I.

INTRODUCTION

This is a case of Patient X who was diagnosed with Uterine Myoma on the 6 th of

March 2009. Myomas or uterine fibroids are lumps that grow on your uterus. One can

have fibroids on the inside, on the outside, or in the wall of your uterus. Doctors may call

them fibroid tumors, or leiomyomas. But fibroids are not cancer. One does not need to

do anything about them unless they are causing problems. Fibroids are very common in

women in their 30s and 40s. By the time they are 50, about 80 women out of 100 have

fibroids. But fibroids usually do not cause problems. Many women never even know

they have them.

Doctors are not sure what causes fibroids. But the female hormones estrogen

and progesterone seem to make them grow. A female body makes the highest levels of

these hormones during the years when she menstruates. Fibroids usually shrink after

menopause and stops causing symptoms.

Often fibroids do not cause symptoms. Or the symptoms may be mild, like

periods that are a little heavier than normal. If the fibroids bleed or press on a patient’s

organs, the symptoms may make it hard for her to enjoy life. Fibroids make some

women have: Long, gushing periods and cramping. Fullness or pressure in their

abdomen, Low back pain, dyspareunia or pain during sex, and an urgency to urinate

often. Sometimes heavy bleeding during your periods can lead to anemia. Sometimes

fibroids can make it harder to get pregnant. Or they may cause problems during

pregnancy, such as going into early labor or losing the baby.

As for Patient X, she was recently admitted at Xavier University Community

Health Care Center (XUCHCC) or German Doctors Hospital on April 19, 2009. She was

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admitted at the said hospital under the care of Dr. Boromeo for her scheduled surgery,

Total Abdominal Hysterecomy-Unilateral Salphingo Oophorectomy (TAH-USO) which

was performed last April 22, 2009. Furthermore, the patient has been on recovery until

April 24, 2009.

With the acquired information given by the patient, the group aims to present the

case of Patient X comprehensively and discuss the ideal and actual management done

to improve the condition of the client, including an individualized nursing care plan done

to relieve the nursing problems identified by the team in the small span of time that we

were able to care for the patient. In the process, we aim to enhance our knowledge,

skills and attitude to further improve ourselves in our nursing practice.

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A. GENERAL OBJECTIVE:

At the end of 2 hours of case presentation, the group will be able to increase our
knowledge pertaining to our patient’s case and other concepts most useful in the
surgical ward, enhance our skills in making and conducting all parts of our case study,
and develop a good attitude of cooperation and camaraderie among every member of
the group.

B. SPECIFIC OBJECTIVES:

At the end of 2 hours of case presentation, we will be able to:

1. lay out our general and specific objectives to the panel of CI’s clearly.
2. discuss our general assessment of the patient thouroughly.
3. expound the pathophysiology of our patient’s case knowledgeably.
4. present the medical and the nursing management carried out by the group to the
patient.
5. answer the questions thrown by the CI’s to the group correctly.

C. SCOPE AND LIMITATIONS

This case presentation will attempt to cover and discuss the disease process and
present condition of the patient as assessed in the five days of assessment and duty, at
Xavier University Community Health Care Center. It will also present the nursing and
medical care as provided during the 32 hours of duty (April 20-23, 2009).

This case presentation will be limited only to the patient’s verbalizations,

laboratory reports, signs and symptoms as evidenced by and observed from the patient
within the engaged days and how the medical team (doctors, nurses, SN, etc.) has
managed each of them.

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II. ASSESSMENT

A. ASSESSMENT TOOL

I - GENERAL INFORMATION
Name: Patient X Age: 42y.o.
Birthday: December 25, 1966 Civil Status: M
Sex: F Religion: R.C. Occupation: Housewife Informant: Patient X
Relation: patient
Admission Date: April 19, 2009 Time: 10 am
Chief Complaint: hypogastric mass
Reason for admission: for further evaluation and management: TAH- USO
Attending Physician: Dr. Rico Borromeo
Diagnosis/Impression: Uterine Myoma
History of Present Illness:
March 6, 2009- Patient sought consultation at German Doctor’s Hospital
due to noticed palpable mass at right hypogastric region- (-) tender and (-)
movable. (+) monthly menses lasting three days with increased blood flow
volume. Patient experienced urinary frequency- about 15-20 times a day with an
estimated amount of 200cc per urination. Undergone ultrasound and result
showed enlarged uterus (11cm x 9cm) and isoechoic mass of anterior
myometrium (9.7cm x 7.5cm) and was advised for admission on April 19, 2009.
Patient frequently sought consultation and completed laboratory exams (CBC,
U/A, CXR and ECG) and thus admitted and scheduled for surgery.

Past Medical/Surgical History:

Illness Date
None

Legend: Black – Day 1(April 19); Blue – Day 2(April 20); Green – Day 3(April 21); Violet
– Day 4(April 22); Orange – Day 5(April 23)

Vital Signs: HR = 75 bpm RR= 19 cpm BP = 120-80 mmHg Temp = 36.8°C

Temperature Heart Rate Respiratory Blood Pressure

36.8oC 88 bpm 18cpm 120/80mmhg
36.7oC 78 bpm 16cpm 130/80mmhg
37.2oC 78 bpm 18cpm 120/80mmhg
37.3oC 102 bpm 16cpm 130/90mmhg

II - ACTIVITY/REST

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 Subjective
Usual activities/hobbies: Doing household chores, vending snacks, working as a
barangay health worker
Leisure time activities: Watching TV
Limitations imposed by condition: Cannot perform usual activities due to stay in
hospital
Sleep number of hours: 4-5 hours, not continuous Naps: None Aids: None
Difficulty in sleeping: None
Feeling on awakening: Most of the time, patient feels well rested but there were
times when she feels heavy as if she never had a rest at all
Others/Comments:
“Bulog usahay akong ulo pagmata kay kulang tulog,” as verbalized by the
patient.

“Sige man gud og mata-mata kung gabii kay mangihi ko. as verbalized by the
patient.

“Dili pud ko kabawi ug tulog kay trabaho man nako sa hapon. Daghan ko
ginabuhaton ba. ”as verbalized by the patient.

Objective
Observed response to activity:
Cardiovascular: Increased PR- 81 bpm Respiratory: Increased RR-23 cpm
Mental Status: Oriented Posture: Erect
LOM: None Tremors: None
Others/Comments: The patient responds normally to activities.

III – CIRCULATION

Subjective
History of hypertension: None Heart trouble: None
Ankle/leg edema: None Slow healing: None
Claudication: None Cough/hemoptysis: None
Extremities: Numbness: None Tingling: None
Change in frequency/amount of urine: 15-20x a day
4-6x a day
Others/Comments: Frequent urination has always been the patients problem.
Patient reported that she voids 15-20x per day, about 200cc per urination before
admission.
“Ga sige ko og ihi-ihi, ika-kinse or ik-bente sa isa ka adlaw, adtong wala ko na
admit. Pag-admit nako kay ika-napulo o ika-kinse nalang sa usa ka adlaw.” As
verbalized by the patient.

Objective

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 BP R: Lying: 120-80 mmHg Sitting: 120/80mmHg
Standing: 120/80mmHg
L: Lying: 120/80mmHg Sitting: 120/80mmHg
Standing: 120/80mmHg
Pulse Pressure: 40 mmHg PMI: Apex of the heart
Heart Sounds: Rate: 75 bpm Rhythm: Normal sinus rhythm
Pulse: Carotid: 79 bpm Radial: 75 bpm
Popliteal: 71 bpm Temporal: 78 bpm
Femoral: 79 bpm Dorsalis Pedis: 79 bpm
Vascular Bruit: None Breath Sounds: Bronchovesicular
Jugular Vein Distention: None
Extremities: Temperature: 36.8°C Color: Slightly pale
Capillary Refill: Returns after 2 seconds
Homan’s sign: none Varicosities: None
Color/Cyanosis: Nail beds: Pale Lips: Brown
Mucous membranes: Moist
Sclera: Whitish
Others/Comments: Patient’s lips are cracked and dry, palms are having some
palmar pallor.

IV - EGO INTEGRITY

Subjective
Report of Stress Factors: Second child’s behavior
Ways of handling stress: Nagging
Financial Concerns: Presently experienced
Relationship Status: Strained relationship with second child
Lifestyle: Active with no vices
Recent changes: Patient can’t perform usual activities.
Patient stays still in bed.
Patient was on a clear liquid diet.
Feelings of: Helplessness: None Hopelessness: None
Powerlessness: None

Other/Comments:

“ Wala kay ko problema sa akong kinamagulangan og kinamanghuran na

anak. Kato ra akong ikaduha kay sige’g kahubog,” as verbalized by the
patient.

“Usahay muabot man jud ng problema pang pinansyal. Labaw na karon

nahospital pa jud ko,” as verbalized by the patient.

Objective

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

Observed physiologic response: Patient was able to establish good eye contact.
Others/Comments: The patient is able to answer all the questions asked
appropriately.

V – ELIMINATION

Subjective
Usual Bowel Pattern: Irregular (3-4 days interval) before admission
Character of Stool: Hard, formed, brown in color, and minimal in amount
Last BM: April 19, 2009 – 4:30 pm
April 20, 2009 – 6:00 am
April 21, 2009 - 7:30 am
April 23, 2009 – 9:00 am & 8:00 pm
Laxative use: Dulcolax (April 22& 23)
History of bleeding: None Hemorrhoids: None
Constipation: None Diarrhea: None
Usual voiding pattern: 15-20x per day Incontinence: None
Urgency: (√) Retention: None Frequency: (√)
(-) (-)
Pain/Burning/Difficulty in voiding: None
History of kidney/bladder disease: None
Others/Comments: The patient has an abnormal voiding pattern at night with an
amount of 200 cc urine per voiding, however, the patient does not drink much
water about 2 – 3 glasses per day only. The patient also mentioned that she
experienced straining upon defecation.

