SAINT LOUIS UNIVERSITY COLLEGE OF NURSING
Hydrosalpinx, Acute appendicitis
Presented to: Mrs. Melody D. Baliang, RN
Presented by: Ayugat, Roland Alcantara, Nadine Ceriaco, Chedan Gonzales, Bianca Macayan, Katrin Rayray, Ciara
Date: June 17, 2008
PATI EN T P ROFI LE
Name: Age: Citizenship: Birth date: Religion: Birth Place: Address: Educational Attainment: Admitting Physicians: Attending Physician: Date and Time Admitted: Room and Bed Number: Impression Diagnosis: Operations performed: Mrs. M. T. M. (Initials for anonymity) 42 years old Filipino September 15, 1965 Roman Catholic Baguio City, Philippines San Vicente, Baguio City High School Graduate Dr. Bibat, Dr. Catalan Dr. Malinit June 13, 2008; 11:10AM Pay ward, 025 Adnexal Mass, Left, to consider ectopic pregnancy, G7P6 (6016) Salpingectomy Elective Appendectomy (Both done last June 14, 2008) Hydrosalpinx, Left, s/p sapingectomy, G7P6 (6016), Acute appendicitis, congestive s/p Appendectomy
HIS TORY OF P RESE NT IL LN ESS
Patient’s condition started one month before admission, when she experienced profuse vaginal bleeding with discharge amounting to approximately two fully soaked diapers and had been diagnosed of threatened abortion 10 weeks AOG. She had then undergone completion curettage last May 08, 2008 at the Sto. Nino Hospital, Baguio City. The bleeding was controlled but resumed a few days after the curettage with discharge amounting to approximately 1 to 2 minimally soaked pads. The patient had not taken any medications and verbalized to have no associated abdominal pain, dysuria, or fever accompanying her existing condition. Six days prior to admission, the patient complained of experiencing abdominal pain with an intensity of 5 out of 10 and no radiation. No medications were taken and there had been no accompanying symptoms such as fever, dysuria, nausea and vomiting. About two days before admission, patient’s condition persisted, prompting her to seek advice from a private physician. A complete blood count, urinalysis and pelvic ultrasound were then requested for further diagnosis. The complete blood count revealed no significant health deviations, while the urinalysis suggested the presence of a urinary tract infection and the Pelvic
ultrasound showed left adnexal mass, suspicious for ectopic pregnancy, mild hydrosalpingitis. Due to these findings, the patient was advised for admission, hence admitted.
PAST M EDI CAL H IS TOR Y
The patient verbalized to have been previously hospitalized at Sto. Nino Hospital for her completion curettage and named no other succeeding condition necessitating hospitalization apart from her present admission at Saint Louis University - Hospital of the Sacred Heart. She also claimed to have no existing allergies to food and drugs and has had no previous intake of maintenance drug for any serious health complication. Furthermore, she has had no history of ovarian carcinoma, dysfunctional uterine bleeding, myoma, Hydatidiform mole, pelvic inflammatory disease, cervicovaginitis, or polycystic ovarian syndrome.
FAMI LY ME DI CAL H IS TORY
The patient claimed to have no existing history of heredofamilial disease conditions such as hypertension, cerebrovascular diseases, asthma, diabetes mellitus, cancer, peptic ulcer disease, hyperthyroidism, or arthritis. She has no family member with an existing contagious disease such as with pulmonary tuberculosis.
COU RS E OF C ONF IN EM EN T
This nursing care plan presents the case of Mrs. M. T. M., 42 year-old female, Filipino, a Roman Catholic, married, born on September 15, 1965, a resident of San Vicente, Baguio City, with a chief complaint of flank pain and vaginal bleeding. This was her second hospitalization, but had been admitted for the first time in Saint Louis University - Hospital of the Sacred Heart last June 13, 2008 at 11:10 am by Dra. Catalan and Dra. Bibat, with an impression diagnosis of
Adnexal Mass, Left, to consider ectopic pregnancy, G7P6 (6016).
