of accessory muscles Abnormal finding of Inability to exhibit full expansion of lungs with 2 centimeter chest expansion. Percussion on the ribs normally elicits dullness. symmetry. Normal vocal fremitus of the anterior thorax. spinal alignment. Right and left shoulders are equal in height. right and left shoulders and hips are at the same height Percussion notes resonate. Bronchovesicular and vesicular breath sounds beginning over the bronchi between the sternum and the clavicles. and deformities) Percussion (to determine if lung is filled with air. Chest symmetric. Thumbs separate 3-5 cm 1 ½ to 1 ½ inches during deep expiration. Crackles are heard during auscultation. no tenderness. Skin and chest wall are intact. Normal findings Percussion notes resonate. Chest wall intact. Posterior Thorax Inspection (Shape. costal angle) Uniform skin temperature w/ no tenderness and masses. Dullness is noted upon percussion on the ribs. Spine vertically aligned.

THORAX Posterior Thorax Palpation (vocal (tactile) fremitus) Bilateral symmetry of vocal fremitus. ACTUAL FINDINGS Skin is intact. uniform in temperature. and peritoneal friction rubs) Percussion (presence of tympany. Not assessed. consistent tension. or a full bladder. Abnormal tenderness and muscle guarding was noted. Chest wall intact. Tympany over the stomach and gas-filled bowels. Tenderness may be present near the xiphoid process. The client¶s post operative dressing is dry and intact. Unblemished skin. over cecum. Normal findings Inspection (skin integrity. Respiratory excursion of 2 ½ cm. Not assessed. The client¶s post operative dressing is dry and intact. Palpation (tenderness and/or muscle guarding) The client¶s post operative dressing is dry and intact. uniform in color. The client¶s post operative dressing is dry and intact. no masses. silver-white striae (stretch mark) or surgical scars. No tenderness and masses noted. Visible peristalsis in very lean people. respiratory excursion) NORMAL FINDINGS Skin intact. Low-pitched voices of symmetrical and is easily palpated males are more readily palpated than higher pitched voices of females. Aortic pulsations in thin persons at epigastric area. dullness. tenderness and muscle guarding was noted. Full symmetric chest expansion. Fremitus is heard most clearly at the apex Vocal fremitus is bilaterally of the lungs. Absence of friction rubs. contour. Symmetric movements caused by respiration. and over the sigmoid colon. . INTERPRETATION Abnormal respiratory excursion of 2 ½ cm. or scaphoid (concave). no tenderness. The client¶s post operative dressing is dry and intact. especially over the liver and spleen. relaxed abdomen with smooth. Thumbs separate 3-5 cm 1 ½ to 2 inches during deep expiration. and dullness . No tenderness. The client¶s post operative dressing is dry and intact. rounded (convex). The client¶s post operative dressing is dry and intact. Audible bowel sounds. Flat. ABDOMEN The client¶s post operative dressing is dry and intact. and symmetry) Inspection (Abdominal movement) Four quadrants of Abdomen Auscultation (bowel sounds. vascular sounds.AREAS TO BE ASSESSED METHODS OFASSESSMENT Palpation (Lesions.

Not palpable. Visible veins were also noted. ACTUAL FINDINGS Liver was not palpated. INTERPRETATION Not done No urinary retention. No tenderness or swelling No swelling Joints Inspection (swelling) . Muscle is thin but with smooth and coordinated movements. No swelling Normal findings Muscle LOWER EXTREMITIES Bones Muscle strength test Equal strength on each body side. Inspection Equal size on both sides of body. With elastic bandage on both legs. contractures contractures and tremors. and tremors) LOWER EXTREMITIES Muscle Palpation (muscle tonicity) Normally firm with smooth coordinated movements. Lower extremities¶ muscles also have 75 percent of strength (grade IV) but still on normal range. No deformities. Border feels smooth.AREAS TO BE ASSESSED SPECIFIC ORGAN Liver Bladder METHODS OFASSESSMENT Palpation (enlargement and tenderness) Palpation (possible urinary retention) NORMAL FINDINGS May not be palpable. Not palpable. With elastic bandage on both legs. Swelling noted on both legs. Normal findings Muscles on the left leg are smooth with coordinated movementIt is firm and smooth on palpation. Normal findings Swelling noted on both legs. No (Size and symmetry. Muscle strength on the lower extremities is equal on both sides with muscle strength Grade of IV. No tenderness. Normal findings Inspection Palpation (Edema and tenderness) No deformities.

swelling. Joints move smoothly.AREAS TO BE ASSESSED Joints Popliteal. swelling. Capillary refill of 2-3 seconds. untrimmed and dirty nails Skin is uniform in color. ACTUAL FINDINGS There are no tenderness. Small amount of thick white smegma between the glans and foreskin. and pedal pulse Not done due the unavailability of reflex hammer. LOWER EXTREMITIES Elicit reflex Not done. Capillary refill = 4 seconds Not assessed for privacy INTERPRETATION Normal findings Pulses are palpated over the popliteal. crepitation. posterior tibial. swelling. and characteristics of pubic hair) Triangular distribution. Not assessed for privacy Not assessed for privacy Penis Palpation (tenderness. Not assessed for privacy Not assessed for privacy . nodules. There is presence of thick. Appears slightly wrinkled and varies in color as widely as other body skin. There is no swelling and lesions that was noted. swelling. and nodules) Smooth and semifirm. Nails and skin Inspection Presence of thick.. thickening. or nodules. Not assessed for privacy Penis INGUINAL AREA Inspection (lesions. Capillary refill of 4 seconds was also noted FEMALE GENITALS AND Pubic Hair Inspection (distribution. posterior tibial. No swelling or lesions. and pedal arteries. smoothness of movement. often spreading up the abdomen. and pedal arteries Deep tendon reflex METHODS OFASSESSMENT Palpation (tenderness. and inflammation) skin is intact. untrimmed and dirty nails. amount. Flexion of the elbow after sticking of the reflex hammer. Skin is uniform in color. Is slightly movable over the underlying structures. posterior tibial. Normal findings. Responses are symmetrical on both arms Nail is trimmed and clean. Joints could also move smoothly Palpable pulses over the popliteal. crepitation or nodules that was noted. crepitation. and presence of nodules Palpation NORMAL FINDINGS No tenderness.


METHODS OFASSESSMENT Inspection (swelling, inflammation, and discharge) Inspection (appearance, general size, and symmetry) Palpation (status of underlying testes, epididymis, and spermatic cord. Inspection (bulges)

NORMAL FINDINGS Pink and slit like appearance at the tip of the penis. Scrotal skin is darker in color than that of the rest of the body. Size varies with temperature. Scrotum appears asymmetric (left testis is usually lower than the right) Testicles are rubbery, smooth, and free of nodules and masses. Epididymis is resilient, normally tender, and softer than the spermatic cord which is firm to touch. No swelling or bulges. Intact perianal skin; usually slightly more pigmented than the skin of the buttocks. Anal skin is normally more pigmented, coarser, and moister than perianal skin and is usually hairless. Anal spinchter has good tone. Rectal wall is smooth and not tender. Brown colored feces.

ACTUAL FINDINGS Not assessed for privacy

INTERPRETATION Not assessed for privacy


Not assessed for privacy

Not assessed for privacy


Not assessed for privacy

Not assessed for privacy

Inguinal area

Not assessed for privacy

Not assessed for privacy

Anus RECTUM Anus

Inspection (color, integrity, and lesions) Palpation (tonicity, nodules, masses, and tenderness)

Not assessed for privacy

Not assessed for privacy

Not assessed for privacy

Not assessed for privacy

Summary of abnormal findings:

During inspection of the scalp, dandruff flakes was noted. Pale palpebral conjunctiva was noted upon inspection of the eyes. The client was not able to read print due to the presence of Endo tracheal tube and just nodded when asked if she couldn¶t see the print. In addition, client is not able to hear normal voice tones clearly as well as the ticking of the watch during the watch tick test. The client also has a pale colored, dry and peeling with teeth, yellowish in color. On inspection, client has thin upper extremities and visible swelling on both arms. Upon palpation, client has weak brachial and radial pulses. Nails are thick, untrimmed and dirty on both upper and lower extremities with capillary refill of 4 seconds. Finger pads are yellowish in color. During the inspection client was seen on shallow labored breathing with use of accessory muscles with time of expiration twice longer than the inspiration. Presence of crackles on both lungs during auscultation. Upon percussion of the anterior thorax, dullness over the lung tissue was noted. The client was unable to exhibit full expansion of lungs with 2 cm chest expansion on anterior thorax and 2 ½ cm on posterior side. The post operative dressing was dry and intact but with tenderness and guarding behavior upon palpation. The client has pitting edema on both legs and wears elastic dressing.