“Dili na regular ako paglibang. Sukad tong niaging bulan kay mga tag-tulo
o upat ka adlaw ko ayha malibang. Ginagmay nga gahi akong tahi.
Usahay galisod pud ko ug libang” as verbalized by the patient.

“Gasige ko ug ihi-ihi, ika-kinse o ika-bente sa isa ka adlaw, adtong wala

pa ko na admit. Paadmit nako kay ik kinse o ika napulo na lag sa isa ka
adlaw.”, as verbalized by the patient.

“Karon dili na ko sige’g ihi-ihi. Mga kaupat o kaunom sa isa ka adlaw

nalang,” as verbalized by the patient.

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

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 abdomen
Palpable mass at right lower quadrant of the
abdomen absent
Size/Girth: 40 inches
37 inches
Bowel Sounds: Present ( Once in every 30 seconds)
Bladder palpable: No Distended: No distention
Others/Comments: Abdominal pains were felt after the surgery and even 2-3
hours after.

VI - FOOD/FLUID

Subjective
Usual diet (type): DAT
NPO PMN
Clear Liquid Diet
Number of meals daily: 3 meals a day which usually comprises of rice, fish or
chicken but not much of vegetables.
Last meal/intake: Lunch (12:00nn)(Apr. 19, 2009) Loss of appetite: None
Nausea/Vomiting: None Dentures: none
Allergy/Food intolerance: None
Heartburn/Indigestion: None
Mastication/swallowing problems: Difficulty masticating solid foods such as meat
d/t lack of teeth
Usual Weight: “65kg man tingali ko sa una” as verbalized.
Changes in weight: 6 kg
Diuretic use: None

Others/Comments:

“Isda, dili kayo ko gakaon anang gulay, Gana-gana ra. Dilli pud ko hing-
inom ug tubig. Mga 2-3 ra ka baso akong mainom sa isa ka adlaw” as
verbalized by the patient.

Objective
Current Weight: 59 kg upon admission Height: 5’0”
Body Build: Stout
Skin Turgor: Good Mucous membranes: Dry
Moist
Hernia/Mass: Palpable mass at right lower quadrant of the abdomen
Palpable mass at right lower quadrant of the abdomen
Palpable mass at right lower quadrant of the abdomen
Edema: General: None Dependent: None
Periorbital: None Ascites: None
Thyroid enlarged: Not enlarged Halitosis: Evident

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 Condition of teeth/gums: 1 tooth on upper jaw; 4 teeth on lower jaw; pinkish
gums
Appearance of tongue: Pinkish
Others/Comments: Mass at right hypogastric region was removed.

VII – HYGIENE

Subjective
Activities of Daily Living (Dependent/Independent)
Pls. encircle

Mobility: D/I Feeding: D/I

Hygiene: D/I Dressing: D/I
Toileting: D/I

Mobility: D/I Feeding: D/I

Hygiene: D/I Dressing: D/I
Toileting: D/I

Mobility: D/I Feeding: D/I

Hygiene: D/I Dressing: D/I
Toileting: D/I

Others: None
Equipment/prosthetic devices required: None
Assistance provided by: Husband if activity is too heavy for the patient brought
about by her condition.

Others/Comments:
“Gapatabang pa kog bakod bakod og adto sa CR,” as verbalized by the
patient.

Objective

General Appearance: Patient is a fair- skinned, stout woman with a black, short,
and wavy hair. Her teeth are losing. And her nails are long and her feet are
dusty.
Manner of dress: Appropriate for age Personal Habits: Takes a bath once a day
Body odor: Evident Condition of scalp: Dry
Presence of vermin: None
Others/Comments: Patient appears neat except for her untrimmed nails and
some flakes on her hair.
Horizontal incision in the hypogastric region of the abdomen with dressing and
abdominal binder noted. Redness of surrounding skin is also noted.

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 “Dako akong samad. Ginabutangan pa gain ni ug binder para dili ma-ukab and
tahi kay sakit man. Magsige na lang ko higda kay sakit musamot kung mulihok.
Tuloy-tuloy iyang pagsakit. Ngut-ngot nga dili masabtan.”as verbalized.

VIII – NEUROSENSORY

Subjective
Fainting Spells/dizziness: None
Headache: Location: None
Onset: Not applicable (N/A)
Frequency: N/A
Seizures: None Aura: N/A How controlled: N/A
Eyes: Vision Loss: R: None L: None
Last examination: Never been examined
Glaucoma None Cataract: None
Ears: Hearing Loss R: None L: None
Last examination: Never been examined
Sense of smell: No problem reported Epistaxis: None
Others/Comments: Patient’s overall neurosensory state is normal.

Objective
Mental Status
Oriented / Disoriented Time: (√) Place: (√) Person: (√)
(√) Alert ____ Drowsy ____ Lethargic
____ Stuporous ____ Comatose (√) Cooperative
____ Combative
Affect: Appropriate Delusions: None Hallucinations: None
Memory: Recent: Good
Remote: Good: Able to recall onset of signs and symptoms of
existing disease
Speech pattern: Spontaneous Congruence: Congruent
Glasses: None Contacts: None Hearing Aids: None
Pupil size/reaction: R: PERRLA – 2mm L: PERRLA – 2mm
Facial droop: None Swallowing: Good: No problems with swallowing
Handgrip/release: R: Strong L: Strong
Posturing: Erect DTR: Not assessed Paralysis: None
Others/Comments: Patient’s overall mental status is good.

IX – PAIN

Subjective
Onset: April 21, 2009 Duration: Continuous
April 22, 2009 Continuous

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Location: Epigastric region Intensity: Pain score of 4 with 10 as the highest
Hypogastric region Pain score of 6 with 10 as the highest
Pain score of 3 with 10 as the highest

Frequency: 5 minutes Quality: Regular

5 minutes Irregular
Description of Pain (check all that apply)
____Shooting ____Stabbing ____Gnawing
____ Sharp ____ Dull ____ Aching
____ Numb (√) (√)_ Throbbing ____ Radiating
_(√)_ Burning ____ Unbearable

Precipitating Factors: None

Aggravating Factors: Frequent movements
How relieved: Change in position
Associated Symptoms: None

Others/Comments: “ Sakit akong kuto-kuto, hapdos siya. Gi gutom na gyud

kaayo ko.” As verbalized by patient.
“Dili lagi ko lugos kalihok kay tungod sa kasakit sa samad. Magsige na lang man
ko ug higda. Musakit man ug samot pag maglihok-lihok ko” as verba;ized by the
patient.
“ Human pag opera kay sakit kaayo akong tahi. Mas musakit kung mag lihok ko
mao nga ga puyo lang ko, unya gaka-irita pud ko kung nay gasaba-saba.” As
verbalized by patient.

Epigastric pain was related to NPO status. It was no longer present after the
surgery.

Objective
(Check all that apply)
(√) _Grimacing _(√) Being Irritable
(√) _Moaning ____ Sitting Rigidly
____Sighing (√)(√) Moving very slowly
____Limping ____ Clenching Teeth
(√) Avoiding Physical Activity ____ Narrowed focus
(√)__Lying down during the day
____Requesting help with walking
____Walking with an abnormal gait
____Stopping frequently while walking
_(√) Frequently shifting posture or position
_(√) Moving in a guarded or protective manner
____Holding or supporting the painful body area
____ Asking to be relieved from tasks or activities
____ Asking such questions as “Why did this happen to me?”
____ Using a cane, cervical collar, or other prosthetic

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 Others/Comments: Patient is able to tolerate pain. Difficulty in turning to sides
noted.

X – RESPIRATION

Subjective
Dyspnea, related to: None
Cough/sputum: None
____ Bronchitis ____ Asthma ____ Tuberculosis
____ Emphysema ____ Recurrent Pneumonia
____ Exposure to noxious fumes
Smoker: No Pack/day: N/A Number of years: N/A
Use of respiratory aids: None Oxygen: None

Others/Comments: Patient has been experiencing second-hand smoke for four

years now. Her second child started smoking at the age of 17.

Objective
Respiratory: Rate: 19 cpm Depth: Deep: unlabored Symmetry: Symmetrical
Use of accessory muscle: None Nasal Flaring: None
Fremitus: Present Breath sounds: Bronchovesicular
Cyanosis: None Clubbing of fingers: None
Sputum characteristics: N/A
Mentation/restlessness: None
Others/Comments: Patients had no observable signs of respiratory problems.
Respiration rate and rhythm is within normal range.

XI – SAFETY

Subjective
Allergies/sensitivity: None
Reaction: N/A
History of STD (date/type): None
Blood transfusion/number: Never When: N/A
History of Accidental injuries: None
Fractures/dislocations: None
Arthritis/unstable joints: None
Back problems: Present
Changes in moles: None Enlarged nodes: None
Prosthesis: None Ambulatory devices: None
Expression of ideation of violence (self/others): Patient is non violent to herself
and others
Others/ comments: “Usahay kay gasakit akong bat-ang, labaw na anang gikan
kog panglimpyo,” as verbalized by the patient.