The patient was admitted with the following diagnostic tests: hematology dated June 11, 2008; complete blood count dated June 11, 2008; urinalysis dated June 11, 2008; whole abdominal sonogram dated June 11, 2008; and a specimen histopathology that had been reported last May 18, 2008. During the second day of hospitalization, June 14, 2008, the patient had undergone the following operations: Salpingectomy, Elective Appendectomy both with duly accomplished consent forms with proper pre-operative preparation.
During Hospitalization, the patient received the following medications: Nalbuphine (10mg); Cefalozine (1gm); Metoclopramide (10mg); Ranitidine (50mg); Ketorolac (30mg) and Tranexamic Acid (500mg). The patient had been infused with and consumed 2 bottles of D5LRS (1L) and 1 bottle of PLRS (1L).
DIA GNO ST IC S AN D IM PLI CATION S
Hematology (June 11, 2008)
Result: blood type “O” Rh positive The hematology test was completed to identify the patient’s blood type and Rh blood group. Laboratory technicians determine the patient’s blood type and then either cross match it to the potential donor or screen it for the presence of antibodies; this is done to avoid blood type mismatches which may trigger damaging antigen-antibody responses (agglutination) or rupture of red blood cells (hemolysis).
Reference: Tortora, et. al.; Principles of Anatomy and Physiology; 11th edition
Complete Blood Count (June 11, 2008)
Hgb Hct Leukocyte Neutrophils Lymphocytes Eosinophils Platelet Normal values 120-160 g/L 0.37-0.47 Vol % 5-10 10^9/L 0.5-0.7 0.2-0.4 0-0.07 150-440 x10^9/L Patient Value 127 g/L 0.38 Vol% 10.15 10^9/L 0.82 0.17 0.01 383 x 10^9/L
The complete blood count was done to identify if the patient’s active bleeding has taken effect on the present level of blood components, apparently, no significant deviation is seen.
Reference: Smeltzer, et. al.; Textbook of Medical Surgical Nursing; 10th edition
Urinalysis (June 11, 2008) Color: dark yellow Appearance: turbid Reaction: acidic (ph6) Specific Gravity: 1.015 Albumin: (+) Sugar: (-)
Pus cells: 40-50/hpf RBC: 20-30/hpf Bacteria: some/hpf Yeast Cells: none found Mucus threads: loaded Epithelial cells: some Amorphous Urates/Phosphates: few
A urinalysis is a diagnostic physical, chemical, and microscopic examination of a urine sample (specimen). Specimens can be obtained by normal emptying of the bladder (voiding) or by a hospital procedure called catheterization. Red blood cells in the patient’s
urine can be due to bleeding in the genitourinary tract as a result of systemic bleeding disorders or bacterial infections while pus in the urine may be indicative of urinary tract infection.
Ultrasound- whole abdominal Sonogram (June 11, 2008)
The uterus is midline, anteverted and normal in size, measuring 5.9 x 3.4 x 4.9 cm. It shows homogenous echotexture. The endometrial stripe is thin (5.0mm). A complex mass is noted at the left adnexal area adjacent to the ovary, measuring 3.0 x 2.3 cm. There is mild dilation of the right fallopian tube which is fluid filled. The right ovary is intact. The cul-de-sac is clear. IMPRESSION: Left adnexal mass, suspicious of ectopic pregnancy Mild Hydrosalpingitis, Right Unremarkable Sonogram of the liver, gallbladder, pancreas, spleen, kidneys, urinary bladder Medical sonography (ultrasonography) is an ultrasound-based diagnostic medical imaging technique used to visualize muscles, tendons, and many internal organs, their size, structure and any pathological lesions with real time tomographic images. An adnexal mass is a lump in the tissues near the uterus, usually in the ovary or fallopian tube, which usually include ovarian cysts, ectopic (tubal) pregnancies, and benign (noncancerous) or malignant (cancerous) tumors. A hydrosalpinx is a distally blocked fallopian tube filled with serous or clear fluid. The blocked tube may become substantially distended giving the tube a characteristic sausage-like or retort-like shape.