III. MEDICAL PLAN OF CARE To ensure and confirm diagnosis, series of diagnostic tests and laboratory exams should be done to the client that will verify the diagnosis: a. Client¶s Health History - Health history of the client may reveal past or recent illness. b. Physical examination ± To assess present health condition of the client as well as the signs and symptoms present to him. c. Complete Blood Count- to assess presence of infection and d. Blood Coagulation ± to measure time required for clotting e. BUN- indicator of renal function f. Urinalysis- use to assess the effects of CVD on renal function and the existence of concurrent renal or systemic disease. g. Electrolytes- affects cardio contractility specifically Na, K, Ca h. Electrocardiogram- graphical recording of the electrical activities of the heart i. Arterial Blood Gas- to evaluate oxygenation and acid/base status in the body j. Pulse Oximetry- device used to measure the oxygen saturation of arterial blood. To determine the percentage of oxyhemoglobin in blood. To maintain effective airway of the client: a. Keep client on moderate high back rest to promote proper lung expansion and to prevent aspiration. b. Encouraged client to do deep breathing exercises to maximize expansion of the lungs and smaller airways c. Maintained mechanical ventilator settings as ordered by the physician to assist breathing. To ensure condition, progress and response to treatment, continuous monitoring of the client is required: a. Monitor vital signs and record. This is done to be able to evaluate the body¶s response to treatment. b. Monitoring fluid intake and urinary output every hour and record to be able to assess the kidney function based on the amount of her daily intake of fluids, through oral means and intravenous fluid administration, and urinary output. c. Monitor neurologic vital sign- to assess neurologic status of the client To maintain adequate nutrition and hydration: a. NGT (nasogastric tube) -A tube that is passed through the nose and down through the nasopharynx and esophagus into the stomach. It is done to put substances into the stomach, and so it may be used to place nutrients directly into the stomach when a client cannot take food or drink by mouth. In this case, done for decompression, or lavage of abdominal fluids in the stomach. b. IVF of PNSS- to replace fluid and electrolyte loss c. IVF of D5NR ± to serve as a source of glucose while the client is on NPO d. Nothing per orem as ordered.

b. CBG every 4 hours To prevent spread of infection and further complications: a. b. Observe safety precaution by raising side rails. d. d. .To facilitate treatment of the condition. e. To prevent recurrence of the disease: a. medications should be given as prescribed: Metronidazole 500g IV every 8 hours Ceftazidime 1 gm IV every 8 hours Tranexamic acid 1 gm IV every 8 hours Omeprazole 40 mg IV once a day Morphine Sulfate 2g IV every 2 hours round the clock. watch out for morphine toxicity f. b. Always keep the client¶s back dry c. c. To prevent further injuries. Assist in activities of daily living. Compliance of medications as prescribed by the physician b. c. To prevent further injuries: a. Wash hands before and after assessing the client and after each procedure Wear mask and gloves in every procedure that is needed to be done Practice aseptic technique in every procedure to prevent infection Encourage hygiene to prevent growth of microorganisms a. Morphine sulfate 1g IV for severe pain g.

5 20.5 26. Increase or decrease in the partial carbon dioxide would indicate whether the imbalance is respiratory or metabolic in nature.4 HCO3 22-26 20.IV. Laboratory Results A. This detects a respiratory abnormality and to determine the alkalinity or acidity of the blood. Thus.4 uncompensated. Measures the effectiveness of the lungs to oxygenate the blood. The severity of impairment of the ability of the lungs to diffuse oxygen across the alveolar membrane into the circulating blood is indicated by the level of partial pressure of oxygen.35 ± 7.1 180. A sudden decrease. Observe the site for bleeding Monitor oxygen level of the client to prevent oxygen toxicity or atelectasis PO2 80. Or increase is indicative of homeostatic interference. respiratory Acidosis . Apply pressure or a pressure dressing to the site to prevent further bleeding. 2010 7. It is a measurement of ventilation.1 SIGNIFICANCE This is a measurement of chemical balance of the body and is a ratio of acid and bases.0 ± 100. NURSING RESPONSIBILITY Explain the need for ther procedure . Arterial Blood Gas REFERENCE RANGES pH PCO2 7.3 August 15.0 503.53 23. 2010 7. it is associated with chronic obstructive pulmonary disease and pneumonia.0 RESULTS August 13. tell the client that no fasting is needed. Respiratory Acidosis uncompensated. it directly reflects how well air is exchanging with blood in the lungs. This is indicative for the process responsible for the homeostasis of the metabolic system.45 35.0 ± 45. When taken as an arterial sample.

34 Neutrophil 0. They constitute a primary defense against microbial invasion through the process of phagocytosis. Since the plasma and the blood cells are separated by centrifugation.0-11 Unit K/UL Result August 12.50 gm/L 0. and the stinging sensation that may be felt. Decrease values have been detected due to hemolytic reaction due to infectious agents. Observe the site for bleeding. Nursing Responsibilities The client or the client¶s significant other should be informed of the reasons the specimen was ordered. Age is also a contributing factor to the decrease erythrocyte count in this age group. the equipment needed.B.6 Significance It serves as a usual guide to the severity of the disease. Thus identifies a certain person with increase susceptibility to infection. It also serves as one of the primary buffer substances in extracellular fluid and helps maintains acid-base balance by the process of chloride shift. There are no fluid restrictions before collection of the specimen.7 0. 2010 27. This means to separate blood which underscores the mechanism of the test.40-0. Decrease values have been detected due to hemolytic reaction due to the presence of infectious agents. Label the obtained specimen and secure it properly Apply pressure or a pressure dressing to the venipuncture site to prevent further bleeding. how it is to be collected. Provide safety to the client Hemoglobin 140-170 gm/L 126 Hematocrit 0. These cells can also cause some damage to body tissues by their release of enzyme and endogenous pyrogens. Increase percentage of neutrophils represents severity of infection. Hematology Examination WBC Normal Value 4.916 . It serves as a vehicle for transportation of oxygen and CO2. It is an important type of white cells in the body¶s reaction to inflammation.5-0. Increase values indicates an immune response to infection.

Examination Lymphocyte Normal Value 0. and the stinging sensation that may be felt. Observe the site for bleeding Label the obtained specimen and secure it properly Platelet 150-400 K/UL 91 MCV 60-100 fL 83. There are no fluid restrictions before collection of the specimen. This is associated with iron deficiency anemia It is the measure of the average amount or weight of Hgb within an RBC It is the measure of the average concentration or percentage of Hgb within a single RBC Nursing Responsibilities The client or the client¶s significant other should be informed of the reasons the specimen was ordered. Decrease values indicates delayed coagulation in cases of bleeding or blood loss It is the measure of the average volume or size of a single RBC.038 N Significance These cells are the sources of immunoglobulins and of cellular immune response and play an important role in immunologic reaction. how it is to be collected.9 N MCHC RDW 320-360 11-16 gm/dL % 336 15. When MCV is decreased.2-0. This test is also used in following the course of the disease due to the activated coagulation mechanism resulting in local formation of the thrombin.5 Unit % Result August 12. Apply pressure or a pressure dressing to the venipuncture site to prevent further bleeding. the equipment needed.6 N N . 2010 0. RBC is said to be abnormally small. Platelet development takes place primarily in the bone marrow and possibly in the lungs.

