Father Saturnino Urios University Nursing Program Butuan City

An Individual Case Study On

UTERINE MYOMA
Presented to:

Ms. Xy-za C. Montilla, RN.

Supervising Clinical Instructor

In Partial Fulfillment of the Requirements In Nursing Care Management 103A

Presented by:

Mr. Felecidario O. Taer

Student Nurse

INTRODUCTION
Being a nurse means caring of people with a wide variety of diseases and conditions. Adequate and holistic care to individuals must be rendered and does, it is necessary that nurses be equipped with proper knowledge and nursing skills in dealing with various health states. Through continuous experience at hospitals and continuous learning at school and research study, we gain these necessary knowledge and skills. A case study is one of those that can help a student to gain these knowledge and skills where they gathered data about the disease and condition, analyzed it, making nursing diagnosis, planning for appropriate interventions and set a goals. Student nurses also learn actively and will be able to handle patients and experience what it means to care for a patient with that particular condition. They learn, from continuous interaction with the patients along side with inquires into books and informative journals of the disease process, it symptoms, and corresponding treatments. So the next time they encounter same condition and disease they will utilize what they learned. Uterine Myoma or Uterine fibroid or fibroid tumors are condition where there is a benign growth or tumor of smooth muscle in the wall of the uterus. The said growth is made up of fibrous tissue; hence it is often called a fibroid tumor. The fibroids start off very small, actually from one cell, and generally grow slowly over years before they cause any problems. It may grow as a single nodule or in clusters, and may range in size from 1 mm to more than 20 cm in diameter. Most fibroids are benign; malignant fibroids are rare. The cause of myomas has not actually been determined, but known predisposing factors are gender (women produce extra estrogen), age (30 -50 yrs old), Genetic (Family history, having a mother or sister who had fibroids, may increase risk), Race (Black women are more likely to have fibroids than are women of other racial groups and have fibroids at younger ages, and they're also likely to have more or larger fibroids) and Pregnancy and childbirth (Pregnancy and childbirth seem to have a protective effect and may decrease your risk of developing uterine fibroids). The known precipitating factors are Obesity or High fat diets, Oral contraceptives, Anxiety/ stress, Hormone replacement therapy (may shrink or stimulate growth of fibroids), luteal insufficiency and coffee/ caffeine intake. Fibroids may cause no symptoms, or they may produce abnormal vaginal bleeding. Other symptoms result from pressure on the surrounding organs and include pain, backache, pressure, bloating, constipation, and urinary problems. Menorrhagia and metrorrhagia may occur because fibroids may distort the uterine lining. Fibroids may interfere with fertility. Treatment of uterine fibroids may include medical or surgical intervention and depends to a large extent on the size, symptoms, and location, as well as the womans age and her productive plans. Fibroids usually shrink and disappear during menopause, when estrogen is no longer produced. Simple observation and follow up may be all the management that is necessary. The patient with minor symptoms is closely monitored. If she plans to have children, treatment is as conservative as possible. As a rule, large tumors that produce pressure symptoms should be removed (myomectomy). A hysterectomy or TAHBSO may be performed if symptoms are bothersome and childbearing is completed. Several other alternatives to hysterectomy have been developed for the treatment of excessive bleeding due to fibroids. These include hysteroscopic resection of myomas, laparoscopic myomectomy, laparoscopic myomectomy, laparoscopic myolysis, laparoscopic cromyolysis and Uterine Artery Embolization (UAE). Medications include leuprolide or other gonadopropin- releasing hormone (GnRH) analogues, which induce a temporary menopause-like environment, may be prescribed to shrink the fibroids. Antifibrotic agents are under investigation for long-term treatment of fibroids. Mifepristone, a progesterone antagonist, has also been prescribed. Approximately 25 % of the myomas will cause symptoms and need medical treatment. Myomas that that do not produce symptoms, do not need to be treated. They said 25 % of women cause significant morbidity, including prolonged or heavy menstrual bleeding, pelvic pressure or pain, and in rare cases, reproductive dysfunction. In the Philippines, the estimated number of women is 86,241,697 squared, and the 4,312,084 had been affected of Myoma. I decided to accept the case for my Individual Case Study for this condition is common and it caught my attention and my curiosity to have a thorough research on this. I hope in this case study, my goals that Ive been settled will come into success and made this as an instrument for me to learn more and guide me in my journey in my chosen profession.