References: http://en.wikipedia.org/wiki/Hydrosalpinx; http://en.wikipedia.org/wiki/Hydrosalpinx; http://en.wikipedia.org/wiki/Ultrasound
Histopathology (Submitted- May 12, 2008)
(Reported- May 18, 2008)
Diagnosis: Abortion, incomplete, 11 weeks age of gestation, G8P7 (7016); status completion curettage Histopathologic Diagnosis: Uterine Curettings- Decidual tissues, chorionic villi, blood clots Gross description: Specimen consists of irregular fragments of tan membranous and spongy tissues admixed with blood clots forming an aggregate measuring 3 x 3 x 3 cm
Histopathology refers to the examination of a biopsy or surgical specimen by a pathologist, after the specimen has been processed and histological sections have been placed onto glass slides. This is the most important tool of the anatomical pathologist in routine clinical diagnosis of cancer and other diseases. This was done to identify the tissues extracted
during the patient’s completion curettage. The test seems to have identified tissues resembling the products of conception hence the identified diagnosis suggests an incomplete abortion.
MEDI CATION LI ST
Ranitid ine (5 0mg) Histamine H2 receptor antagonist
Indication: Relief of heartburn associated with acid indigestion and sour stomach. Treatment of GERD. Action: competitively inhibits gastric acid secretion by blocking the effect of histamine on H2 receptors. Both daytime and nocturnal basal gastric acid secretion, as well as foodand pentagastrin – stimulated gastric acid are inhibited. Contraindications: cirrhosis of the liver, impaired renal or hepatic function Side effects: Headache, abdominal pain, consitipation, diarrhea, nausea and vomiting. Nursing Considerations: o Give antacids concomitantly for gastric pain although they may interfere with ranitidine absorption. o Assess stomach pain o Avoid alcohol, aspirin – containing products, caffeine containing products (may increase stomach acid) Cefazolin ( 1gm) First generation cephalosporin Indication: UTI Action: Antibacterial – interferes with the final step in cell wall formation, resulting into unstable cell membranes that undergo lysis. Also, cell division and growth are inhibited First generation – effective activity against gram – positive microorganisms (S. aureus) and relatively mild activity against gram – negative microorganisms( E.coli). Side effects: Diarhhea, N/V, abdominal pain, rash, fever Nursing considerations: o Take as directed/ complete subscription
o Report adverse effects Tranexamic Aci d (500m g)
Antifibrinolytic agent Indication: Active vaginal bleeding Action: Tranexamic acid is a competitive inhibitor of plasminogen activation, and at much higher concentrations, a noncompetitive inhibitor of plasmin. Contraindications: active intravascular clotting, acquired defective color vision, since this prohibits measuring one endpoint that should be followed as a measure of toxicity Side effects: Gastrointestinal disturbances, Hypotension Nursing Considerations: o Use cautiously on pregnant women o Patients with a previous history of thromboembolic disease may be at increased risk for venous or arterial thrombosis. Nalb uphi ne (10 mg) Brand name: Nubain Drug Classification: Opioid analgesic Indications: Management of moderate to severe pain. Also used as an analgesic during labor, as a sedative prior to surgery, and as a supplement in balanced anesthesia. Action: Binds to opiate receptors in the CNS. Alters the perception of and response to painful stimuli, while producing generalized CNS depression. In addition, has a partial antagonist property, which may result in opioid withdrawal in physically dependent patients. Contraindications: Hypersensitivity to nalbuphine or bisulfites. Patients who are physically dependent on opioid analgesics and have not been detoxified (may precipitate withdrawal). Caution: Head trauma, increased intracranial pressure; severe renal, hepatic, or pulmonary disease; hypothyroidism; geriatric/debilitated patients. Adverse reactions: Sedation, headache, dizziness, vertigo, respiratory depression, nausea and vomiting, clammy feeling. Nursing Considerations: o Assess type, location, and intensity of pain. o Assess BP, PR, and RR before and periodically during administration. o Prolonged use may lead to physical and psychological dependence and tolerance. o Patient teaching: Instruct on how and when to ask for pain medication. Advise to call for assistance when ambulating.