Nursing Responsibilities Explain the need for this procedure to client. The rate at which BUN rises is influenced by degree of tissue necrosis. Metabolic Profile Normal Examination Unit Value BUN 53-115 umol/L 8/10/10 19. including bilirubin. It plays an important role in keeping the fluid from the blood from leaking out into the tissues. progesterone.54 8/13/10 Significance It is measuring the nitrogen portion of the urea.6 4. is used as glomerular function and production and excretion of the urea. tell the client that no fasting is needed. It is produced at a constant rate depending on muscle mass of the person and is removed from the body by the kidneys. This test can help determine if a patient has liver disease or kidney disease. Creatinine 53-115 umol/L 164 158 176 Sodium 135-145 mmol/L 132 141 Potassium 3. Potassium level evaluates changes in body potassium and is helpful in diagnosing disorders of acid-base and water balance in the body. and medications.34 Result 8/12/10 22.5 ± 5. protein catabolism and the rate at which the kidneys excrete urea nitrogen. It signifies Impaired renal function. Observe the site for bleeding. calcium. Creatinine is the byproduct in the breakdown of muscle creatinine phosphate resulting from energy metabolism.1 Albumin 34-50 g/L 29 18 .5 mmol/L 4. or if the body is not absorbing enough protein Albumin helps move many small molecules through the blood. Apply pressure or a pressure dressing to the site to prevent further bleeding. Sodium concentration is under control of the kidneys and the central nervous system acting through the endocrine system.4 4. resulting in increased levels of blood creatinine. It is not an absolute value and varies with the circulatory volume and other factors such as taking diuretics.C. A disorder in kidney function reduces excretion of creatinine. Sodium maintains the osmotic pressure and acid-base balance and to transmit nerve impulses.

and helps with muscle contraction.67 1.52 mmol/L 2. and blood clotting.07 1.Calcium 2. It works with other electrolytes such as potassium. Decrease level of Calcium may indicate malabsorption in the intestinal tract. Increase levels may indicate dehydration especially since the client underwne t diarrhea and vomiting for 3 days. It is important for heart function. nerve signaling. .96 chloride 98-107 mmol/L 99 112 Calcium helps build strong bones and teeth. sodium. and carbon dioxide (CO2) to help keep the proper balance of body fluids and maintain the body's acid-base balance.122.

It is a means by which the kidney¶s ability to concentrate urine is measured. This is an indication of the renal tubule¶s ability to maintain normal hydrogen ion concentration in the plasma and extracellular fluid. Appearance Clear Cloudy Normal Result Odor Ph Aromatic 4 ± 6. Alkaline urine may appear cloudy because of phosphates. URINALYSIS ( August 11. It indicates the concentration of the specific gravity of urine. The perianal area should be washed if it soiled with feces.8 Aromatic 5 Normal Result Normal Result Specific Gravity 1.005 ± 1. However. normal urine may also be cloudy which provides a warning abnormality such as pus. Food and fluid restrictions are not necessarily before collection of the specimen. acid urine may appear cloudy because of urates The aromatic odor of fresh normal urine is caused by the presence of volatile acid. However. The range of urine specific gravity depends on the state of hydration varies with urine volume and the loads of solid excreted. RBC.D. . 2010 ) Examination Color Normal Value Pale Yellow to Amber Result Yellow Interpretation Normal Result Significance The color of the urine ranges from pale yellow to amber because of the pigment chrome.030 1. or bacteria. Explain the purpose and specific method of urine collection to the client. if necessary. Specific gravity is a measurement of the concentration of urine. Give the client the proper specimen jars and cleansing agents. The color of the urine is primarily due to the urochrome( pigments that are present in the diet or formed form the metabolism of the bile). Due to the present of the abnormal pigments the color of urine changes in many disease sates The normal urine should be clear. excretion of cloudy urine may not be abnormal since the change in pH may cause precipitation within the bladder of normal urinary constituents. Nursing Responsibilities The client should be told the type of specimen needed and the best time of day to collect it. enough to moisten a small strip of pH paper. A freshly avoided specimen of at least 30ml is needed for most urinometers.030 Normal Result A small amount of fresh urine is required.

The client may have a glass of water after then first specimen is taken to ensure adequate urine formation for the collection of the second. It also acts as a protective mechanism for invasion of bacteria in pneumonia Red cells are occasionally found in the urine but the persistent findings of even small number of RBCs should be thouroughly investigated since these cells come from kidney and indicate serious renal disease. confirming a diagnosis of diabetes. monitoring the effectiveness of diabetic control. The presence of more than 5 white blood cells can indicate bacterial infection in the urinary tract.Examination Glucose Normal Value (-) Result (-) Interpretation Normal Result Significance Glucose can indicate if the client is diabetic. WBC 0-17 46 Increased WBC RBC 0-11 uL 76 Increased RBC . Nursing Responsibilities Foods and fluids are restricted overnight for 8 hours before collection of a fasting urine specimen. some glucose spills into the urine. It is important for a careful examination of urinary sediment for leukocytes There are no food or fluid restrictions before collection of the specimen. Urine normally contains no glucose. When the blood glucose level exceeds the renal threshold for the reabsorption of glucose.voided specimen. Glucose is always present in the glomerular filtrate but it is reabsorbed in the proximal tubule.

2 41. for patient plasma to clot after the addition of an intrinsic pathway activator. Apply pressure or a pressure dressing to the site to prevent further bleeding. A Prothrombin time test can be used to check for bleeding problems. It measure of the integrity of the intrinsic and common pathways of the coagulation cascade. in seconds. Observe the site for bleeding INTERPRETATION NURSING RESPONSIBILITIES Activated Partial Thromboplastin Time 38 sec 47. The APTT is the time. tell the client that no fasting is needed.5 UNIT sec RESULTS 8/10/10 8/12/10 11. Blood Coagulation Studies EXAMINATION Prothrombin time NORMAL VALUE 12.3 It measures how long it takes blood to clot. Explain the need for this procedure to client.5 . phospholipid and calciu.8 12.E.

Symptoms of Uterine Myoma may include: . DATA FROM THE TEXTBOOK MYOMA When a benign (not recurring or progressive) tumor grows in the muscles of the uterus. and can be done laparoscopically. or MRIs may be necessary to fully diagnose uterine Myoma. In certain very rare cases (less than 1/2 of 1% of the time) the tumors can become malignant. Because they cause symptoms that may be the same as ovarian tumors that may be cancerous. Ultrasounds. or a constant need to urinate. Uterine Myoma can be treated through hormonal and/or herbal treatments. Uterine Myoma often goes undetected. If you have symptoms of Uterine Myoma. it is referred to as uterus myomatosus. your health care provider will help you determine the best way to diagnose the problem. Some research suggests that Uterine Myoma is less common in women who have had at least two children. When the Myoma pushes on the intestines or the bladder.lumbago . the surgery can become much less invasive.irregular vaginal bleeding . it is known as sarcoma. Rather.anemia. When the Myoma penetrates the entire wall of the uterus. The causes of uterine Myoma are not fully understood.dizziness . they give a temporary relief of the symptoms of Uterine Myoma. surgery is typically an option. these hormones may have certain side effects. Hormonal treatment typically do not cure the Uterine Myoma. The typical Myoma.hyper menorrhea . however. it is known as uterine Myoma. If these hormone treatments do not work. If the tumor pushes on the nerves in the spinal cord. it can result in pain of the back or the legs.V.lower abdominal pain . sometimes growing as large as a melon. ovarian cysts should always be . These tumors can grow very large. it can result in constipation. pain of the bladder. there seems to be a genetic predisposition. Description Ovarian cysts are common and the vast majorities are harmless. For at least one form of uterine Myoma.dymenorrhea . In addition. When this happens. CT Scans. OVARIAN NEW GROWTH/CYST Ovarian cysts are sacs containing fluid or semisolid material that develop in or on the surface of an ovary. Once it is diagnosed. Surgical options include the surgical removal of the Myoma tumors (known as an enucleation) or a complete hysterectomy. Recent advances in laser surgery may make this an option also. If this is the case. is around the size of an egg.