DEFINITION OF TERMS
Biopsy - removal and examination, usually microscopic, of tissue from the living body, performed to establish precise diagnosis. Bloating- Vox populi A lay term for post-prandial abdominal fullness or swelling. Dysmenorrhea Dysmenorrhea is the occurrence of painful cramps during menstruation. Hormone replacement therapy- Hormone replacement therapy (HRT) is the use of synthetic or natural female hormones to make up for the decline or lack of natural hormones produced in a woman's body. HRT is sometimes referred to as estrogen replacement therapy (ERT), because the first medications that were used in the 1960s for female hormone replacement were estrogen compounds. Hysterectomy -Hysterectomy is a major surgical procedure in which the uterus is removed. Hysteroscopy - Hysteroscopy is a procedure that allows a physician to look through the vagina and
neck of the uterus (cervix) to inspect the cavity of the uterus. A telescope-like instrument called a hysteroscope is used. Hysteroscopy is used as both a diagnostic and a treatment tool. Hysterosonography (sonohysterography) - is a new noninvasive technique that involves the slow infusion of sterile saline solution into a woman's uterus during ultrasound imaging. Hysterosonography allows the doctor to evaluate abnormal growths inside the uterus; abnormalities of the tissue lining the uterus (the endometrium); or disorders affecting deeper tissue layers. Hysterosonography does not require either radiation or contrast media, or invasive surgical procedures.

Magnetic Resonance Imaging (MRI) - Magnetic resonance imaging (MRI) is the newest, and perhaps most versatile, medical imaging technology available. Doctors can get highly refined images of the body's interior without surgery, using MRI. By using strong magnets and pulses of radio waves to manipulate the natural magnetic properties in the body, this technique makes better images of organs and soft tissues than those of other scanning technologies. MRI is particularly useful for imaging the brain and spine, as well as the soft tissues of joints and the interior structure of bones. The entire body is visible to the technique, which poses few known health risks. Menorrhagia - Excessive bleeding Metrorhagia Irregular Bleeding Myolysis - A laser or electrical needles are coagulate the fibroid. Myomectomy - is an operation to remove fibroids while preserving the uterus. For women who have fibroid symptoms and want to have children in the future, myomectomy is the best treatment option. Oophorectomy - is the surgical removal of an ovary or ovaries. Salpingectomy - refers to the surgical removal of a Fallopian tube. TAHBSO - Total Abdominal Hysterectomy and Bilateral Salpingo-Oophorectom, is the removal of entire uterus, the ovaries, fallopian tubes and the cervix. TAHBSO is usually performed in the case of uterine and cervical cancer. This is the most common kind ofhysterectomy. Removal of the ovaries eliminates the main source of the hormone estrogen, so menopause occurs immediately. Ultrasonography (Ultrasound) - The imaging of deep structures of the body by recording the echoes of pulses of ultrasonic waves directed into the tissues and reflected by tissue planes where there is a change in density. Diagnostic ultrasonography uses 110 megahertz waves. Uterine Artery Embolization (UAE) Polyvinyl alcohol or gelatin particles are injected into the blood vessels that supply the fibroid via the femoral artery, resulting in infarction and resultant shrinkage.

NURSING HEALTH HISTORY

Nursing health history is the first part and one of the most significant aspects in case studies. It is a systematic collection of subjective and objective data provided by the patient or the patients significant other. It provides a step-by-step process inculcating detailed information in determining patients history, health status, functional status and coping pattern. These vital information provide a conceptual baseline data utilized in developing nursing diagnosis, subsequent plans for individualized care and for the nursing process application as a whole. On June 16, 2011 8:00 A.M, I, the student affiliate reported on duty at Surgical Ward at Manual J. Santos Hospital ready to put action the principles and related concepts I have learned which geared me towards delivering effective nursing care and to further broaden my knowledge towards my patient. I chose this case on June 18, 2011 Saturday 8:00 AM and was handled 2 days (June 18, 2011 and June 23, 2011). I started the interview and assessment on the day I handled my patient. In accordance with the principle of confidentiality and maintenance of the patients dignity, I decided to address him as Patient M. Patient M is a native of Cabadbaran city. She is a 52 years old. She was delivered through normal spontaneous vaginal delivery as a healthy baby girl with the help of folk healer on May 2, 1959. She was breastfed and had some immunization which she doesnt know what it was. Her father, who is a smoker, works as OFW died of heart attack at age 70. And her mother, who is also a smoker, a businesswoman died of bone cancer at age 66 had also undergone TAHBSO at age 35. Patient M was diagnosed of rheumatic fever when she was a child and was admitted at the hospital for treatment. She had also had chicken pox when she is still a child. Patient M has high fat diet as she verbalized Paborito nako ang karneng baboy pero bisag unsa mokaon man ko same ra sa guikaon sa uban gud, bugas, sahay gulay, prutas pero pirmi gud karne baboy kay paborito man nako. She had finished her college degree as commerce. She then continued taking up BS Education and had finished it also. Patient M got married at age 25 on December 17, 1984 to the man younger than her who is 23 yrs old. She works as a teacher in elementary at the towns elementary school. She was also an employee of Department of Education (DepEd). At Age 27, she bore her eldest son who is now a nurse and at age 30 she bore her youngest son who is now currently a 3rd yr student nurse at Cebu City. Both her son delivered through normal spontaneous vaginal delivery as a healthy child at the hospital. Both has prenatal during her pregnancy and had complete immunization. During her adult life, she had measles and mumps. Patient M had a minor surgery for biopsy for mass at the left breast which was diagnosed as benign tumor when she was 38 yrs old. She also had mild hypertensive when she was 40 yrs. old. When she was on her 40s she had undergone ultrasonagraphy on her uterine. A mass was spotted during the examination. She decided not to have medical intervention yet. She sometimes felt mild pain on her back but decided not to take action for it was manageable at that time. On year 2009, Patient M and his husband got separated. Their marriage didnt work out. Her husband leaves her as she verbalized Ambot langga nawala raman kalit. Gibayaan ko nangita na tog mas bata pa nako. Naa nato sa maayohong kamot.. During that time Patient M was very depressed and lonely. On year 2010, she again had a minor surgery for biopsy for mass at the upper portion of her back. Patient M also had less fluid intake as she verbalized di man ko katimaan pila gd ka baso, basta kanang uhaw na moinum ko, tagahuman kaon pd mo moinum ko. Mga 4-6 ka baso siguro ka baso ako mahurot sa isa ka adlaw.. She also had constipation sometimes as she verbalized Na sahay Dili na regular ako paglibang. Sukad tong niaging bulan kay mga tagtulo o upat ka adlaw ko ayha malibang. Usahay galisod pud ko ug libang. It was on June16, 2011 when she had discomfort at the hypogastric. She had decided to go to the hospital for check up. She was examined by Dr. Marilyn Jumapao. Doctors orders were the following and carried out by staff nurse on duty: Admit 217 TPR @4h DAT