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 Objective:
Temperature: 36.8°C Diaphoresis: None
Skin integrity: Dry and intact
Dry but no longer intact due to surgical incision; abdominal binder
noted
Scars: None Rashes: None
Lacerations: None Ulcerations: None
Ecchymosis: None Blisters: None
Burns, degree/percent: None
Drainage (note location): None

General Strength: Patient is generally strong. She is able to do daily activities of

daily living.
Patient appears generally weak and has complains of pain.
Patient has regained some of her strength.

Muscle tone: Good

Gait: Normal Paresthesia/Paralysis: None
Others/Comments:

XII – SEXUALITY

Sexually active: Not much

Sexual concerns/difficulties: None
Recent change in frequency/interest: Still interested but seldom does it

Subjective
Age of menarche: 13y.o.
Length of cycle: 26 – 30 days interval Duration: 3 days
Last menstrual period: Mar. 10, 2009
Menopause: Early menopausal due to TAH-USO, April 22, 2009
Vaginal discharge: None
Bleeding between periods: None
Deliveries/Pregnancies: G 3 P 3 T 3 P 0 A 0 L 3
Episiotomy: None Lochia: None
Complications of pregnancy: None
Surgeries: For TAH-USO on April 22, 2009
Post TAH-USO on April 22, 2009

Hormonal therapy/calcium use: Used contraceptive pills for 13 years after 2nd
child
Practices self-breast examination: Yes Discharges: None
Last Pap smear: 2007 Method of birth control: Artificial method: pills,
and calendar method

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 Others/Comments: When menstruating patient consumes 4-5 sanitary pads per
day.
“Dili man daghan ang gagawas kung dug-on ko sa una, dili naman gain ko
ganapkin ato. Katong naa na gitubo kay ganapkin nako. Kusog2x naman ang
dugo. Ika upat o ika lima ko makapuli ug napkin sa isa ka adlaw.” As verbalized
by patient

Objective
Breast Examination: No palpable mass, non-tender
Vaginal warts/lesions: None
Others/Comments: No discharges from the breast were noted.

XIII - SOCIAL INTERACTIONS

Subjective
Marital status: Married Years in relationship: 24 years
Living with: Husband and 3 sons, parents, and an adopted son
Concerns/stresses: Second child’s behavior and financial concerns
Extended family: Yes
Other Support Persons: None
Role within family structure: Co-bread winner
Report of problems related to illness/condition: Inability to work and earn money
for their needs
Others/Comments:
“Katong akong ikaduha ra jud og kwarta hilabi na karon nga nahospital ko.
Dili ko makapamaligya,” as verbalized by the patient.

Objective
Speech: (√) Clear ____Slurred
____Unintelligible ____ Aphasic
Others/Comments: Patient remained calm and attentive throughout the interview.

XIV - TEACHING/LEARNING

Subjective
Dominant Language (specify): Cebuano Literate: (√)
Educational Level: High school graduate
Health beliefs/practices: Patient believes in hilot, panuhot,and bughat as well as
the use of herbal medicines.

Familial risk factors (check all that apply & indicate relationship):
__ Diabetes ______
____Tuberculosis _______
____ Heart Disease _______
Stroke _______
__ High BP _______

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 ____ Epilepsy _______
____ Kidney Disease _______
Cancer _______
____ Mental Illness _______

Use of Alcohol (amount/frequency): No

Others/Comments: Patient’s sister was also diagnosed of uterine myoma.

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

Dry scalp with some flakes

Epigastric
pain 4/10 Palpable mass
X
Hypoactive Suture line with dressing
bowel sounds xx and binder hypogastric
Catheter pain 6/10
Attached to X 4/10
urobag x IV line: D5LR 1000cc
(4/22 – 4/23) regulated @ 30 gtts/min

Dirty Nails

Scar
General weakness

Dusty Feet

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B. Laboratory/Diagnostic Results:

Ultrasound 03/06/09

Sonography Report:
The uterus is enlarged in size measuring 11cm x 9 cm. There is an isoechoic
mass at the anterior myometrium 9.7cm x 7.5 cm. Both adnexa are unremarkable. No
fluid in the posterior culdesac.

Impression:
Myoma uteri, intramural, anterior

Interpretation: to consider uterine myoma

Hematology 04/14/09
Complete Blood Count:

Hematocrit: 40 F 37-47 vol. %

Hemoglobin: 13.3 F 12-16 gms%
WBC: 5,700 5000- 10,000/cumm
Differential count:
Segmenters: 56 55-75%
Lymphocytes: 34 20-35%
Eosinophils: 7 1-3%
Stabs: 5/100% 0-9%
Platelet count: 170,000 150,000-350,000/cumm

Bleeding Time: 2’15” 1-3 mins

Clotting time: 3’30” 2-6 mins.

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

ECG 4/14/09
WNL

Chest PA 4/14/09
Radiological Findings:
The heart is normal in size. The lungfields are clear. Hemi diaphragms and sulci
are intact. The thoracic aorta is atheromatous.
Impression:
Atheromathous Thoracic Aorta

Interpretation: possible presence of fats in the thoracic aorta

17
III. ANATOMY AND PHYSIOLOGY
Anatomy of Female reproductive system

The internal reproductive organs

1) Vagina – a 3-4 inch long dilatable canal located between the bladder and the

rectum;contains rugea (which permit considerable stretching without

tearing);organ of copulation; passageway of menstrual discharges and fetus.

2) Uterus – hollow pear-shaped fibromuscular organ 3 inches long, 2 inches

wide,1 inch thick and weighing 50-60 grams in non –pregnant woman.

- held in place by broad ligaments (from sides of the uterus to pelvic

walls;also hold fallopian tubes and ovaries in place) and round ligaments )

from sides of the uterus to mons pubis)

- abundant blood supply from uterine and ovarian arteries.

- Composed of 3 muscle layers :perimetrium,myometrium,endometrium.

- Consist of 3 parts: corpus(body) – upper portion with triangular part

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

18
 of the lower uterine segment ; cervix- lower cylindrical portion.

- Organ of menstruation;site of implantation; retainment and nourishment of

the products of conception.

3) Fallopian tubes- 4 inch long from each side of the fundus; widest part called

ampulla spread into finger like projections called fimbriae.

-responsible for transport of mature ovum from ovary to uterus; fertilization takes

place in its outer third or outer half.

4) Ovaries- almond-shaped,dull white sex glands near the fimbriae ,kept in place by

ligaments. Produce mature and expel ova and manufacture estrogen and

progesterone.

Hormones

1) estrogen

• inhibits production of follicle stimulating hormone.

• Causes hypertrophy of the myocardium.

• Stimulates growth of the ductile structure of the breast.

• Increases quantity and pH of cervical mucus,causing it to become thin

and watery and can be stretched to a distance of 10-13 cm.

2) progesterone

• Inhibits production of leutenizing hormone.

• Increases endometrial tortuosity.

• Increases endometrial secretions.

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 • Inhibits uterine motility.

• Decreases muscle tone of gastrointestinal and urinary tracts.

• Increases musculoskeletal motility.

• Facilitates transport of the fertilized ovum through the fallopian tubes .

• Decreases renal threshold of lactose and dextrose.

• Increases fibrinogen levels;decreases hemoglobin and hemtocrit.

• Increase body temperature after ovulation.

The phases of menstrual cycle

1) First phase(proliferative)-immediately after the menstrual flow(which occurs

during the first 4-5 days of a cycle),the endometrium ,or lining of the uterus,is very

thin,approximately one cell layer in depth. as ovary begins to produce estrogen(in

the follicular fluid,under the direction of the pituitary FSH),the endometrium begins to

proliferate. this growth is very rapid and increases the thickness of the endometrium

approximately eightfold. this increase continues for the first half of the menstrual

cycle (from approximately day 5 to day 14).this half of a menstrual cycle is term

interchangeably the proliferative, estrogenic ,follicular,or postmenstrual phase.

2) Second phase(secretory)-after ovulation,the formation of progesterone in the

corpus luteum (under the direction of LH) causes the glands of the uterine

endometrium to become corkscrew or twisted in appearance and dilated with

quantities of glycogen (an elementary sugar) and mucin (a protein).the capillaries of

20
 the endometrium increases in amount until the lining takes in the appearance of

rich,spongy velvet. This second phase of menstrual cycle is termed the

progestational , luteal,premenstrual,or secretory phase.

3) Third phase (ischemic)-if fertilization does not occur,the corpus luteum in the

ovary begins to regress after 8-10 days. as it regresses,the production of estrogen

and progesterone decreases. with the withdrawal of progesterone stimulation ,the

endometrium of the uterus begins to degenerate (at approximately 24 or 25 day

cycle).the capillaries rupture,with minute hemorrhages,and the endometrium sloughs

off.

4) Final phase (menses)- the following products are discharges from the uterus as

menstrual flow or menses:

a. blood from the ruptured capillaries.

b. mucin from the glands.

c. fragments of endometrial tissue.

d. the microscopic,atrophied, and unfertilized ovum.

-menses is actually the end of an arbitrarily defined menstrual cycle. because

it is the only external marker of the cycle,however,the first day of menstrual flow is

used to mark the beginning day of a new menstrual cycle.

- contrary to the common belief ,a menstrual flow contains only approximately

30-80 ml of blood; if it seems like more,it is because of accompanying mucus and

endometrial shreds .the iron loss in a typical menstrual flow is approximately 11mg ,this

21
is enough loss that many women need to take a daily iron supplement to prevent iron

depletion during their menstruating years.