This fails to produce progesterone and brings about hormonal imbalance. Follicular cysts occur frequently during the years when a woman is menstruating. fruits. are also occasionally found in the ovary. . These factors should not be isolated however. Genetic predisposition: Genetic predisposition is often considered the leading cause of ovarian cysts. such as bleeding and pain. as it is not able to put up a natural fight against ovarian cyst triggers. disappearing within two to three menstrual cycles. Corpus luteum cysts occur occasionally during the menstrual years and during early pregnancy. the ovaries fail to release egg on a monthly basis. They usually disappear in a few weeks but can grow to more than 4 in (10 cm) in diameter and may twist the ovary. (Dermoid cysts. and are nonexistent in postmenopausal women or any woman who is not ovulating. Primary factors that cause ovarian cysts: There are many primary factors. and all essential nutrients each and everyday are important to help your body flush out toxins that can aggravate ovarian cysts problem. which may contain hair. Corpus luteum cysts occur when the corpus luteum²a small. However.) Some ovarian cysts cause problems. The most common types of ovarian cysts are follicular and corpus luteum. This can then lead to the formation of ovarian cysts.checked out. which lead to ovarian cysts. which are related to the menstrual cycle. Poor dietary choices: Eating poorly can cause hormonal imbalance that can weaken your immune system making you more vulnerable to ovarian cysts. including during pregnancy. or skin derived from the outer layer of cells of an embryo. Surgery may be required to remove cysts larger than 5 centimeters in diameter. Ovarian cysts can develop any time from puberty to menopause. teeth. yellow body that secretes hormones²doesn't dissolve after the egg is released. Follicular cysts occur when the cyst-like follicle on the ovary in which the egg develops does not burst and release the egg. This reduces the serum sex-hormone binding globulin or SHGB. Avoiding foods that are rich in carbohydrates and sugar are important and making sure you are getting enough fresh vegetables. Research has shown that the genetic pattern of women who suffer from this chronic condition is different as compared to women who never get ovarian cysts or PCOS. They are usually small and harmless. The SHBG can in turn aggravate the ovarian cyst condition to quite an extent. Insulin resistance: High level of insulin can stimulate ovarian androgen production. Weak immune system: Like I just mentioned a weak immune system can be trouble. which leads to the production of male hormones. this should not be a death warrant as many times the genetic characteristics can be modified with the help of environmental factors and proper lifestyle related changes. Failed ovulation process: Sometimes. as sometimes the combination of these factors can together lead to the causes of ovarian cysts. Many factors including dietary factors and sleep deprivation can lead to weakened immune system.

This test is used in the assessment of epithelial ovarian cancer and may help determine if an ovarian mass is harmless or cancerous. toxins in liver and even environmental toxins can aggravate and cause ovarian cysts. An ectopic pregnancy (pregnancy outside the uterus) must be ruled out because some of the symptoms of ectopic pregnancy may be similar to those of ovarian cysts. However. so the test does not positively establish the diagnosis of ovarian cancer. frequently does not cause symptoms until the tumors have become quite large. a small probe is inserted in the virginal and can be positioned closer to the ovaries. Serum CA-125 assay: This is a blood test that checks for a substance called CA-125. Hence. . unlike most other lymphomas. Culdocentesis: This test involves taking a fluid sample from the pelvis with a needle inserted through the vaginal wall behind the uterine cervix. sometimes non-harmful conditions may result in the elevated levels of CA125 in the blood. Hormone levels: A blood test to check LH. Diagnosis of Ovarian Cysts Diagnosis Tests A healthcare provider may perform the following tests to determine if a woman has an ovarian cyst or to help characterize the type of cyst that is present: Endovaginal ultrasound: This is a special imaging test developed to examine the pelvic organs and is the best test for diagnosing an ovarian cyst.Besides the above primary factors. ovarian cyst condition is not a simple one to understand or treat. MESENTERIC LYMPHOMA The mesentery is a type of connective tissue in the abdominal cavity that contains lymph nodes. estrogen. An endovaginal ultrasound is a painless procedure that resembles a pelvic exam. and testosterone levels. mesenteric lymphoma. Cancer sometimes arises from these nodes and is called mesenteric lymphoma. FSH. Pregnancy testing: The treatment of ovarian cysts is different for a pregnant woman than it is for a non-pregnant woman. Other imaging: CT scanning aids in assessing the extent of the condition. which is associated with ovarian cancer (the CA stands for cancer antigen). Because of the particular circulatory properties of the mesentery. MRI scanning may also be used to clarify results of an ultrasound. The surgeon identifies the cyst through the scope and may remove the cyst. This type of ultrasound produces the best image because rather than a scan. Laparoscopic surgery: A procedure when a surgeon fills a woman's abdomen with a gas and makes small incisions through which a thin scope (laparoscope) can pass into the abdomen. Checking these levels is used to indicate potential problems concerning those hormone levels.

fatigue and malaise. Symptoms of Mesenteric Lymphoma Most of the noticeable symptoms of mesenteric lymphoma result from the tumors becoming large enough to affect normal intestinal function.Fortunately. The pain is usually diffuse. sometimes accompanied with nausea. This sign is highly characteristic of mesenteric lymphoma and is unlikely to arise from anything else. called cytokines. per Harrison's Principles of Internal Medicine. while looking for something else. Anatomy of the Mesentery The mesentery is a network of fatty connective tissue that suspends and connects some of the organs inside the abdomen. Physicians have encountered mesenteric lymphomas incidentally during the course of unrelated abdominal surgery. Finding Mesenteric Lymphoma Because mesenteric lymphomas can become quite large before causing symptoms. It does contain some lymph nodes. The most common complaint of patients with mesenteric lymphoma is abdominal pain. these tumors usually do not spread aggressively and surgical removal is often an effective treatment. there is a particular sign that appears on an abdominal CAT scan that is very specific for mesenteric lymphoma. low-grade fever. It is called the "sandwich sign. Because the mesentery is poorly connected with these systems. The Sandwich Sign A particular finding on an abdominal CAT scan is highly suggestive of a mesenteric lymphoma. an abdominal CAT scan will be performed for some other reason and the sandwich sign will show that there is mesenteric lymphoma present. Because of the poor circulatory connection with the rest of the body. The mesentery is poorly supplied with blood and with vessels of the lymphatic system. and often described as being deep within the abdomen. . and so tumors can occasional grow in them. many tumors are found incidentally. Constitutional Symptoms of Lymphoma Other lymphomas frequently cause weight loss. They are caused by the release of chemical signals. Frequently. These symptoms usually occur before lymph nodes become noticeably swollen or painful. Sometimes a patient may even notice an unusual lump in the abdomen. vomiting or constipation. mesenteric lymphoma often does not cause the constitutional symptoms typical of other lymphomas. cytokines often do not become widely disseminated in mesenteric lymphoma and these symptoms often do not occur. and are often what bring lymphoma patients in to see the doctor. night sweats." because of the characteristic appearance of the darker "buns" of the tumor enclosing either side of a lighter middle region. Fortunately. from the tumor into the blood stream and lymph system.

it is very sensitive to stimulation and may become erect. provide an environment for fertilization of the egg by a male sperm (male gamete).VI. they are called the "vulva") are composed of the genital structures visible from outside the body: the greater lips (labia majora). the clitoris. and support the development and expulsion of a fetus in pregnancy and childbirth. the lesser lips (labia minora). and the opening of the vagina to the outside (the other end of the vagina opens inside the body to the womb). ANATOMY AND PHYSIOLOGY FEMALE REPRODUCTIVE SYSTEM Definition The female reproductive system is composed of organs that produce female eggs (called female gametes or ova). Description The normal female reproductive system is composed of external and internal genitals (genitalia). The outer surface of these lips is covered with oil-secreting (sebaceous) glands. The labia majora are two large lips that protect the other external genitals. External genitals The external genitals (together. The clitoris is a small structure found at the top of the lesser lips. The perineum is the area between the vagina and the anus in . their inner surface has hair. The lesser lips (labia minora) are found just inside the greater lips and protect the immediate opening to the vagina (this opening is called the "introitus." Latin for "entrance") and the opening to the urethra (which carries urine from the bladder out of the body).