 CBC now save serum BP of 4h Bisacodyl P.O @ h.s Metramidazole 400mg TID P.O Cefurixime 500mg I tab BID to start tomorrow A.M Patient M had her CBC after seeing Dr. Jumapao and waited for the result. On the following day, June 17, 2011, by 4.27p.m, patient M was admitted to room 217E with new doctors order was carried out by staff nurse on duty: Refer to Dr. Bringas for clearance (for TAHBSO). On same date, Dr. Bringas had provided the clearance and new doctors order was carried out by staff nurse on duty: Needs 2 units FWB for OR use. By 8:30 AM, She was examined by Dr. Jumapao. And new doctors orders were the Following and carried out by the staff nurse on duty: For TAHBSO 8AM Fleet enema in AM Blood typing now. Around 9:06 AM, a blood typing result was in. Patient M blood type was A+. She had no sons and relatives with blood type of A+, so she and his family decided to try to buy in Red Cross. By 10:00 AM, she was examined by Dr. Jumapao and new doctors orders were carried out by the staff nurse on duty. Reschedule TAHBSO at 5:30 (6/18/11) Enema @4:00 PM (6/18/11) Start Cefuroxime 500mg in 8A.M 2nd dose @ 12nn NPO @ 12nn Start venochysis with d5lr@20gtts/min after fleet enema. Around 10:30 AM, she was examined by Dr. Villanueva and new doctors order was carried out by staff nurse on duty: To secure limit of WB after screened @ cross match for OR use. It was on June 18, 2011 by 8:00AM. I first met Patient M. She was sitting on bedside awake and coherent upon interaction without IVF. I establish rapport and a close relationship towards patient M. As a student nurse, I did my assessment towards my patients condition. Upon assessing, I was able to take and record her vital signs: T:> 35.80C PP:> 80bpm RR:> 16 breaths per min BP:> 120/80 mmHg Patient was waiting for the results for blood screened cross matching. I took the chance for the interview while rendering care. She was relaxed and no signs of anxiety. She knew the procedure and already accepted it as she verbalized Dili naman ko mag magbalaka langga na matanggal ning reproductive organ nako kay tigulang naman pod ko. She has decreased hemoglobin count at 108 g/L. I instructed her about the need for blood transfusion and the signs and symptoms of hypersensitivity and when to contact health care provider. I gave health teachings about food rich in iron to increase her hemoglobin count and high fiber for her constipation. I advised her to increase fluid intake. She was on NPO at 12nn after her meals. She ate well. At 2:00 pm, a result of cross matching was in. While waiting for her enema at 4pm. I continued the interview. On this day, I was able to identify problems. (1) Ineffective tissue perfusion (2) Constipation At 3:00pm, after pre-surgery checklist was done, the staff nurse on duty had performed perineal care to patient M. At 4:00, enema was done. At 5pm, patient M was accompanied by