- in women who are going through menopause ,menses may typically consist

of a few days of spotting before a heavy flow, or a heavy flow followed by a few days of

spotting,because progesterone withdrawal is more sluggish or tends to “staircase”

rather than withdraw smoothly.

22
IV. NARRATIVE PATHOPHYSIOLOGY

Leimyomas are the most common benign tumors of the female genital tract. The
mass is mostly composed of muscles and fibrous connective tissue. It is hypothesized
that its growth is related to estrogen stimulation. The incidence is higher on women
during the reproductive years where estrogens and other hormones are actively
produced by the body. Many women opt to use oral contraceptives as a birth control
method. Oral contraceptives promote estrogen dominance and eventually influence the
growth of the cells in the uterus. High-fat diet is also considered a source of estrogen
where as diets rich in fiber and low in fat decreases estrogen reabsorption. Leimyoma
formation is also possible because of hyperestrogenism due to progesterone deficiency
that is caused by luteal insufficiency. Apart from estrogen stimulation, heredity is a
factor in the occurrence of leimyomas. Fibroids formation is 4.2 times more common in
first-degree relatives than with fibroids without genetic influence.

Estrogen is vital in the regulation the menstrual cycle. Presence of this hormone
during the first phase influences the proliferation of smooth muscle cells in the uterine
walls. Overstimulation increases the size of the uterine lining and further develops into a
fibroid. During menstruation, the excessively thickened endometrium does not
desquamate (shed its lining) easily (or even completely) at the end of the cycle,
resulting in prolonged and/or excessive menstrual bleedings. Following the
degeneration of the interior part of the fibroid, are the degenerative changes that
eventually replace smooth muscle cells by fibrous connective tissue. The fibroid
continually grows and its size puts pressure on the adjacent organs, the bladder and
rectosigmoid. Urinary frequency and constipation, respectively, are the results of the
compression of these organs.

23
 V. SCHEMATIC PATHOPHYSIOLOGY
Uterine myomas also called “fibroids” are tumors that grow from the wall of the
uterus.

Predisposing Factors
Precipitating Factor
• Age- 42 y.o.
• Luteal
• Gender Insufficiency

• Family History- sister • High fat diet

• Use of OCP- 13 years

Increased hormonal production of estrogen

Proliferation of smooth muscle

Overgrowth of uterine
lining

Development of uterine Increased blood

flow volume
(before: does not
use sanitary pads;
upon palpation of
Degeneration of interior part of the mass: 4-5 sanitary
pads/day during
menstruation)

Hyaline Red or carneous

Degeneration

Smooth muscle cells are replaced

by fibrous connective tissue

24
 Increased
Continued growth of abdominal
fibroid girth
(40 inches
preop)
Endometrial
Palpable mass
distention
at right
hypogastric
region.
(UTZ showed
enlarged uterus Recto sigmoid
and isoehoic Pressure on
pressure
mass at bladder
anterior uterus)

Constipation
( Once every 3-4 days,
Urinary frequency and minimal amount of
urgency hard formed stool,
(preop: 10-15 times/ decreased bowel
day) sounds- 1 in every 30
seconds)

Legend:

Manifestations

Signs and Symptoms

25
VI. MEDICAL MANAGEMENT

A. Ideal Management:

Uterine Myoma

There's no single best approach to uterine myoma or fibroid treatment. Many

treatment options exist. In most cases, the best action to take after discovering fibroids

is simply to be aware they are there. Because fibroids aren't cancerous and usually

grow slowly, patients have time to gather information before making a decision about if

and how to proceed with treatment. The option that's right for a patient depends on a

number of factors, including the severity of the signs and symptoms, the plans for

childbearing, how close one is to menopause, and ones feelings about surgery.

Watchful waiting- If patient has no signs or symptoms, watchful waiting

(expectant management) could be the best course. Fibroids aren't cancerous. They

rarely interfere with pregnancy. They usually grow slowly and tend to shrink after

menopause when levels of reproductive hormones drop. This is the best treatment

option for a large majority of women with uterine fibroids.

Medications- Medications for uterine fibroids target hormones that regulate

menstrual cycle, treating symptoms such as heavy menstrual bleeding and pelvic

pressure. They don't eliminate fibroids, but may shrink them. Medications include:

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

menstrual cycle, a control center in the brain called the hypothalamus

manufactures gonadotropin-releasing hormone (Gn-RH). The substance

travels to the pituitary gland, a tiny gland also located at the base of the brain,

26
 and sets in motion events that stimulate the ovaries to produce estrogen and

progesterone.

Medications called Gn-RH agonists (Lupron, Synarel, others) act at the same

sites that Gn-RH does. But when taken as therapy, a Gn-RH agonist

produces the opposite effect to that of the natural hormone. Estrogen and

progesterone levels fall, menstruation stops, fibroids shrink and anemia often

improves.

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

produce androgens, the so-called male hormones. Given as medical therapy,

androgens can relieve fibroid symptoms.

Danazol, a synthetic drug similar to testosterone, has been shown to shrink

fibroid tumors, reduce uterine size, stop menstruation and correct anemia.

However, occasional unpleasant side effects such as weight gain, dysphoria

(feeling depressed, anxious or uneasy), acne, headaches, unwanted hair

growth and a deeper voice, make many women reluctant to take this drug.

• Other medications. Oral contraceptives or progestins can help control

menstrual bleeding, but they don't reduce fibroid size. Nonsteroidal anti-

inflammatory drugs (NSAIDs), which are not hormonal medications, are

effective for heavy vaginal bleeding unrelated to fibroids, but they don't

reduce bleeding caused by fibroids.

Hysterectomy- This operation — the removal of the uterus — remains the only

proven permanent solution for uterine fibroids. But hysterectomy is major surgery. It

ends ones ability to bear children, and if a patient elects to have her ovaries removed

27
also, it brings on menopause and the question of whether she'll take hormone

replacement therapy.

Myomectomy- In this surgical procedure, the surgeon removes the fibroids,

leaving the uterus in place. If one wants to bear children, she might choose this option.

With myomectomy, as opposed to a hysterectomy, there is a risk of fibroid recurrence.

There are several ways a myomectomy can be done:

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

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

remove the fibroids.

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

the patient and the doctor may opt for a laparoscopic procedure, which uses

slender instruments inserted through small incisions in your abdomen to

remove the fibroids from your uterus. The doctor views the abdominal area on

a remote monitor via a small camera attached to one of the instruments.

• Hysteroscopic myomectomy. This procedure may be an option if the

fibroids are contained inside the uterus (submucosal). A long, slender scope

(hysteroscope) is passed through the vagina and cervix and into the uterus.

The doctor can see and remove the fibroids through the scope. This

procedure is best performed by a doctor experienced in this technique.

Variations of myomectomy — in which uterine fibroids are destroyed without actually

removing them — include:

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

fibroids and shrinks the blood vessels that feed them.

28
 • Cryomyolysis. In a procedure similar to myolysis, cryomyolysis uses

liquid nitrogen to freeze the fibroids.

The safety, effectiveness and associated risk of fibroid recurrence of myolysis

and cryomyolysis have yet to be determined.

• Endometrial ablation. This treatment, performed with a hysteroscope,

uses heat to destroy the lining of the uterus, either ending menstruation or

reducing menstrual flow. Endometrial ablation is effective in stopping

abnormal bleeding, but doesn't affect fibroids outside the interior lining of the

uterus.

Uterine artery embolization- Small particles injected into the arteries supplying

the uterus cut off blood flow to fibroids, causing them to shrink. This technique is

proving effective in shrinking fibroids and relieving the symptoms they can cause.

Advantages over surgery include:

• No incision

• Shorter recovery time

Complications may occur if the blood supply to the ovaries or other organs is

compromised.

Focused ultrasound surgery- MRI-guided focused ultrasound surgery (FUS),

approved by the Food and Drug Administration in October 2004, is a newer treatment

option for women with fibroids. Unlike other fibroid treatment options, FUS is

noninvasive and preserves the uterus. This procedure is performed while one is inside

of a specially crafted MRI scanner that allows doctors to visualize ones anatomy, and

then locate and destroy (ablate) fibroids inside the uterus without making an incision.

29
Focused high-frequency, high-energy sound waves are used to target and destroy the

fibroids. A single treatment session is done in an on- and off-again fashion, sometimes

spanning several hours. Initial results with this technology are promising, but its long-

term effectiveness is not yet known.

It is recommended that before making a decision, women must consider the pros

and cons of all available treatment options in relation to their particular situation.

Remember most women don't need any treatment for uterine fibroids.

B. Actual Management

In our patient’s case, she was scheduled and has undergone Total Abdominal

Hysterecomy-Unilateral Salphingo Oophorectomy (TAH-USO) which includes the

removal of the uterus and an ovary. This procedure lets our patient have an early

menopausal and ends her ability to bear a child. She was not given any medications

that may prevent the reoccurrence of fibroids; Instead, she was given medications that

could prevent possible infections due to her surgery (such as antibiotics), could relieve

pain from surgery and could improve her body’s immunity and functioning (such as

multivitamins and ferrous sulfate).