It contains half the number of chromosomes of a human cell that is not egg or sperm (that is. women past menopause have been impregnated with another woman's egg after it has been fertilized by artificial insemination.000 remain at onset of puberty. Menstruation occurs when the lining of the womb begins to shed menstrual fluid. small spherical sacs that burst when the mature egg (called an ovum) is ready to be released into a fallopian tube for possible fertilization. and only about 300 of these will develop fully and enter a fallopian tube for possible fertilization. The neck is the opening of the womb to the vagina that allows sperm to enter the womb and allows menstrual fluid to exit. The human egg is a round cell that. one located on either side of the introitus. FUNCTIONS Menstruation The menstrual cycle ranges from 21 to 40 days in most women. the resulting cell will have the full number of forty-six chromosomes and will be considered a diploid (two-fold) cell. The vagina extends approximately 3 to 4 inches (7 to 10 cm) from the outside of the body to the opening of the womb. The eggs start as oocytes and develop in what are called ovarian or Graafian follicles. When the egg is fertilized by sperm. the permanent cessation of menstruation some decades later is called "menopause" and marks the traditional end of a woman's ability to reproduce. The first time a girl has a period (the onset of menstruation) is called "menarche". only about 300. the womb (uterus). they secrete a mucus that provides lubrication during sexual intercourse. The womb is the organ found at the top of the vagina and consists of two main parts: the neck (cervix) and the body (corpus). A fallopian tube is the site of normal fertilization.the female (in the male. The inner lining of the body of the womb is called the endometrium. zona pellucida. and the ovaries. A female human being will not produce any new developing eggs (oocytes) after she is born. The . In the 1990s. The fallopian tubes facilitate the transfer of a mature egg from one of the two ovaries to the body of the womb. Two glands. The menstrual cycle has two phases. The fallopian tubes (also called the oviducts or uterine tubes) are muscular structures that extend from the upper edges of the womb to the ovaries. or for discharge in the menstrual fluid if fertilization does not take place. The body of the womb is the main part of the womb²the womb in the narrower sense of the word. The neck is an important means of protecting the body of the womb from diseasecausing germs. although she is born with approximately two million eggs. and zona radiata). the first day of bleeding is the first day of the menstrual cycle. The ovaries are a pair of small oval-shaped structures and are suspended near the fallopian tubes by ligaments. with an average cycle lasting 28 days. Internal genitals The internal genitals are the vagina. It can enlarge to hold a developing fetus during pregnancy. are called Bartholin's glands. 23 instead of 46 chromosomes) and is therefore called a haploid (one-fold) cell. when mature. The lower third of the vagina (closest to the outside) is encircled by muscles that control its opening and closing. the perineum is the area between the scrotum and the anus).000 to 400. which thickens and then sheds menstrual fluid during each menstrual period if fertilization does not occur. a thick mucus normally covers the neck of the womb but changes in consistency during ovulation to allow sperm to penetrate. the fallopian tubes. and these older women have successfully given birth to healthy babies. is surrounded by a number of protective layers (the oolemma.

Hormones A complex balance of hormones is required for reproduction. FSH and LH also control the production of ovarian hormones (the second group of hormones regulating the female reproductive system). Fertilization During the ovulatory phase of the menstrual cycle. this replicating cluster of cells is called a blastocyst. The first group contains hormones of the central nervous system (CNS). If sperm cells are present in the fallopian tube. Relaxin is produced near the end of pregnancy by the corpus luteum and promotes relaxation of the birth channel. fertilization may occur. Gonadotropinreleasing hormone (GnRH) secreted by the hypothalamus triggers the release of gonadotropic hormones from the anterior pituitary gland. Inhibin is secreted by the granulosa cells of the follicles. the mature egg is released from the ovary and swept into the fallopian tube. Gonadotropin refers to any hormone that stimulates the gonads (the structures capable of producing eggs or sperm. then begins to move down the fallopian tube into the womb. eight weeks after conception. inhibin and relaxin. Thus inhibin has a role in controlling further follicular development. when a surge of LH causes the mature follicle to burst and release an egg. There are two gonadotropic hormones secreted by the anterior pituitary gland: the folliclestimulating hormone (FSH) and the luteinizing hormone (LH). .follicular phase extends from the first day of the cycle until immediately before a mature egg gets released from the ovary. and contributes to the production of eggs or sperm. increasing levels of FSH cause maturation of ovarian follicles (only one follicle will mature completely). The fertilized egg. the mature follicle bursts and releases an egg. when the sperm penetrates the egg. regulates their development and their hormone-secreting functions. after two weeks of development. called the "luteal" phase. it secretes so-called releasing hormones that travel to the pituitary gland located at the base of the brain. that is. Pregnancy begins at the moment of fertilization (also called conception). During the first half of the follicular phase. it is called an embryo. where it implants itself in the thick tissue of the lining of the womb. also called a zygote. The second phase of the menstrual cycle lasts approximately fourteen days until the first day of the next period (using as an example the average 28 day menstrual cycle). the ovaries or the testicles). The ovarian hormones in turn are divided into two groups: ovarian peptide hormones and ovarian steroid hormones. The ruptured empty follicle collapses to form the corpus luteum. It inhibits the releasing of FSH from the anterior pituitary gland and also inhibits the release of GnRH from the hypothalamus. FSH (as its name suggests) stimulates the development of several follicles in each cycle. it is called a fetus. A part of the brain called the hypothalamus is the main area of hormonal control. In the second phase of the menstrual (ovulatory) cycle. It is the LH that begins the second phase of the menstrual cycle. There are two ovarian peptide hormones. a process called ovulation. There are two main groups of hormones that are necessary for normal functioning of the female reproductive system. The development of the ovarian follicles is dependent upon these hormones. In the womb.

. perhaps. Human chorionic gonadotropic hormone maintains the secretory integrity of the corpus luteum. Progesterone is a hormone produced by the corpus luteum. It is synthesized and secreted by ovarian follicles. to induce estrus. Another important endocrine organ secreting the steroid hormones (estrogen and progesterone) is the placenta. The most potent estrogenic hormone in human beings is estradiol. which is then converted into estradiol and estrone). It helps maintain the uterine mucosa during pregnancy. it prepares the endometrium for implantation of the fertilized ovum. It has the following biological functions: to promote the growth and maturation of the female secondary sex characters. Estrogen is produced by the granulosa cells of developing follicles and by the corpus luteum following ovulation.) Together with estrogen. and it promotes the development of the fetus. in conjunction with progesterone to prepare the endometrium for implantation of a fertilized ovum. This production of estrogen is dependent upon luteinizing hormone (LH). Estradiol can also be synthesized by the fetoplacental unit and. The actions of human chorionic gonadotropin (hCG) resemble those of LH. (It can also be secreted by the placenta and by the adrenal cortex. The presence of hCG in urine in early pregnancy is the basis of most pregnancy tests. by the adrenal cortex. and to support pregnancy. The placenta also produces and secretes chorionic gonadotropic hormone.There are two biologically extremely active ovarian steroid hormones: estrogen and progesterone. specifically by the theca interna cells (these cells synthesize androstenedione. it maintains the uteroplacentofetal unit.