OR nurse on duty to the OR. After the operation was finished, new doctors order were the following and carried out by staff nurse on duty: To PACU for 2hrs Monitor vital signs every 15 mins for 1st 2 hours then every 20 minutes for the next 2 hours then hourly to every shift when stable. Flat on bed until 1:00 A.M then turn to sides. NPO IVF # 2(ongoing) PNSS @ 30 gtts/min. IVF#3(to follow up) D5LR@ 30 gtts/min. On June 21, 2011, Catheter was pullout. And on June 23, 2011, by 8:00am, I receive patient M lying on bed awake and coherent upon interaction without IVF with postop dressing dry and intact at lower quadrant. I did my assessment towards my patients condition. Upon assessing, I was able to take and record her vital signs: T:> 36.30C PP:> 78bpm RR:> 15 breaths per min BP:> 130/80 mmHg She had pain scale at 4 when not moving as she verbalized Sakit pa ako samad labaw na if molakaw ko. Hinay2x lng ko ug lakaw. She can ambulate but with pain scale at 7 when ambulate as she verbalized Kung 10 ang pinakasakit, naa sa 7 ang sakit kung molakaw ko. While giving health teaching, I did the physical assessment and continue the interview. Patient M was advised to increase fluid intake and increased intake of food rich in protein. She was advised to performed deep breathing exercise. I stressed the proper hand washing techniques. She was encouraged to ambulate regularly. On this day, I was able to identify problems. (1) Risk for infection (2) Impaired physical mobility (3) Acute pain At 2:00 pm, she was visited and examined by Dr. Jumapao. Uterine myoma was the final diagnosis and was written in the chart. I assist the doctor and noted and carried out doctors orders: MGH Be back at hospital after 1 week for biopsy result. Take home medicaton: o Cefuriximine 500mg 1 tab BID o Metramidazole 500mg 1 tab TID o Clindamycin 150mg 1 cap TID o Paracetamol 500mg 1 tab TID o Tramadol hydrochloride 500mg TID Around 4:00 pm, Patient M was discharged.

PHYSICAL ASSESSMENT
Physical assessment is an organized systematic process of collecting objective data upon health history. A complete health assessment may be conducted starting at the head and proceeding in a systematic manner downward (head-to-toe assessment).Manner of assessment as cephalocaudal assessment. An accurate physical assessment requires an organized and systematic approach using the techniques of inspection, palpation, percussion, and auscultation. It also requires a trusting relationship and rapport between the nurse and the patient to decrease the stress the patient will be much more relaxed and cooperative if you explained what will be done and the reason for doing it. While the findings of a nursing assessment something contributes to the identification of a medical diagnosis, the unique focus of a nursing assessment is on the patients responses to actual or potential problem. The purpose of physical assessment is the following: 1. To obtain baseline physical assessment; 2. To support, confirm or question data obtained in the nursing history; 3. To obtain support data that will help the nurse establish nursing diagnosis and plan patient care; 4. To evaluate the appropriateness of the nursing interventions in the resolving the patients identified problems. GENERAL SURVEY Date assessed: June 23, 2011 2:00pm Patient M was first met sitting in bedside without IVF and without foley catheter. She is a 52 year old woman. Her youngest son and helper were with her. The patient was alert, and coherent upon interaction. She gave full and detailed responses to all of the questions asked. She is 50 with black hair. Her facial grimace doesnt show any problem with pain that time. He can walk but slower. Her clothes were just appropriate as well as her appearance. There is no deformity visible from the patient except in the incision at the lower abdominal. She has a normal size for her age and she has a good posture. The patient has no noted body odor. Vital signs were taken and recorded as follows: T: > 36.3 0C PP:> 78 bpm Body Mass Index: Weight: 64 kls Height: 50 or 60 inches or 1.524 m 64 kls. = 27.56 Overweight 2 (1.524 m) RR:> 15 breaths/min BP:> 130/80 mmHg O2 Sat:> 97%

Result is 27.56. It is classified to the category of Overweight in which the normal BMI is 18.524.9 and 25 -29.9 is overweight.

PARTS SKIN, HAIR, AND NAILS

HEAD

EYES

INSPECTION >Skin is dark brown in color and even in distribution. >Hair is black, fine, and even in distribution. >Scalp is clean and dry. >Nails are pale pink in color >No presence of nail clubbing >Head is symmetric and midline to the patients body. >No presence of visible lesions. >Face is symmetric with an oval appearance. >Head circumference measures 58 cm. >The eyebrows are evenly distributed and symmetrically aligned. >each upper eyelid cover the top quarter of the iris. >The surface of the right eye is covered with whitish membrane w/c is microcornia >eye lashes equally distributed, straight outward. Assessing the Eye muscle function Left Lateral and Right Lateral. >The left and right eye was able to follow the

PALPATION >Skin turgor of 3 seconds. >Hair is smooth, thin and fine. >Nail capillary refill of 3 seconds.

PERCUSSION

AUSCULTATION

>No swelling >No mass when palpate. >Frontal and maxillary sinuses are non tender to palpation.

>No drainage noted from the puncta upon palpation of the nasolacrimal duct. >No palpable masses.

object without moving his head and without any difficulty Down Ward >Was able to follow the object with his eyes without moving his head and any difficulty. Upper >Was able to follow the object with his eyes without moving his head. >able to recognize and identify the face of his son and helper. >Color is the same as the rest of the face. >Nasal structure is both smooth and symmetric. >Nasal mucosa is pink, moist, and free of exudates. >The ear is line up w/ the outer corner of the eye symmetrical, w/ an angle of attachment of no more than 10 degrees. >The auricle has no lesion, drainage nodules or redness >The opening of the ear canal has a presence of discharges >Able to hear clearly. >Lips are cracked and dark brown in color. >Teeth have a yellowish

NOSE

>Airway is patent while the other nostril is occluded. >No masses upon palpate.