30
31
 Name of Patient: ______________Patient X _________________________ Age: 42
Diagnosis/Impression: ________Uterine myoma _________________________ Attending Physician: __Dr. Borromeo________

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

Ampicillin 04/19/0 antiinfective 500 mg Bacteria resist • Skin • Sensitivity • Anaphylaxis • Give on an empty
9 1 tab qid penicillins by structure to • Drug fever stomach, at least
producing infections penicillins • Rash 1h before or 2h
penicillinases – • Staphyloc • Overgrowth of after meal.
enzymes that convert occal non- • Take medication
penicillins to inactive infections susceptible around the clock,
penicillin acid. organisms do not miss one
Cloxacillin resist dose, and continue
these enzymes. taking medication
until it is finished.
• Instruct patient to
take each dose with
a full glass of water
and not with fruit
juice or carbonated
beverage because
their acid will
inactivate drug.

32
 Name of Patient: ______________Patient X _________________________ Age: 42
Diagnosis/Impression: ________Uterine myoma _________________________ Attending Physician: __Dr. Borromeo________

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

Metronidazol 04/19/0 Antibacterial 500 mg It enters the cell of • Prophylaxis • Liver • Hypersensiti • Give oral form with
e 9 1 tab tid microorganisms that in elective disease vity meals to minimize
contain hysterectom • Alcoholism • Irritability GI upset.
nitroreductase y or vaginal • Blood • Drowsiness • Instruct patient in
unstable compounds repair dyscrasias • Dyspareunia proper hygiene.
are then formed that • Active • Dryness of • Tell patient that
bind to DNA and CNS vagina and metallic taste and
inhibit synthesis, disease vulva dark or red-brown
causing cell death colored urine may
occur.
• Tell patient to
avoid alcohol or
alcohol-containing
drugs during
therapy and for at
least 3 days after
therapy is
completed.

33
 Name of Patient: ______________Patient X _________________________ Age: 42
Diagnosis/Impression: ________Uterine myoma _________________________ Attending Physician: __Dr. Borromeo________

DRUG STUDY
Name of Patient: ______________Patient X _________________________ Age: 42
Name of Drug Date Classification Dose/ Mechanism of Specific Contraindicati Side Effects/ Nursing Precautions
(Generic & ordered of Drug Frequen Action Indication on Toxic Effects
Brand) cy

Diclofenac Na 04/24/0 NSAIDs 250 mg Potent inhibitor of • Post- • Hypersens • Prolonged • Do not crush,
9 1 tab tid cyclooxygenase, operative itivity to bleeding time chew, or break an
thereby decreasing inflammation diclofenac • Inhibit extended-release
the synthesis of • Mild to • Urticaria platelet tablet. Swallow the
prostaglandins moderate • Angioede aggregation pill whole.
pain ma • Skin itching • Do not drink
• Bronchosp or rash alcohol while
asm • Dizziness taking diclofenac.
• Other Alcohol can
• Headache increase the risk of
sensitivity
• Stomach stomach bleeding
reaction
upset caused by
precipitate
by aspirin • Flatulence diclofenac.
or other • Avoid prolonged
NSAIDs exposure to
• bleeding sunlight.
or blood Diclofenac may
clotting increase the
disorder sensitivity of the
skin to sunlight.
• Instruct patient to
use a sunscreen
and wear
protective clothing
when exposure to
the sun is
unavoidable.

34
 Diagnosis/Impression: ________Uterine myoma _________________________ Attending Physician: __Dr. Borromeo________

DRUG STUDY

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

Multivitamins 04/24/0 supplement 1 tab Treat vitamin • Vitamin • If patient • Stomach • Take your
9 OD deficiencies (lack of deficiences takes upset multivitamin with a
vitamins) caused by more than • Headache full glass of water.
illness, pregnancy, the • Unusual or • Never take more
poor nutrition, prescribed unpleasant than the
digestive disorders, dose taste recommended
and many other dose of a
conditions. multivitamin. Avoid
taking more than
one multivitamin
product at the
same time unless
your doctor tells
you to.

Name of Patient: ______________Patient X _________________________ Age: 42

35
 Diagnosis/Impression: ________Uterine myoma _________________________ Attending Physician: __Dr. Borromeo________

DRUG STUDY

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

Ferrous 04/24/0 Iron 1 tab Corrects • May be used • Peptic • Nausea • Give on empty
Sulfate + folic 9 preparation OD erythropietic prophylactic ulcer • Heartburn stomach if
acid abnormalities ally during • Hemolytic • Diarrhea possible because
induced by iron periods of anemia • Constipation oral iron
deficiency but does increased • Regional • Black stool preparations are
not stimulate iron needs enteritis best absorbed
• Yellow brown
erythropoiesis. Folic • Iron • Ulcerative then.
discoloration
acid helps your body deficiency colitis • Do not crush tablet
of eyes and
produce and anemia or empty contents
teeth
maintain new cells, of capsule.
and also helps • Lethargy
• Drowsiness • Do not give tablets
prevent changes to within 1h of
DNA that may lead bedtime.
to cancer. • Avoid taking
antacids or
antibiotics within 2
hours before or
after taking ferrous
sulfate.
• Do not use
discolored tablets.

36
 Name of Patient: ______________Patient X _________________________ Age: 42
Diagnosis/Impression: ________Uterine myoma _________________________ Attending Physician: __Dr. Borromeo________

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

Ranitidine 04/19/0 Anti-ulcer 1 tab q8 Inhibits action of • Upper GI • Hypersen • Vertigo • Assess patient for
9 Drugs hours histamine on the H2 bleeding sitivity to • Malaise abdominal pain.
(H2 PO receptor sites of drug • Dizziness Note presence of
Antagonist) parietal cells • Diminishe • Headache blood in emesis,
decreasing gastric d renal • Mild transient stool, or gastric
acid secretions function diarrhea aspirate.
• Muscle pain • Instruct patient to
• Blurred vision take the drug
without regard to
meals because
absorption is not
affected by food.

37
 Name of Patient: ______________Patient X _________________________ Age: 42
Diagnosis/Impression: ________Uterine myoma _________________________ Attending Physician: __Dr. Borromeo________

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

Tramadol 04/18/0 Narcotic and 75 mg It is thought to bind to • Moderate • Hypersen • Dizziness • Monitor CV and
9 Opioid IVTT q 6 opioid receptors and pain sitivity to • Headache respiratory status.
analgesics hours inhibit reuptake of drug • Nausea Withhold dose and
norephinephrine and • Kidney • Constipation notify physician if
serotonin. disease • Vomiting respirations
• Liver • Dry mouth decrease or rate is
disease below 12 cpm.
• Diarrhea
• History of • Monitor bowel and
alcohol or bladder function.
drug Anticipate need for
dependen laxative.
ce .

38
 Name of Patient: ______________Patient X _________________________ Age: 42
Diagnosis/Impression: ________Uterine myoma _________________________ Attending Physician: __Dr. Borromeo________

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

Amoxicillin 04/19/0 antiinfective 500 mg Bacteria resist • Skin • Sensitivity • Anaphylaxis • Give on an empty
9 1 tab qid penicillins by structure to • Drug fever stomach, at least
producing infections penicillins • Rash 1h before or 2h
penicillinases – • Staphyloc • Overgrowth of after meal.
enzymes that convert occal non- • Take medication
penicillins to inactive infections susceptible around the clock,
penicillin acid. organisms do not miss one
Cloxacillin resist dose, and continue
these enzymes. taking medication
until it is finished.
• Instruct patient to
take each dose with
a full glass of water
and not with fruit
juice or carbonated
beverage because
their acid will
inactivate drug.

39
 PREOPERATIVE NCPS
Name of Patient: Patient X Age: 42
Diagnosis: Uterine Myoma Physician: Dr Borromeo

NURSING CARE PLAN NO. 1

CUES NURSING OBJECTIVE INTERVENTION RATIONALE EVALUATION

DIAGNOSIS
Subjective: Impaired Urinary Short term: Independent Short Term:
“Gasige ko ug Elimination related At the end of 2 1) Encourage - to help maintain At the end of 2
ihi-ihi, ika-kinse o to anatomical hours of nursing gradual increase in renal function and hours nursing
ika-bente sa isa compression of intervention, fluid intake of 8-10 prevent intervention,
k adlaw, adtong the urinary bladder patient will be glasses per day dehydration. objectives were
wala pa ko na able to: from her usual 2-3 fully met. Patient
admit. Paadmit a) verbalize glasses. was able to
nako kay ik kinse understanding of verbalize
o ika napulo na her condition and 2) Restrict fluid - to reduce voiding understanding of
lag sa isa ka the need undergo intake 2-3 hours during the night. uterine myoma
adlaw.”, as surgical removal before bedtime. and the surgery it
verbalized by the of the uterus and required. Patient
patient. ovary 3) Measure and - accurate intake also willingly
record patient’s and output participated and
b) participate and intake and output. measurements are demonstrated use
Objective: demonstrate Document urine essential for of water and mild
-urinary measures such color and correct fluid soap in perineal
frequency= 15- as proper characteristics replacement care. Wiping of
20x per day at perineal hygiene therapy perineal area after
about 200cc per to prevent any urination from
voiding further 4) Assist in - to provide the front to back was
-sonography complications developing toileting patient ease in also demonstrated
report: such as routines as coping with the correctly.
The uterus is infections and appropriate and condition