strenuous exercise or anxiety. more than 100 cycles per minute Tachypnea. trapezius. Sputum Production . The right ventricle of the heart is affected ultimately by lung disease because it must pump blood through the lungs against greater resistance It is caused by lack of oxyhemoglobin Increase workload of the heart Areas of the lungs are not adequately ventilated because of secretions and mucosal edema Compensatory mechanism of grasping for air and vasoconstriction Increased breathing rate to have a sufficient gas-exchange in the body + + + The use of accessory Muscle is done to straighten the vertebral column are brought into use to increase the force of inspiration and to meet the high ventilation demand + Inflammation or edema of the mucous membrane of the mucosa.the feeling of being deprived of oxygen Tachycardia. and abdominal muscles to stabilize the thorax during respiration.Irritation of the respiratory system causes both inflammation of the air passages and a notable increase in mucus secretion Weight loss ± sudden decreased of weight Rationale Due to arterial and venous insufficiency particularly in the lower extremity + + + + + Decreased lung compliance or increased airway resistance.abnormally rapid heart rate. Pallor. the accessory muscles such as the sternocleidomastoid. a decrease in the color of the skin Restlessness.a distressful subjective sensation of uncomfortable breathing that may be caused by many disorders.very rapid respiration.When breathing requires extra effort.inability to relax. SIGNS AND SYMPTOMS TABLE Signs and Symptoms manifested by the client Signs and Symptoms from the Textbook Dependent edema.an abnormal accumulation of fluid in intercellular spaces of the body. pectoralis major. + . edema affecting most severely the lower most important parts of the body Dyspnea. It is due to the decrease of appetite experienced. more than 20 breaths per minute Use of Accessory Muscle .VII. internal intercostals. rest or be stilled Shortness of breath. scalene. including certain heart and respiratory conditions.absence of skin coloration.

presence of poor skin turgor and scaly skin Nausea ± tendency to vomit Vomiting ± matter expelled ejection of contents of stomach through the mouth Weakness. abnormal respiratory sound consisting of discontinuous bubbling noises heard on auscultation of the chest during inspiration.Crackles ± a common.inability to breathe easily except in an upright position Rising fever . Orthopnea . Disordered protein and carbohydrate metabolism Follicles fail to ovulate and fail to undergo atresia and continue to grow Follicles fail to ovulate and fail to undergo atresia and continue to grow Follicles fail to ovulate and fail to undergo atresia and continue to grow Increase in blood flow volume + + + + + + Palpable mass at left hypogastric region 24 x 10 x 14 cm abdominal girth of 79cm + Change in volume of menstruation 4-5 sanitary pads a day + + .lack of strength or potency Abdominal pain + Producing of exudates that interferes with the diffusion of carbon dioxide and oxygen An effort to achieve adequate gas exchange without coughing or breathing deeply Serious bacterial infection There is an increase urine output that causes dehydration Accumulation of ketone bodies in the circulation Accumulation of ketone bodies in the circulation that leads to metabolic acidosis Due to muscle disuse and nerve injury .is any temperature higher than 38 oC Dry Skin.

biopsy of mesenteric mass. adhesiolysis.VIII. Left salphingooophorectomy Hyperstimulation of ovaries Hormonal imbalance Abnormal proliferation of follicle Follicles fail to ovulate and fail to undergo atresia and continue to grow Palpable mass at left hypogastric region: 24 x 10 x 14 cm Abdominal girth of 79 cm Abdominal pain Cyst grow in size . omentectomy. PATHOPHYSIOLOGY Precipitating Factors:  Multiparity  Hyperestrogenic state Predisposing Factors:  Female  57 y/o(menopausal stage  Stress Increase hormonal production of estrogen and luteinizing hormone Proliferation of smooth muscle cells Overgrowth of uterine lining Development of uterine fibroid Degeneration of interior part of the fibroid 4-5 sanitary pads/day during menstruation Increased blood flow volume Hyaline degeneration Red or carneous infarction Smooth muscle cells are replaced by fibrous connective Continued growth of fibroid (leiomyomas) Myoma (2009) Fibroid breaks away from the uterus and develops in other locations Disseminated Peritoneal Leiomyomatosis (spreads to the abdominal wall) T/C mesenteric lymphoma s/p EL.


4. Coughing is a natural self cleaning mechanism. Nursing Care Plans Ineffective airway clearance related to increased sputum production ASSESSMENT Objective: y With Endotracheal tube hooked to mechanical ventilator with the following settings: FiO2 of 40%. odorless and moderate in quantity 2. To assist client in respiration. AC Mode. Demonstrate and help client to perform effective coughing while in fowler¶s position 5. Tachycardia. dysrhythmias ad changes in BP can reflect effect of systemic hypoxemia on cardiac function 2. BUR of 12. To help client reduce secretions and clear airway 4. Assist client to assume position of comfort (semi fowlers) 3. Suction secretions as needed. 5. Semi-fowler¶s position y facilitates respiratory function to aid breathing. INTERVENTION 1. EVALUATION After 15 minutes of nursing interventions: y The client clears airway using controlled coughing techniques and suctioning The client¶s sputum is thin. 3. Maintain ET-MV settings as indicated. Monitor ital signs RATIONALE 1. . chest expansion and ventilate lung fields. white.IX. tidal volume of 400 mL. y With clear to yellow copious amount of secretions when suctioned y (+) crackles upon auscultation on both lung fields y RR= 20bpm DIAGNOSIS Ineffective airway clearance related to excessive mucus production and presence of endotracheal tube PLANNING After 8 hours of nursing interventions the client will be able to have a patent airway free from secretions. assisting the cilia to maintain patent airways. PEEP of 4cm/H20.

Reposition client every 6.6. Encourage deep breathing exercise 7. For drainage of 2 hours secretions 7. Promotes optimal chest expansion .

INTERVENTION RATIONALE 1. and biopsy of the mesenteric mass.and possible fat particle escape and aggregation PLANNING After 8 hours of nursing interventions the client will be able to show no signs or thromboembolic or hemorrhagic complications. a mjor cause of clot 2. adhesiolysis. and Left salphingooophorectomy. dehydration. Perform passive Range 1. exercises(leg Muscle contraction exercises) hourly. EVALUATION After 15 minutes of nursing interventions: y The client clears airway using controlled coughing techniques The client¶s sputum is thin. Leg exercises promote of motion blood flow in the legs.ASSESSMENT Objective: y s/p: exploratory laparotomy. y Post operative Incision at the left hypogastic region. white. compress the veins and help prevent venous stasis. omentectomy.3 (8/12/10) DIAGNOSIS Risk for thromboembolic and hemorrhagic complications related to immobility. dry and intact y With platelet count of: 91 K/uL (140-400) y PT of 12. odorless and moderate in quantity y . formation.

Recommend elevating lower extremities 5. To promote venous return 6. To prevent moisture that would increase risk of wrinkles . To promote circulation and to reduce tissue pressure. To minimize contact with irritants EVALUATION After 8 hours of nursing care the client maintained intact skin and prevented skin breakdown 2. To reduce risk of dermal injury when scratching 3.Provide preventive skin care: Change of diapers frequently 4. squared and filed 3.Keep nails short. To enhance circulation and exercises improve/maintain joint mobility 5.Risk for Impaired Skin Integrity related to limited movements Date: January 27. Assist client with ROM 4.Implement and post a turning schedule restricting time in one position for two hours RATIONALE 1. 2 hours is the maximum time for the cells to withstand pressure 2.Keep linens dry and free 6. 2010 ASSESSMENT Subjective: ³Minsan inuupo ko yan baka kasi magka bed sores´ as verbalized by the client¶s eldest son Objective: y pronounced bony prominences y Immobility y Extreme age y Presence of type 2 diabetes mellitus y Dry skin DIAGNOSIS Risk for impaired skin integrity related to limited movements PLANNING After 8 hours of nursing intervention the client will be able to maintain intact skin and prevent skin breakdown INTERVENTION 1.

of skin breakdown and also to prevent skin irritation ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION .

Bathe with mild soap 7.To improve circulation to the skin and to enhance skin tone 10.7.To relieve dry skin 8.To maintain cleanliness without irritating the skin 8. Use skin cream or lotion after bathing 9.Hygiene prevents accumulation of bacteria thus preventing diseases 9.Emphasize the importance of good hygiene and proper grooming . Massage skin gently 10.