EARS AND HEARING

>The auricles smooth, soft and firm. As pinna is folded forward it recoils after wards >When the helix is pull back there is no tender noted.

MOUTH

>No lesions, ulcerations, or nodules upon palpation. >Gag reflex is

NECK

LUNG AND THORAC

discoloration. >Presence of cracking of the crowns of the wisdom teeth. >Gums are pink in color. >With moist pale-pink buccal mucosa. >Frenulum is midline. >Tonsils and uvula show no presence of swelling. >Throat is pink in color. >The tongue can move in all direction and lie straight to the front at rest. >Neck is no visible bulging mass. > Head movements are coordinated. He can move from side to side and up to down without any difficulties. >Skin color fair like other parts of the body. >Able to swallow his saliva without any difficulties and pain. >Chest moves symmetrically with breathing. >No labor breathing observed. >Respiration of 15 breaths per minute. >Exaggerated spinal curvatures not noted.

present.

>No swelling or tenderness of the lymph nodes. >Lymph nodes are not palpable and not enlarged.

>Free of masses or scars that indicate trauma or surgery. >Equal tactile fremitus noted.

>Resonance is heard throughout all lung fields.

>Vesicular sound heard throughout most of the long fields.

BREAST AND AXILLA

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HEART AND CENTRAL VESSELS

>Jugular venous pulse is not visible when the patient sits upright.

>Arms are UPPER EXTREMITIES bilaterally symmetric with minimal variation in size and shape. >No edema of the hands or prominent venous patterning throughout all extremities. >Veins are flat and barely seen under the surface of the skin. >Consistent with skin color on the rest of the body. >Legs are free of lesions and ulcerations. >With presence ABDOMEN of bandage below umbilicus >Bandage is clean and free of drainage. >Color is consistent with the color of the rest of the body. >No visible veins of the abdomen are present upon inspection. >No presence of ulcerations. >No presence of rashes. >Umbilicus is located on midline of the abdomen. >Abdomen has a

>Carotid artery pulses are equally strong. >Pulses are weak in tonicity at Radial pulse. > Radial pulse (78 bpm) (Normal: 60100bpm). >No presence of enlarged lymph nodes upon palpation. >Negative Homans sign.

>No mumurs or extra heart sounds are heard. >S1 and S2 sounds are clearly heard.

>No palpable masses. >No signs of swelling of the umbilicus; no bulges, or masses.

>Tympany is percussed over the abdomen.

>Soft gurgles are heard at a rate of 6 bpm (Normal is 535).

protruded contour and is round in shape. >She was able to GENITOurinate 2 times a URINARY day and defecate SYSTEM once a day without any difficulty. >Legs same LOWER EXTREMITIES color w/her body except the knee. >Can walk slowly. >Joints are symmetric without signs of redness.

ANATOMY AND PHYSIOLOGY

Anatomy of Female Reproductive System

INTERNAL REPRODUCTIVE ORGAN

Ovaries The two ovaries are small organs suspended in the pelvic cavity by ligaments. The suspensory ligament extends from each ovary to the lateral body wall, and the ovarian ligament attaches the ovary to the superior margin of the uterus. In addition, the ovaries are attached to the posterior surface of the broad ligament by folds of the peritoneum called the mesovarium. The ovarian arteries, veins, and nerves transverse the suspensory ligament and enter the ovary through the mesovarium. A layer of visceral peritoneum covers the surface of the ovary. The outer part of the ovary is made up of dense connective tissue and contains the ovarian follicles. Each of the ovarian follicles contains an oocyte, the female sex cell. Loose connective tissue makes up the inner part of the ovary, where blood vessels, lymphatic vessels, and nerves are located. Uterine Tubes A uterine tube, fallopian tube, or oviduct (named after the italian anatomist, Gabriele Fallopio) is associated with each ovary. The uterine tubes extend from the area of the ovaries to the uterus. The open directly into the peritoneal cavity near each ovary and receive an oocyte. The opening of each uterine tube is surrounded by long, thin processes called fimbriae. The fimbriae nearly surround the surface of the ovary. As a result, as soon as the oocyte is ovulated, it comes into contact with the surface of the fimbriae. Cilia on the fimbriae surface sweep the oocyte into the uterine tube. Fertilization usually occurs in the part of the uterine tube near the ovary known as the ampulla. Uterus The uterus is as big as the size of a medium-sized pear. It is oriented in the pelvic cavity with the larger, rounded portion directed superiorly. The part of the uterus superior to the entrance of the fallopian tubes is called the fundus. The main part of the uterus is called the body,