40
enlarged in size other urinary provide necessary
measuring 11cm problems. equipment such as
x 9 cm. There is bedpans. Long Term:
an isoechoic At the end of 3
mass at the Long Term: 5) Give appropriate -accurate days of nursing
anterior At the end of 3 preoperative and information allows intervention,
myometrium days of nursing postoperative patient to objectives were
9.7cm x 7.5 cm. intervention, instruction and understand the partially met.
patient will be care. Stress the procedure and the Patient was able
able to: pros and cons of benefits of to verbalize
a) verbalize total abdominal undergoing such. increased comfort
increased hysterectomy and with her an
comfort and unilateral salpingo elimination pattern
achieve her oophorectomy of
elimination (amount?,
pattern before of frequency?). Fluid
5-6x per day in 6) Instruct on balance?
moderate amount proper and - cleanliness No further
frequent perineal prevents bacterial complications
b)maintain fluid hygiene. growth and noted.
balance, intake promotes comfort.
equals output
7) Discuss possible -this food are
c) have no further dietary restrictions known as bladder
complications ( coffee, irritant and can
due to condition chocolate, increase the
carbonated drinks, number of urinary
citrus, tomatoes) elimination

41
 Name of Patient: Patient X Age: 42
Diagnosis: Uterine Myoma Physician: Dr Borromeo

NURSING CARE PLAN NO. 2

Cues Nursing Objectives Intervention Rationale Evaluation

Diagnosis
Subjective Constipation Short term: Independent Short Term:
“Dili na regular related to At the end of 4 hours 1) Determine -To evaluate At the end of 4
ako paglibang. anatomical nursing intervention, patients fluid clients hydration hours,
Sukad tong obstruction of patient will be able to : intake status. objectives were
niaging bulan the rectum and a) verbalize fully met. The
kay mga tag- inadequate understanding of 2) Note color, -Provides a patient was able
tulo o upat ka intake of fluids etiology and odor. consistency, baseline for to verbalize her
adlaw ko ayha and bulk appropriate amount, and comparison, understanding
malibang. interventions for frequency of stool promotes of the etiology
Ginagmay nga individual situation. recognition of and appropriate
gahi akong b) verbalize the need 3) Instruct on a changes. interventions;
tahi. Usahay to participate in a diet of balanced participate in
galisod pud ko bowel program as fiber and bulk and -To improve bowel program
ug libang.” indicated. fiber consistency of as and
c) verbalize the need supplements. stool and facilitate verbalized the
“Dili man ko to increase passage through relation of her
gakaon kaayo consumption of high 4) Promote colon. diet to her
ug gulay. fiber foods such as adequate fluid constipation.
Gana-gana ra. fruits and vegetables intake, including -To promote She also
Dilli pud ko and the need to high-fiber fruit passage of soft verbalized the
hing-inom ug increase intake of juices; suggest stool significance of
tubig. Mga 2-3 fluids to 8-10 glasses drinking warm increasing
ra ka baso per day. stimulating fluids. consumption of
akong mainom high-fiber foods

42
sa isa ka Long term: 5) Encourage such as fruits
adlaw.” After 4 days of activity/exercise and vegetables
nursing intervention, within limits of and increasing
the patient will: individual’s ability. -To stimulate intake of fluids
Objective: a) regain normal contractions of to 8-10 glasses.
-bowel sounds pattern of bowel Dependent: intestines.
hypoactive= 1 functioning which was 6) Administer Long Term
in every defecation of soft Bisacodyl 1 adult After 4 days of
30seconds formed stool in suppository stat -To help in intervention, the
moderate amount softening stool to objectives were
-straining with each day. facilitate partially met.
defacation b) demonstrate and elimination. She was
incorporate the observed to
-hard dry and changes in intake of effectively follow
formed stool in high fiber foods and the advised
minimal increase in fluids dietary regimen
amount noted effectively in daily including an
upon living. increase in both
defecation fiber and fluids.
Her normal
pattern of bowel
functioning was
not regained.

43
Name of Patient: Patient X Age: 42
Diagnosis: Uterine Myoma Physician: Dr Borromeo

NURSING CARE PLAN NO. 3

44
Cues Diagnosis Objectives Intervention Rationale Evaluation
Subjective: Sleep pattern Short term: Independent: Independent: Short term:
“Sige man disturbance related At the end of 20 1. Minimize the 1. To provide At the end of 20
gud og mata- to frequency of minutes of nursing environmental noise an environment minutes of
mata kung urine as manifested intervention, patient by closing the door conducive for nursing
gabii kay by reduced number will be able to properly always and sleeping. intervention,
mangihi of hours of sleep. identify methods on maintain comfortable objectives were
ko,”as how to improve temperature and fully met. The
verbalized by quality of sleep. proper ventilation as patient was able
the patient. much as possible. to verbalize ways
“Dili pud ko Long term: 2. Assist in wearing to increase
kabawi ug At the end of 16 comfortable clothes 2. To provide quality of sleep
tulog kay hours of nursing and washing her face comfort and and to limit fluids
trabaho man intervention, patient 3. Assist patient in freshness during bedtime
nako sa will be able to performing bedtime to decrease
hapon. increase in the rituals and provide 3. To urinary
Daghan ko number of hours of sleeping aids such as promote frequency.
ginabuhaton sleep and feeling pillows. relaxation.
ba. ” rested on Long term:
awakening. 4. Provide comfort At the end of 16
“Bulog measures by doing hours of nursing
usahay akong back rub and placing intervention,
ulo pagmata patient flat on bed 4. To patient was be
kay kulang with head elevated by promote rest able to improve
tulog,” as a pillow. and relaxation. sleep pattern as
verbalized by evidenced by
the patient. 5. Organize nursing increase in the
care. number of hours
of sleep and
Objective: feeling rested on
-urinary 5. To awakening.
frequency=15 6. Limit fluids promote
-20x per day before bedtime. minimal
-Decreased interruption in
number of sleep/rest.
hours of sleep
= 4-5 hours 6. To reduce
- need for
voiding during
the night.
45
 POSTOPERATIVE NCPS
Name of Patient: Patient X Age: 42
Diagnosis: Uterine Myoma Physician: Dr Borromeo

NURSING CARE PLAN NO. 1

CUES NURSING OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

DIAGNOSIS

Subjective: Acute pain Short Term: Independent: Short Term:

“Dako akong related to surgical After 4 hours of 1) Perform comfort -these measures Objectives were
samad. incision in the nursing intervention, measures such as reduce muscle fully met. Patient
Ginabutangan abdomen the patient will: massage, bathing tension or spasm; verbalized a pain
pa gain ni ug a) verbalize a and repositioning. redistribute scale of 4,
binder para pain scale of pressure on body increased relief
dili ma-ukab 4-5 and parts and help and comfort.
and tahi kay increased patient focus on Patient also
sakit man. comfort non-pain related demonstrated
Magsige na b) verbalize and 2) Help patient into subjects breathing
lang ko higda demonstrate a comfortable techniques
kay sakit non- position and use -to reduce tension splinting to
musamot pharmacologi pillows to splint or and thus reduce minimize pain.
kung mulihok. c methods to support the incision pain She also
Tuloy-tuloy manage pain area participated in
iyang such as deep conversations

46
pagsakit. breathing 3) Manipulate the done to distract
Ngut-ngot and splinting environment to her from pain.
nga dili during cough provide - this promotes
masabtan.” c) participate in uninterrupted rest health, well-being
the use of and increased Long Term:
diversional 4) Provide energy level At the end of 2
activities diversional important to pain days of
Objective: such as activities such as relief. intervention,
-verbalized a engaging in such as objectives were
pain scale of conversation encouraging visits -to help patient fully met. The
6, in a scale s to minimize of family members focus on non-pain patient verbalized
of 1-10 with pain and engaging in related matters a pain scale of 2
10 as the conversations and increased
most painful comfort.
-sighing and 5) Encourage use Whenever mild
moaning Long Term: of relaxation pain occurred,
noted After 4 days of techniques such as - to distract patient was
-slowed intervention, the focused breathing attention and observed to do
movement patient will: and imaging. reduce tension deep breathing on
-guarding a) verbalize a her own.
behavior pain scale of Dependent
-positioning to 0-2 1) Administer D5LR
avoid pain b) readily 1 liter with
integrate Tramadol 50mg at
non- 30gtts/min -to effectively
pharmacologi reduce or eradicate
c methods in pain
daily
activities
whenever
pain occurs

47
Name of Patient: Patient X Age: 42
Diagnosis: Uterine Myoma Physician: Dr Borromeo

NURSING CARE PLAN NO. 2

CUES NURSING OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

DIAGNOSIS

48
Subjective: Impaired skin Short Term: Independent Short Term:
“Dako akong integrity related to At the end of 1 1) Inspect skin on a - To monitor At the end of 1
samad. surgical incision in hour of nursing daily basis, progress of hour of nursing
Ginabutangan the hypogastric intervention, the describing wound wound healing. intervention,
pa gain ni ug region of the patient will: characteristics and objectives were
binder para dili abdomen a) verbalize and changes observed. fully met. Patient
ma-ukab and demonstrate demonstrated
tahi kay sakit appropriate 2) Instruct the - To assist body’s wound dressing
man.” wound dressing patient and natural process appropriately.
procedure significant others to of repair. Patient also
b) demonstrate keep the area clean demonstrated the
Objective: the use splinting and dry. use of pillow as
-horizontal and support to splint or support
incision in the protect the wound 3) Teach patient of - this involves the during cough.
hypogastric c) verbalize the proper wound patient in her Patient also
region of the need to increase dressing techniques care and verbalized the
abdomen with intake of protein promotes need to increase
dressing and and empowerment protein and
abdominal carbohydrates for over her carbohydrate
binder noted faster wound condition. This intake such as
-redness of healing. also prevents foods as meat,
surrounding skin infection. fish, beans and
noted 4) Instruct patient to -To provide bread.
Long Term: apply splint using a support over the
At the end of 4 pillow when patient incision area. Long Term:
days of nursing coughs or moves. At the end of 4
intervention, the days of nursing
patient will: 5) Position patient -these measures intervention, the
a) display timely for comfort and promote objectives were
healing of wound minimal pressure on circulation, fully met. No signs
without any signs bony prominences. reduce pressure of further infection
of infection such Turn to sides at least and avoid skin were noted. No
as erythema, every 2 hours. breakdown signs of erythema

49
 hyperthermia and and pus formation
pus formation. were noted.