Indication: Chronic obstructive pulmonary disease y y y y y y y Side Effects hypokalemia headache dizziness fatigue hypertension bronchospasm cough Nursing Responsibilities Assess respiratory status before initiation of therapy and monitor for inhalation of ipratropium Give client frequent sips of waste and sugar less hard candy or gum to relieve dry mouth .Drug Study Drug Salbutamol + Ipratropium nebule Dose. Ipratropium antagonizes the effect of acetylcholine. It causes a local and site specific brnchodilation by preventing the increase in intracellular cyclic guanosine monophosphate which is produced by the interaction of acetylcholine with the muscarinic receptors of the bronchial smooth muscles. Route and Frequency 2cc nebulizer every 6 hours PRN for difficulty of breathing Classification bronchodilators Action/ Indication Action: Salbutamol stimulates beta-2 receptorsof bronchioles by increasing levels of cAMP which relaxes smooth muscles to produce bronchodilation.

if decreasing. chloride . sputum. redness Assess urine output. urine. creatinine as it indicate nephrotoxicity Monitor electrolytes such as potassium. nosocomial and community acquired pneumonia y y y y y y Side Effects headache fever dizziness weakness anxiety hypokalemia Nursing Responsibilities Obtain client hertory of hypersensitivity to penicillin. also check for BUN. cephalosporin or other drugs prior to administration Monitor if bleeding occurs Assess client for the signs and symptoms of infection including characteristic of wound.Drug Piperacillin/ Tazobactam Dose. malaise. stool. sodium. It has the potential to enhance the activity of beta lactam antibacterials against betalactamase producing bacteria. sputum. notify physician.000 Assess for overgrowth of infection which indicate fever. Indication: Treatment of severe bacterial infection. cough.5mg IV every 8 hours ANST Classification Antibacterial Penicillin Action/ Indication Action: Inhibits the action of bacterial betalactamases. Route and Frequency 4. fever and WBC > 10. urinary tract infection.

Route and Frequency 500mg/tab 2 tabs per orem OD Classification Antidiabetic/: Biguanide Action/ Indication Action: Decrease intestinal absorption of glucose and hepatic glucose production.Monitor client carefully during first 30minutes after infusion for signs of hypersensitivity Drugs Metformin Dose. It also improves insulin sensitivity(increase peripheral glucose uptake and utilization) Indication: Non-insulin dependent diabetes mellitus type 2 Side Effects y Urinary tract infection y Back pain y Headache y Fatigue Nursing Responsibilities Assess for hypoglycemic and hyperglycemic reactions Assess client¶s renal status Monitor for possible drug induced adverse reactions Assess client¶s and family knowledge on drug therap Inform client that drug must be continued on daily basis to control symptoms and prevent complications Encourage client to take drug in the morning to prevent hypoglycemic at night .

Route and Frequency Classification Action/ Indication Side Effects Nursing Responsibilities .Drug Dose.

prophylaxis of myocardial infarction y dizziness Administer after meals. Also decreases platelet aggregation by preventing formation of thromboxane A.Aspirin 80mg 1 tab per orem after meal OD Anticoagulants Action: Relieves pain and reduces inflammation by inhibition of peripheral prostalglandin synthesis. black tarry stools. leading to heat loss and cooling by evaporation. It also inhibits the synthesis or action of other mediators of inflammation. or tinnitus occurwithhold medication and notify health care provider Advise client to take medicine after meals and with full glass of water . It acts on the hypothalamic heat regulating center to relieve fever. fever. with food or antacid to minimize gastric irritation Do not crush or have client chew enteric-coated or time-release caplets Ensure that bleeding time and prothrombin time have been evaluated before beginning large dose long-term therapy If signs of bleeding. by promoting sweating and vasodilation. Indication: Treatment of mild to moderate pain. a platelet aggregating substance.

Route and Frequency 70 u SQ 6am 10 u SQ 4pm Classification Antidiabetic Action Indication Action: Decrease blood glucose by transport of glucose into cells and the conversion of glucose to glycogen indirectly increases blood pyruvate and lactate. Side Effects y Hypoglycemia y Insulin resistant y Visual impairment Nursing Responsibilities Obtain client¶s hertory and any known allergies Insulin Monitor fasting blood glucose. Indication: Management of type 2 diabetes mellitus or non insulin dependent diabetes mellitus which cannot be controlled by diet and exercise or weight reduction alone. 2 hours after meals: assess client for signs and symptoms of hypoglycemia Monitor body weight periodically Explain technique of administration Observe injected sites for signs and symptoms of local hypersensitivity Assess for adverse effects .Drugs Dose. decreases phosphate and potassium.

anti coagulant Action/ Indication Action: Blocks ADP receptors which prevent fibrinogen binding at that site and thereby reduce the possibility of platelet adhesion and aggregation. vascular death) in clients with atherosclerosis documented by recent MI Side Effects y abdominal pain y headache y dizziness Nursing Responsibilities Advise client that each dose may be taken without regard to meals but to take with food if stomach upset occurs Advise client that if a dose is missed to skip that dose and take the next dose at the regularly scheduled time . Route and Frequency 75mg/tab NGT OD Classification Anti platelet.Drug Clopidogrel Dose. Indication: Reduction of atherosclerosis events (MI. stroke.

Route and Frequency 30mg/tab Per orem OD Classification Anti-Anginal Drugs Action/ Indication Action: Increases supply of oxygen to the heartby dilating both the arterties and veins which supply th heart itself. hypotension and tachycardia Caution client to avoid sudden position changes to prevent orthostatic hypertension . character and intensity Monitor vital signs Give one hour before or two hours after meal with 8 oz of water Tablet should not be crushed or chewed and should be swallowed together Monitor for headache.Drug Isosorbide mononitrate Dose. Indication: Prevention of angina pectoris and treatment of myocardial infarction y y y y Side Effects headache dizziness weakness fatigue Nursing Responsibilities Assess for pain: duration. activity being performed. time started.

Indication: Hypertension y y y y y y y Side Effects Headache dizziness weakness somnolence shortness of breath dyspnea pallor Nursing Responsibilities Assess cardiorespiratory status Assess hydration and fluid volume status Monitor platelet count . Anti-Anginal Drugs Action Indication Action: Inhibits influx of calcium ion across cell membranes to produce relaxation of coronary vascular smooth muscle (dilatation of coronary arteries). Route and Frequency 50mg/tab Per orem OD Classification Calcium Antagonists. decrease peripheral vascular resistance of smooth muscle (decrease blood pressure) and increases myocardial oxygen delivery in clients with vasospastic angina.Drug Amlodipine Dose.

Route and Frequency 25mg per tab. diabetic nephropathy y y y y y y Side Effects dyspnea cough fatigue dizziness headache weakness Nursing Responsibility Monitor blood pressure Monitor blood studies: decreased platelets and renal studies Check potassium levels Store in airtight container Caution client about side effects . inhibits ACE.Drug Captopril Dose. Indication: Hypertension. ¼ tab Per orem TID Classification angiotensinconverting enzyme (ACE) inhibitor Action/ Indication Action: Selectively suppresses rennin angiotensin aldosterone system. prevents conversion Angiotensin1 to Angiotensin2.

Drug Dose. Route and Frequency Classification Action/ Indication Side Effects Nursing Responsibilities .