and the narrower part is termed the cervix and is directed inferiorly. Internally, the uterine cavity in the fundus and uterine body continues through the cervix as the cervical canal, which opens into the vagina. The cervical canal is lined by mucous glands. The Uterine wall is composed of three layers: a serious layer or perimetrium of the uterus, consists of smooth muscle is quite thick and accounts for the bulk of the uterine wall. The inner most layer of the uterus is called the endometrium. The endometrium consists of simple columnar epithelium tissues with an underlying connective tissue layer. Simple tubular glands, called enometrial glands, are formed by folds of the endometrium. The superficial part os the endometrium is sloughed off during menstruation. The uterus is supported by the broad ligament and the round ligament. In addition to these ligaments that support the uterus, much support is provided inferiorly to the uterus by skeletal muscles of the pelvic floor. If ligaments that support the uterus or the muscles of the pelvic floor are weakened such as in childbirth, the uterus can extend inferiorly into the vagina, a condition termed as a prolapsed uterus. Severe cases require surgical correction. Vagina The vagina is the female organ of copulation and functions to receive the penis during intercourse. It also allows menstrual flow and childbirth. The vagina extends from the uterus to outside the body. The superior portion of the vagina is attached to the sides of the cervix so that a part of the cervix extends into the vagina. The wall of the vagina consists of an outer muscular layer and an inner mucous layer. The muscular layer is smooth muscle and contains many elastic fibers. Thus the vagina can increase in size to accommodate the penis during intercourse, and it can stretch greatly during childbirth. The mucous membrane is moist stratified squamous epithelium that forms a protective surface layer. Lubricating fluid passes through the vaginal epithelium into the vagina. In young females, the vaginal opening is covered by a thin mucous membrane known as the hymen. The hymen can completely close the vaginal orifice in which case it must be removed to allow menstrual flow. More commonly, the hymen is perforated by one or several holes. The openings of the hymen are usually greatly enlarged during the first sexual intercourse. The hymen can also be perforated during a variety of activities including strenuous exercise. The condition of the hymen is therefore not a reliable indicator of virginity. Cervix The cervix is the lower constricted segment of the uterus. It is somewhat conical in shape, with its truncated apex directed downward and backward, but is slightly wider in the middle than either above or below. Owing to its relationships, it is less freely movable than the body, so that the latter may bend on it. The long axis of the cervix is therefore seldom in the same straight line as the long axis of the body. The long axis of the uterus as a whole presents the form of a curved line with its concavity forward, or in extreme cases may present an angular bend at the region of the isthmus. The cervix projects through the anterior wall of the vagina, which divides it into an upper, supravaginal portion, and a lower, vaginal portion. The supravaginal portion (portio supravaginalis cervicis) is separated in front from the bladder by fibrous tissue (parametrium), which extends also on to its sides and lateralward between the layers of the broad ligaments. The uterine arteries reach the margins of the cervix in this fibrous tissue, while on either side the ureter runs downward and forward in it at a distance of about 2 cm. from the cervix. Posteriorly, the supravaginal cervix is covered by peritoneum, which is prolonged below on to the posterior vaginal wall, when it is reflected on to the rectum, forming the rectouterine excavation. It is in relation with the rectum, from which it may be separated by coils of small intestine.

HORMONES AND MENSTUAL CYCLES Females of reproductive age experience cycles of hormonal activity that repeat at about one-month intervals. (Menstru means "monthly"; hence the term menstrual cycle.) With every cycle, a woman's body prepares for a potential pregnancy, whether or not that is the woman's intention. The term menstruation refers to the periodic shedding of the uterine lining. The average menstrual cycle takes about 28 days and occurs in phases: the follicular phase, the ovulatory phase (ovulation), and the luteal phase. There are four major hormones (chemicals that stimulate or regulate the activity of cells or organs) involved in the menstrual cycle: follicle-stimulating hormone, luteinizing hormone, estrogen, and progesterone. Hormones Gonadotropin Releasing Hormone (GnRH) Secreted by the hypothalamus Secred in pulses every 1-3 hours Pulsatile nature of GnRH release is essential to its function Stimulate the arterior pituitary to release FSH and LH Pulsatile release of GnRh causes pulsatile output of LH

Follicle-Stimulating Hormone (FSH) Synthesized and secreted by gonadotropes in the anterior pituitary gland. In the ovary FSH stimulates the growth of immature Graafian follicles to maturation. Graafian follicles are the mature follicle. Primary follicles mature to Graafian follicles. As the follicle grows, it releases inhibin, which shuts off the FSH production. Luteinizing Hormone (LH) Produced by the anterior pituitary gland. LH triggers ovulation hereby not only releasing the egg, but also initiating the conversion of the follicle into a corpus luteum that, in turn, produces progesterone to prepare the endometrium for a possible implantation. LH is necessary to maintain luteal function for the first two weeks. Estrogens (estradiol, estriol, and estrone) Estrogens are produced primarily by developing follicles in the ovaries, the corpus luteum, and the placenta. Some estrogens are also produced in smaller amounts by other tissues such as the liver, adrenal glands, and the breasts. The estrogens initiate the formation of a new layer of endometrium in the uterus, histologically identified as the proliferative endometrium. The estrogen stimulates crypts in the cervix to produce fertile cervical mucus, which may be noticed by women practicing fertility awareness. Progesterone Progesterone is produced in the ovaries, the gonads (specifically after ovulation in the corpus luteum), the brain, and, during pregnancy, in the placenta.