6) Encourage early -Promotes

ambulation or circulation And
mobilization. reduces risks
associated with
immobility such
as thrombus
formation and
skin ulcers.
7) Provide optimum -To aid in wound
nutrition, and healing.
increased protein
and carbohydrate
intake such as meat,
fish and bread.
DEPENDENT:
1. Administer
Cloxacillin 500mg 1 -to aid in faster
tab QID, Diclofenac healing process
200mg 1 tab TID, and in preventing
Metronidazole 500 1 infection.
tab TID
Name of Patient: Patient X Age: 42
Diagnosis: Uterine Myoma Physician: Dr Borromeo

NURSING CARE PLAN NO. 3

Cues Nursing Diagnosis Objectives Intervention Rationale Evaluation

50
Subjective Impaired physical Short term: Independent Short Term
“Dili lagi ko lugos mobility related to At the end of 4 1) Instruct patient -Splinting At the end of 4
kalihok kay pain/discomfort hours of nursing to splint the supports the hours of nursing
tungod sa kasakit intervention, wound with a wound and intervention, the
sa samad. patient will be able pillow if patient minimizes the objectives were
Magsige na lang to : attempts to move. discomfort and fully met. The
man ko ug higda. a) Verbalize pain felt. patient verbalized
Musakit man ug understanding of 2) Assist with self understanding of
samot pag situation and care activities. - improves muscle having myoma
maglihok-lihok ko” individual strength and and the treatment
treatment regimen circulation, regimen especially
Objective: and safety enhances patient a change in diet to
-difficulty turning measures. control in the counter the
to sides noted b) Demonstrate situation and problem. Patient
-slowed techniques that promotes self also demonstrated
movement noted enable resumption directed wellness. the use of
-moaning and of activities such 3)Provide splinting during
sighing noted as assistance with -early mobility movement
upon movement splinting, early mobility reduces correctly. Patient
ambulation and complications of also performed
engaging in self- bed rest. self-care activities
care activities. Promotes healing such as dressing,
and normalization tooth brushing and
Long term: of organ function. with assistance
After 2 days of
nursing 4) Monitor BP with - postural
intervention, the resumption of hypotension is Long term:
patient will: activity. Note common to After 2days of
a)Regain mobility reports of patients on bed nursing
at the highest dizziness. rest and may intervention, the
possible level with require objectives were
minimal interventions like fully met. Patient
discomfort. elevation of bed. achieved full

51
 . mobility status
Dependent little complaints of
1) administer -to perit maximal discomfort.
Tramadol 50mg effort and
IVTT every 6 involvement in
hours activity

Name of Patient: Patient X Age: 42

Diagnosis: Uterine Myoma Physician: Dr Borromeo

NURSING CARE PLAN NO. 4

Cues Nursing Diagnosis Objectives Intervention Rationale Evaluation

52
Subjective: Risk for infection Short term: Independent Short Term
“Dako akong related to surgical At the end of 30 1)Observe for After 30 minutes
samad. incision: minutes of nursing localized signs of -To check for any of nursing
Ginabutangan pa intervention infection at signs of infection intervention, the
gain ni ug binder sutures or surgical objectives were
para dili ma-ukab a) identify incision wound fully met. Patient
and tahi kay sakit interventions to mentioned the
man.” prevent/risk for 2)Note signs and -To give importance of
infection symptoms of necessary hygiene,
sepsis; fever, interventions medication
Objective: chills, diaphoresis compliance,
-horizontal b) identify the proper wound
incision in the importance of the 3)Teach patient -To facilitate dressing and early
hypogastric region following the and SO how to wound healing ambulation to
of the abdomen medication cleanse incision and prevent prevent infection.
with dressing and regimen. site daily and infection by
abdominal binder remind the.m to minimizing growth
Long Term
noted change dressings and spread of After 2 days of
-redness of Long term: as needed microorganisms nursing
surrounding skin After 2 days of intervention,
noted intervention, the objectives were
client will be able 4)Encourage early -Ambulation fully met. The
to: ambulation and stimulates patient was able
deep breathing lower extremity to integrate
a)demonstrate ,coughing and circulation interventions in
behaviors position change after her daily activities
showing caesarean such as wound
appropriate birth dressing,
adaptation to coughing and
present condition. position changes.
Dependent: Patient also
1) 1. Administer -Premature complied with the
b)achieve timely Cloxacillin 500mg discontinuation of medication

53
wound healing; be 1 tab QID, treatment when regimen.
free of purulent Diclofenac 200mg client begins to
drainage or 1 tab TID, feel well may
erythema; be Metronidazole 500 result in return of
afebrile 1 tab TID infection this is
also to avoid
parasitic infection
c)comply to
medication
regimen -To avoid cross
accordingly Collaborative: contamination of
1)Stress aseptic microorganisms
or proper
handwashing
technique by all
caregivers

54
VIII. DISCAHRGE PLANNING

o Encourage strict adherence to the

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

Inform patient that level of activity will be

limited:

• Stair Climbing : Keep to a minimum

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

55
 should rest when you are tired.

Instruct patient to do weight bearing

exercises to strengthen the muscle
tone and pelvic bone, such as: walking
and aerobic exercises.

• Shower - You may shower only for the

next 7 to 10 days, and until groin
puncture sites are completely healed.
• Sexual Relations: You may have
unrestricted activity, including sexual
relations and exercise , seven days
after the procedure.
• Date to return to work: You will need
about one week off from work.

• Other Limitations: No heavy lifting,

pushing or pulling for 4 weeks.

o Instruct the client in the prescribed

medication regimen.
Treatment/Therapy o Encourage routine and reminders to
facilitate adherence.
o Family Therapy- The family members
must provide the patient with
adequate emotional support, care, and
may pray for the patient.

Wellness hints:

o Instruct patient to eat a variety of

healthy foods every day to help you
feel better and have more energy. Diet
should include fruits, vegetables,
breads, chicken, fish, and beans.

o Try to buy organic foods (grown

without the use of pesticides or
herbicides). Growing your own food
Health Teachings when possible and washing food
before using it may also be helpful.

o Suggest limiting how much meat fat,

fish, dairy products, and egg yolks you
eat. Eating too much of these foods

56
 can cause an increased estrogen level
in the body.
o Maintain a healthy weight: instruct
patient to talk to caregiver about ideal
weight. Encourage an exercise
program. It is best to start slowly and
do more as patient get stronger.
Instruct patient to try to exercise at
least 30 minutes everyday.

o Encourage patient to have adequate

rest periods.

Instruct patient to seek medical help IF:

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

57
 Tips for preventing anemia

o Increase the amount of iron in your

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

o Encourage the patient to hear

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

58
IX. PROGNOSIS

The prognosis for patient X is good. Uterine myomas/fibroids are not cancerous

and usually shrink after menopause. Her myoma mass found at the anterior portion of

the uterus, her uterus and her one ovary have been removed which had all led to the

elimination of the signs and symptoms she has experienced prior to surgery.

Throughout her stay in the hospital, she has been responding well to the medical

regimen given to her and has showed no signs and symptoms of possible complications

or infections. However, patient X may not be able to bear a child due to her surgery.

Nevertheless, the procedure she has undergone eradicates the possibility of another

growth of a myoma mass.

59
X. RECOMMENDATION

Recommendations are necessary for patient X to be able to improve health and

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

60
consider in planning care. Physical, social, spiritual, emotional, and mental feedbacks
and motivations can also be considered in imparting to the client.

XI. CONCLUSION

In conclusion, the group was able to come up with a comprehensive case

presentation on uterine myoma, especially concerning our client, Patient X. Information
presented here were factual, basing on our actual assessments by interview and by
using available secondary sources, such as her chart. The group was able to work
together to surface this case study in the best way that we can, using every resource we
can find useful in making every part of this write up.

In the process, we were able to enhance our knowledge about uterine myoma, its
signs and symptoms and treatment modalities, as well as on how we, future nurses, can
care for patients similar to Patient X. Moreover, we have taken our grand case
presentation enactment to the next level, owing this to our extensive learning from our
experiences this semester as well as our previous wisdom acquired in the classroom
and hospital settings. Lastly, the group has developed a better working relationship with
one another, especially through this challenging and demanding stretch of our student
life.

61
BIBLIOGRAPHY

Book Sources:

• .Bullock, B. & Henze, R. (2000). Focus on Pathophysiology. Lippincott Williams &

Wilkins.

• Doenges, M. (2006). Nursing Pocket Guide. 10th ed. Igroup Press Co., Ltd.