Route and Frequency Classification Action/ Indication Side Effects Nursing Responsibilities . character Assess patient in respiration and pulmonary secretions. frequency. exercise caution Drug Dose. It also promotes the detoxification of an intermediate paracetamol metabolite which is used in the management of paracetamol overdosage Indication: Treatment of respiratory affections characterized by thick and viscous hypersecretions: acute and chronic bronchits and its exacerbation y y y y y headache chest tightness dizziness mild fever dyspnea Assess patients hertory of underlying condition like cough: type.Generic: NAcetylcysteine 60g/tab + 100cc water NGT OD Mucokinetic/ Expectorant Action: Decreases the viscosity of secretions by splitting of disulphide bonds in mucoproteins.

gastrointestinal genitourinary and general body side effects. discontinue the treatment and notify health care provider immediately Assess patient for respiratory. y y y y y y cough headache dizziness fatigue hypertension bronchospasm Monitor patient¶s respiratory status during each treatment. If bronchospasm worsens during or shortly after treatment.Tiotropium lurdiplate 1 cap PRN NGT x dob Anticholinergic Action: Tiotropium bromide. a longacting quaternary ammonium antimuscarinic. is structurally related to ipratropium. It is a nonselective competitive antagonist of muscarinic (M1-M5) receptors and causes bronchodilation by inhibiting the actions of acetylcholine and other cholinergic stimuli at M<290>3<>190> receptors in the smooth muscle of the respiratory tract. Inform health provider if noted and significant . Indication: Maintenance therapy of COPD.

which is responsible for catalyzing and an early step in the synthesis of cholesterol Lowering of total and LDL cholesterol Indication: To reduce low density lipoprotein cholesterol. and triglycerides. apolipoprotein beta. Route and Frequency 40mg/tab 1 tab PO OD at HS Classification Lipidlowering agents Action Indication Action: Inhibit an enzyme. To increase high density lipoprotein cholesterol in the treatment of hyperlipidemia Side Effects y Dizziness y headache Nursing Responsibilities Assess client¶s nutrition Monitor creatinine phosphokinase levels due to possibility of myopathy and serum cholesterol Monitor triglycerides. 3 hydroxy 3 methylglutarylcoenzyme A (HMG-CoA) reductase.Drugs Simvastatin Dose. cholesterol baseline and throughout treatment Evaluate therapeutic response and adverse reactions on a regular basis .

Drug Lactulose Dose. It also lowers intentional absorption of ammonia presumably due to increased utilization of ammonia by intestinal bacteria. water or milk to make more palatable Teach client that normal bowel movements do not always occur daily and that adequate fluid consumption is necessary (none of these were manifested by the client) . Decreased in luminal pH (due to bacterial metabolism) further increased motility and secretion. Bacterial metabolism of the drug to lactate and other acids which are only partially absorbed in the distal ileum and colon augments the osmotic effect of lactulose. Indication: Constipation y y y y y y Side Effects Diarrhoea Nausea Vomiting Hypokalaemia bloating abdominal cramps Nursing Responsibilities Assess client¶s condition before therapy and reassess regularly to monitor drug effectiveness Monitor fluid and electrolyte status Monitor for increased glucose level in diabetic client Mix with fruit juice. The distention of the colon due to increased fluid enhances intestinal motility and secretion. Ther result to the passage of soft stools. Route and Frequency 30cc PO OD at HS Classification Laxatives Action/ Indication Action: Causes an influx of fluid in the intestinal tract but increasing the osmotic pressure within the intestinal lumen.


respiratory disease Side Effects y pallor y weakness y delayed wound healing y headache y hypertension y blurred vision Nursing Responsibilities Assess patient¶s condition before starting therapy and re-assess regularly Monitor for possible drug induced adverse reactions Monitor intake and output. inhibit migration of macrophages. leukocytes and fibroblasts at sites of inflammation. Indication: Treatment of primary or secondary adrenal cortex insufficiency. Route and Frequency 100mg IV every 6 hours Classification Corticosteroid Action/ Indication Action: Gluco-corticoid with antiinflammatory effect because of its ability to inhibit prostaglandin synthesis. phagocytosis and lysosomal enzyme release.Drug Hydrocortisone Dose. It can also cause the reversal of increased caplliary permeability. signs of infection especially fever and WBC count .

HEALTH TEACHING Topic: Hygiene Time allotment: 10 minutes Objectives Content Teaching strategy Evaluation .X.

After 10 minutes of lecturediscussion. Demonstrate and identify ways on how to perform proper hygiene.  Explain to the client the importance of changing catheter every 3 days to prevent any infection.  Body hygiene: Perform bed bath with the help of the significant other. Topic: Drug Compliance Time allotment: 30 minutes Objectives Content Teaching strategy Evaluation . Lecture/demonstration  Oral hygiene: Gargle mouth wash or use Bactidol every morning and at night to avoid halitosis and mouth sores.  Hand hygiene: Wash hands with water and soap. Identify and verbalize the importance of proper hygiene.  To look presentable. Demonstrate ways on how to perform proper hygiene. -Demonstrate ways on how to perform proper hygiene. the client was able to met the goal for he was able to: -Verbalize the importance of proper hygiene. 2.  Ear care: Clean the ears every other day using cotton buds and discard properly after use.  To feel comfortable and to feel relaxed.  Perineal care: Clean the area using soap and water and dry the area with clean cloth before putting another clean diaper. Through re-demonstration and question and answer. use deodorant to prevent body odor. Lecture / discussion  Proper hygiene is done to prevent spread of bacteria. the client will be able to: 1.Discuss to the client the importance of proper hygiene. Dry hands with towel to prevent contamination of bacteria.

to lower down temperature.  To promote fast recovery.Identify importance of drug compliance. the importance of Lecture / discussion drug compliance:  Drug compliance is important to prevent resistance to the drugs. -Verbalize understanding of the actions and side effects of the drugs.  Taking medications as ordered/instructed to attain the desired therapeutic effect. y Palpitations y Hypertension y Headache y Dizziness y Cough  Anti-diabetic.to decrease sugar level in the blood.  To prevent further complications and recurrence of the disease. Discuss to the client and to the significant other. Lecture/discussion .  It is better to have a pill box so to be organized with the medications that is to be taken every day. the client was able to met the goal for he was able to: . y Abdominal bloating  Antipyretic. Discuss to the client and to the significant other. y Visual disturbance y Bronchoconstriction Through redemonstration and question and answer. the client will be able to: 1. the actions and common side effects of the drugs:  Bronchodilators. Verbalize understanding of the actions and side effects of the drugs.to dilate the bronchioles for easy breathing. 2. Identify importance of drug compliance.After 30 minutes of lecturediscussion.

Objectives Content Teaching strategy Evaluation .

to increase bowel movement.to decrease the viscosity of secretions. y Dyspnea  Anti-bacterial y Nausea y Vomiting y Rash  Laxatives. y Distention hyperglycemia  Calcium antagonist.decrease glucose level. Antihypertensive.to lower down blood temperature. . y Headache y Dizziness y Fatigue  Palpitation Mucolytic.

Adult Health Nursing: A biopsychosocial Approach. Lippincott Williams and Wilkins. Malan Press Inc. and AMES. Tortora and Bryan H. Black and Jane Hawks  Medical Surgical Nursing: A Nursing Process Approach. SW (1986). 12th Edition Volume 1 by Gerard J. J. and AMES.. W. Tortora and Bryan H.al  Essentials of Human Anatomy and Physiology. Singapore  Beare P. Elaine N (2006). California  Kneisl CR. 4th Ed. Textbook of Medical Surgical Nursing 11th Edition. Publishing as Benjamin Cummings  Kneisl CR.V. Elsevier Science. M. Addison ± Wesky Publishing. USA . Myers J. Support and Movement and Control Systems of the Human Body.XI. (2005): Stedman¶s Medical Dictionary for the Health Professions and Nursing 5th Edition by Wolters.. Adult Health Nursing: A biopsychosocial Approach (The text whose time has come!). Metcalf.. a Wolters Kluwer business. A.  Principles of Anatomy and Physiology: Maintenance and Continuity of the Human Body. Missouri  Brunner and Suddarth (2008). Derrickson (2009)  Principles of Anatomy and Physiology: Organization.. Smeltxer. Derrickson (2009)  Stegman. Mosby Co.. 12th Edition Volume 2 by Gerard J. Khiwer Health Co. C.. SW (1986).. et al (2002): Mosby¶s Pocket Dictionary of Medicine. References  Allen. Philippines  Brunner and Suddarth¶s textbook of Medical Surgical Nursing ± 11th Edition [edited by] Suzanne C. (2008). Pearson Education Inc. Nursing and Allied Health Sciences.. Lewis. previous Edition: Addison ± Wesky Publishing company Inc. 8th edition by Marieb. 2nd Edition Phil. 3rd Edition by Alison Miller  PPD Nursing Drug Guide.et. California  Manual of Laboratory Diagnostic Exam by Nenita Gonzales UERMMMC  Medical Surgical Nursing Clinical Management for Positive Outcomes by Joyce M. (1990): Principles and Practice of Adult Health Nursing.

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