 Progesterone converts the endometrium to its secretory stage to prepare the uterus for implantation. At the same time progesterone affects the vaginal epithelium and cervical mucus, making the mucus thick and impermeable to sperm. If pregnancy does not occur, progesterone levels will decrease, leading, in the human, to menstruation. Normal menstrual bleeding is progesterone withdrawal bleeding. During implantation and gestation, progesterone appears to decrease the maternal immune response to allow for the acceptance of the pregnancy. Progesterone decreases contractility of the uterine smooth muscle. In addition progesterone inhibits lactation during pregnancy. The fall in progesterone levels following delivery is one of the triggers for milk production. A drop in progesterone levels is possibly one step that facilitates the onset of labor. The Stages of menstrual cycle Days 1-5: Menstrual Phase During this interval, the superficial functional layer of the thick endometrial lining of the uterus is sloughing off, or becoming detached, from the uterine wall. This is accompanied by bleeding for three to five days. The detached tissues and blood pass through the vagina as the menstrual flow. The average blood loss during this period is 50-150 ml (or about to cup). By day 5, growing ovarian follicles are beginning to produce more estrogen. Days 6-14 Proliferative Phase Stimulated by ring estrogen levels produced by the growing follicles of the ovaries, the basal layer of the endometrium regenerates the functional layer, glands are formed in it, and the endometrial blood supply is increased. The endometrium once again becomes velvety, thick, and well vascularized. (Ovulation occurs in the ovary at the end of this stage, in response to the sudden surge of LH in the blood.) Days 15-18 Secretory Phase Rising levels of progesterone production by the corpus luteum of the ovary act on the estrogen- primed endometrium and increases its blood supply even more. Progesterone also causes the endometrial glands to increase in size and to begin secreting nutrients into the uterine cavity. These nutrients will sustain a developing embryo (if one is present) until it has implanted. If fertilization does occur, the embryo produces a hormone very similar to LH, which causes the corpus luteum to continue producing its hormones. If fertilization does not occur, the corpus luteum begins to degenerate toward the end of this period as LH blood levels decline. Lack of ovarian hormones in the blood causes the blood vessels supplying the functional layer of the endometrium to go into spasms and kink. When deprived of oxygen and nutrients, those endometrial cells begin to die, which sets to stage for menses to begin again on day 28. 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 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.

LABORATORY RESULTS
Date Ordered: June 16, 2011 Date Done: June 17, 2011 Physician: Dr. Marilyn Jumapao

HEMATOLOGY
Complete Blood Count Results Hemoglobin 108 Unit g/L Normal range 117-140 Interpretation Decreased Indication Indicates blood loss or iron- deficiency or anemia Normal Normal

Hematocrit WBC

0.36 7.29

x10 /L

0.34-0.44 5-15 Differential Count

Results Segmentors Lymphocytes Band Eosinophils Monocytes 0.51 0.36 0.00 0.03 0.07

Unit x104/L x104/L x104/L x104/L x104/L x104/L

Normal range 0.37-0.72 0.20-0.50 0.02-0.05 0.00-0.06 0.08-0.14

Interpretation

Indication Normal Normal Indicates acute stress Normal Indicates leukopenia or low production in bone marrow. Indicates chronic inflammation, the presence of a hypersensitivity reaction to food, or radiation therapy. Normal

Decreased Decreased

Basophils

0.02

0-0.01

Increased

Platelet count

292

x104/L

150-390

DRUG LIST
PRE-OPERATIVE MEDICATIONS o Bisacophyl P.O @ h.s o Metramidazole 1tab 500mg TID P.O o Cefurixime 500mg 1tab BID INTRA-OPERATIVE MEDICATIONS o IVF PNSS @30 gtts/min o IVF D5LR POST-OPERATIVE MEDICATIONS o o o o o Tramadol Hydrocloride 1tab 500mg TID P.O Metronidazole 500mg 1tab TID P.O Paracetamol 500mg 1tab TID Clindamycin 150mg 1cap TID Cefurizime 500mg 1tab BID

PROBLEM LIST
Priority Number Problem Identified Date Identified Date Evaluated

Ineffective tissue perfusion related to decreased hemoglobin concentration in the blood.

June 18, 2011

June 18, 2011

Risk for infection related to surgical incision.