• (2007). Nursing 2007 Drug Handbook. 27th ed. Lippincott Williams & Wilkins

Internet Sources:

• Advance Fertility Center of Chicago . Uterine Fibroids and Fertility

Potential.<http://www.advancedfertility.com/uterinefibroid.htm>

• Elizabeth Smith, M.D. Uterine Fibroid.<http://www.fibroid101.com/index.htm>

• http://encyclopedia.thefreedictionary.com/uterine+fibroids

• http://www.amazingpregnancy.com/pregnancy-articles/513.html

• http://www.anticancer.net/resan/myoma.html

• Uterine Fibroids Health Center. Uterine Fibroids - Treatment Overview

<http://women.webmd.com/uterine-fibroids/uterine-fibroids-treatment-overview>

62
APPENDIX A NURSES NOTES
April 3 -11

20,2009
3:00 pm  Received awake on bed c ongoing IVF of

D5LR 1L@ 330 ml level regulated @ 30

gtss/min infusing well on L arm

 conscious and coherent

 dry lips noted

 c complaints of pain at the epigastric region

of the abdomen with a pain scale of 4/10,

with 10 as the most painful

 initial vital signs taken: T:36.8oC; PR:88

bpm; RR: 18 cpm; BP: 120/80 mmHg

 for TAH-USO tomorrow

 afternoon care done

 wet cottonballs applied on lips

 encouraged to take adequate oral fluid

intake

 encouraged deep breathing exercised to

minimize pain

63
  adequate rest provided

 health teaching imparted with emphasis on:

a) adequate fluid intake 6 – 8 glasses a day

b) strict medication compliance

c) compliance to clear liquid diet

 all needs attended

11:00 pm
 kept watched for any unusualities

 endorsed with latest vital signs: T: 36.8 oC;

PR: 86 bpm; RR: 16 cpm; BP: 120/80

mmHg

Jayson Pauig

XUSN3
April 21, 3 – 11

2009
3:00 pm  Received awake on bed c on going IVF of

D5LR 1L @ 930 cc level regulated @ 30

gtts/min infusing well @ L arm

 c foley bag catheter attached to urobag

draining well c straw colored urine @ 750 cc

level

 appears weak

 dry lips noted

 c complaints of radiating pain @ incision site

c a pain scale of 6/10, 10 as the most painful

64
  initial vital signs taken: T:36.7 oC; PR:78bpm;

RR:16 cpm: BP: 130/80mmHg

 wet lips c wet cotton balls

 encouraged deep breathing exercises for 2

5:00 pm minutes to minimized pain
NPO  turned to sides q2

 maintained

 health teachings reinforced with emphasis

on:

1) Proper wound care and dressing

2) Strict medication compliance

3) Adequate intake of food rich in

vitamins and minerals such as

green leafy vegetables; vitamin c

for faster wound healing

1100 pm
 kept watched for any unusualities

 intake and output monitored & recorded

 endorsed with latest vital: T:37.4 oC; PR: 90

bpm; RR: 16 cpm; BP: 130/90mmHg.

Jayson Pauig

XUSN 3
April 22, 3 – 11

2009
3:00 pm  Received awake lying on bed with ongoing

65
 IVF of D5LR 1L @ 180 cc level regulated @

30 gtts/min infusing well @ L arm

 with foley catheter attached to urobag

draining well with straw colored urine @ 80

cc level

 initial vital signs taken : PR: 78 bpm; RR: 18

cpm; BP: 120/80 mmHg; T: 37.5 oC – febrile

 tepid sponge bath done

 temperature rechecked: 37.2 oC

NPO
 encouraged to ambulate

 maintained

 health teachings reinforced with emphasis

on:

1) proper wound care and dressing

2) strict medication compliance

3) eating nutritious food rich in

vitamins and minerals such as

11:00 pm
green leafy vegetables

 I & O monitored and recorded

 endorsed with latest vital signs: T: 37.4 oC;

PR:80 bpm; RR: 18 cpm; BP: 130/90 mmHg

Jayson Pauig

XUSN 3

66
April 23,

2009
3:00 pm  Received awake lying on bed with on going

IVF of D5LR 1L @ 400 cc level regulated @

30 gtts/min infusing well @ L arm

 with foley bag catheter attached to urobag

draining well @ 10 cc level with straw

colored urine

 with complaints of bearable pain @ incision

site with a painscale of 3/10, 10 as the most

painful

 initial v/s taken: Bp: 130/90mmHg; RR:

16cpm; PR:102 bpm: T: 37.8 oC – febrile

 tepid sponge bath done

 temperature rechecked: 37.3 oC

 encouraged deep breathing exercise for 1 -2

mins to minimize pain

Clear liquid
 encouraged to ambulate
6:30 pm Soft diet
 maintained until pm

 consumed 1 cup of porridge with good

appetite

 health teachings reinforced with emphasis

on:

67
 1) proper wound care and dressing

2) strict medication compliance

11:00 pm 3) eating nutritious foods rich in

vitamins and minerals such as green

leafy vegetables

 intake and output monitored and recorded

 endorsed with latest v/s: T: 37.3 oC; PR:100

bpm; RR: 20cpm: BP: 120/80mmHg

Jayson Pauig

XUSN 3

68
APPENDIX B DOCTOR’S ORDER

Date Doctor’s Order Rationale

04/19/09 - Please admit under the service of - Admitting the patient in the

Dr. Borromeo agency provides a chance for

- Consent to care the medical personnel’s to

- TPR every shift monitor the health status of

- For TAHUSO the patient.

- Attach all labs

- CP clearance - SOP before any surgical

- Please inform procedures to anticipate/

surgeon/anaestheologist/ Dr. prevent possible

Luminarias/OR of this admission complications.

- Refer for any unusualities

- Refer accordingly

04/20/09 - NPO for midnight - Needed for surgery

- Full oral and body hygiene - Preparation for surgey

- Insert IVF with D5LR 1L at 30 - Acts as fluid replacement

gtts/min

- Ranitidine 1tab every 8 hours PO - To decrease gastric acid

secretions

- Pre Op meds given @ AM

69
 - Secure one unit FWB for possible - For blood replacement

OR use in properly typed and cross- during surgery

matched

04/21/09 Post-Op orders

11:30 AM -Flat in bed until 5:00pm then turn to - Safety precautions to

sides every 2 hours prevent falls, thrombus

formation and skin

-vital signs every 15 minutes until breakdown.

stable - For monitoring patient’s

status.

-MPD until further orders

-IVF @ 30gtts/min ; follow up with - IVF follow-up

D5 LR 3L at same rate

-Ampicillin 1gm IVTT every 6 hrs - Prophylaxis against GI

ANST (-) infections

-Metronidazole 500mg by IV drip for - Prophylaxis against

30 mins every 8 hours bacterial infections

-Tramadol 50 mgs IVTT every 6 - To decrease pain

hours

04/22/09 -Insert Bisacodyl 1 adult suppository -To soften stools

70
 per rectum now

-May have clear liquid diet once able -To monitor GI function

to pass flatus

-Encourage ambulation -To promote circulation

-Cont IVF and IVT meds

-I&O every shift -To monitor fluid balance

-no dressing till ordered

04/23/09 8:00 AM

(-) flatus - GI function has not restored

-Insert another Bisacodyl adult - To soften stool

suppository per rectum now

-may have clear liquid diet at lunch

time

-Continue IVF

-Pls. inform once with flatus

-for full ambulation

1:30 PM - GI functioning restored

(+) flatus - To have the stomach adjust

-may have clear liquid this lunch

Then general liquid tonight

71
 (+) defecation

-May have general liquid now then

soft diet tonight

Dr. Luminarias

04/24/09 8:00 AM

(+) BM

-May have DAT now

-IVF to consume

-Shift IVT meds to PO once IVF is

consumed

1) Amoxicillin 500mg QID #28 - For prophylaxis and/or

treatment of infection

2) Metronidazole 500mg TID PO - For prophylaxis and/or

p.c. #26 treatment of infection

3) Diclofenac Na 25 mg TID PO - For pain

p.c. #30

-Start: MV 1-0-0 #30 - To increase body’s

FeSO4 + FA 1-0-0 #30 PO immunity

p.c. - Acts as Iron

-For dressing today supplementation

- To promote wound healing

72
 -Remove FBC now – refer if unable and prevent infection

to void 4 hrs. after - To prevent infection

-Please prepare above meds for

possible home meds - To continue prescribed

-For D/C tomorrow medications at home

- May continue recovery

outside hospital premises

APPENDIX C

URINE AND STOOL

4/19 4/20 4/21 4/22 4/23

73
 AM PM AM PM AM PM AM PM AM PM
U 7-3 3 2 C C C
3-11 2 2 C C C
11-7 2 2 C C C
S 7-3 0 1 0 0 1
3-11 1 0 0 0 1
11-7 1 1 0 0 0

APPENDIX D

INTAKE AND OUTPUT SHEET

DAYS DATE INTAKE OUTPUT

Shif Oral Tuba Parente Total Urin Suctio Oth Total
t l ral e n ers
4/21 7-3 NPO 250 250 100 100
1 3- NPO 920 920 300 300
11
11- NPO 1000 1000 800 800
7
24 2170 0 1200
H
4/22 7-3 NPO 720 720 250 250
2 3- NPO 960 960 250 250
11

74
Precipitatin
g Factor
1. Lut
eal
Insu
11- NPO 750 750 500 500
7
24 2430 0 1000
H
4/23 7-3 Clea 640 640 100 100
r
liquid
3 3- Clea 960 960 150 150
11 r
liquid
11- 200 850 1050 500 500
7
24 2650 750
H

75