June 23, 2011

June 23, 2011

Impaired physical mobility related to pain/discomfort

June 23,2011

June 23, 2011

Acute pain related to surgical incision in the abdomen

June 23, 2011

June 23, 2011

Constipation related to anatomical obstruction of the rectum and inadequate intake of fluids and bulk

June 18,2011

June 18, 2011

DISCHARGE PLAN MEDICATIONS

Encourage strict adherence to the medication regimen to attain therapeutic effects Instruct patient to strictly follow orders for take home medications upon discharge as prescribed by physician. Instruct patient to take medications prescribed such as: 1. Cefuriximine 500mg 1 tab 2xday (8am-6pm) 2. Metramidazole 500mg 1 tab 3xday (8am-12nn-6pm) 3. Clindamycin 150mg 1 cap 3xday (8am-12nn-6pm) 4. Paracetamol 500mg 1 tab 3xday (8am-12nn-6pm) 5. Tramadol hydrochloride 500mg 1 tab 3xday (8am-12nn-6pm) Instruct patient to follow right dose and timing of medications, and not to stop taking them abruptly without physicians order. Report any adverse effects and drug-drug interactions/ drug-food interactions of the medications to the physician.

ENVIRONMENT

Maintain a quite, pleasant environment to provide relaxation. Provide clean and comfortable environment. To keep the surroundings safe by keeping sharp and pointed objects at their right places to avoid any accidents. Keep floor always dry to avoid being fall.

TREATMENT

Instruct the patient to be back to hospital for check up after 1 week. Instruct the patient in the prescribed medication regimen. Encourage routine and reminders to facilitate adherence. Family Therapy- The family members must provide the patient with adequate emotional support, care, and may pray for the patient.

HEALTH TEACHINGS
Instruct patient to eat a variety of healthy foods every day to help you feel better and have more energy. Diet should include fruits, vegetables, breads, chicken, fish, and beans. Try to buy organic foods (grown without the use of pesticides or herbicides). Growing your own food when possible and washing food before using it may also be helpful. Suggest limiting how much meat fat, fish, dairy products, and egg yolks you eat. Eating too much of these foods can cause an increased estrogen level in the body. Maintain a healthy weight: instruct patient to talk to caregiver about ideal weight. Encourage an exercise program. It is best to start slowly and do more as patient get stronger. Instruct patient to try to exercise at least 30 minutes every day. Encourage patient to have adequate rest periods.

OBSERVABLE S/SX

Instruct patient to seek medical help if: o You have fever. o You are vomiting and cannot keep food or liquids down. o You have a very bad headache, or you feel dizzy. o Your pain is worse or does not go away after taking your pain medicine.

o You have questions or concerns about uterine fibroids, their treatment, or your medicine. o You become pregnant while having treatment. o You have pain in your abdomen or lower back that does not go away after taking pain medication. o You have heavy or unusual vaginal bleeding. o You have trouble urinating or emptying your bladder completely. o Your symptoms are getting worse or coming back.

DIET

Increase the amount of iron in your diet. Your body needs iron to make new blood cells, and your diet is the best source. Get 18mg to 20mg of iron per day. Red meats, shellfish, eggs, beans, leafy green vegetables, and iron-enriched breads and cereals are the best sources of iron. 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. No restrictions Increase your fluids and fiber. Prune juice or mild laxative may be helpful to keep your bowels soft.

SPIRITUAL

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

LEARNING OUTCOMES
For 9 days of duty at surgical ward, as usual, duty at ward was tiring. Charting while monitoring your patient was not that easy especially if your nursing diagnosis was incorrect or your SOPIE was incorrect. You had to write again. And sometimes you had a lot of medication to give; you will have to drug study those medications. Time was so fast. You didnt even know it was lunch time already. I have encountered several difficulties with regards to interventions. Especially those procedures that is new to me. And specially in dealing surgical ward patient who are need to be closely monitored. Their status is not that stable specially those patient with medications that can alter vital signs. We have to be focus. We have to keep tract on time and manage and utilize the time well. I have my personal problem one time it almost failed me to do the things that I had to do but Im glad I manage it. I planned not to duty that day but I cant waste the day. I cant imagine what it feels like for the day we will be assign at medical ward. I feel anxious when handing critical patients. But I always put it in my mind that this people are needs to be cared and that is what we are as student nurses to use our knowledge and skills to care them. Sometimes I feel empathy to what they have gone through not only to my patient but to those patients in ward. I always put in my mind always that we are not God, we can only help them through health teachings, monitor their status and advocate to their needs. My patient (Patient M) was a mother, shes like my mother. I really feel sad even though she show no sign of sadness and worried. I feel bad knowing she had this tumors that is appearing anywhere in her body alternately. But Im glad it was not malignant. I hope and I pray her condition will not progress to cancer. But the most important of all and the most significant is that I learned a lot. I learned a lot from this rotation. The medications, interventions, procedures, making SOPHIE, charting and in the knowledge I will gain from this ICS (which is my first time making ICS), it will help me a lot in pursuing my goal. Thanks for the staff nurses that had show kind to us and who also taught us some new things and thanks to our supervising C.I for devoting her time to teach us to be good and competitive nurse someday.