Ketor olac (30 mg) Brand name: Toradol, Ketomed Drug Classification: Non-opioid analgesic; NSAID Indications: Short term management of pain. Management of ocular itching due to seasonal allergic conjunctivitis. Action: Inhibits prostaglandin synthesis producing peripherally mediated analgesia. It also has an antipyretic and an anti-inflammatory property. Contraindications: Cross-sensitivity with other NSAIDs may exist. Lactation. Caution: History of GI bleeding, CVD, and renal impairment. Adverse reactions: Drowsiness, abnormal vision, asthma, pallor. Nursing Considerations: o Assess pain, noting type, location, and intensity. o Patients with asthma, aspirin-induced therapy, and those with nasal polyps are at increased risk for developing hypersensitivity reactions. o Patient Teaching: Instruct on how and when to ask for pain medications.
Metoclop ramide ( 10 mg) Brand name: Plasil Drug Classification: Anti-emetic Indications: It is used short-term to treat heartburn caused by gastroesophageal reflux in people who have used other medications without relief of symptoms. It is also used to treat slow gastric emptying in people with diabetes (also called diabetic gastroparesis), which can cause nausea, vomiting, heartburn, loss of appetite, and a feeling of fullness after meals. Action: Metoclopramide increases muscle contractions in upper digestive tract. This speeds up the rate at which the stomach empties into the intestines. Contraindications: In patients with a history of hypersensitivity to metoclopramide or any of the components. In the presence of GI hemorrhage, mechanical obstruction, or perforation. In those with pheochromocytoma, in epileptics and in those with extrapyramidal reactions. Caution: Pregnancy and lactation. Adverse reactions: Restlessness, drowsiness, fatigue and lassitude. Less frequent reactions are insomnia, extrapyramidal symptoms, headache, dizziness, nausea, galactorrhea, gynecomastia, rash and urticaria, or bowel disturbances. Nursing Considerations:
o Extract from history if the patient has epilepsy, GI perforation, pheochromocytoma, or bleeding in the intestines. o The drug can pass into the breast milk and may harm the baby. o Metoclopramide is usually taken before meals and at bedtime. o Patient Teaching: Instruct to take with a full glass of water.
THI RTE EN AR EAS OF ASSESS MEN T
I. Psycholog ical St atus Mrs. M. T. M. is 42 years old. She is an Igorot and was born and raised in San Vicente, Baguio City. Her parents are also from San Vicente, Baguio City. Presently, her family is residing in San Vicente, Baguio City. They live in an owned, concrete 1-storey house with two rooms. The patient is a Roman Catholic and verbalized that she has no beliefs or practices that may hinder health care rendered to her. She is married and was blessed with 6 children. She is a retailer of ready-to-wear clothes or mostly commonly known as “wagwag”. According to her, she avails of the dry goods from Manila. The patient is accommodated at the Pay ward section of the OB ward of Saint Louis University-Hospital of the Sacred Heart. The patient is a mother to 6 children. She verbalized that they have good family relationships. The patient’s second child is the one staying with her in the hospital. All in all, there are 9 members of her family and they live together. Prior to hospitalization, she was independent; however, during her confinement, her daughter had been assisting her in performing ADLs as the patient’s condition necessitated dependency since the procedures performed rendered her to be temporarily in need of assistance in doing activities she used to do alone. Her diversional activities include taking care of her children, doing household chores, or managing in her business. Her OB history is as follows: *OB score-G7P6 (6016) G1: 1984, home delivery, NSD, term baby boy G2: 1989, home delivery, NSD, term baby boy G3: 1991, home delivery, NSD, term baby boy G4: 1996, home delivery, NSD, term baby girl G5: 2001, home delivery, NSD, term baby boy G6: 2006, home delivery, NSD, term baby girl G7: 2008, spontaneous abortion, 12 weeks AOG II . Mental and Em otional Status
The patient is awake and coherent, oriented to time, place, and person. She is a high school graduate and is able to read, write, comprehend and follow directions. Regarding her health problem, she is grateful in having undergone left salpingectomy and appendectomy which afforded her relief from pain. She has no unusual beliefs about the cause of her health problem. This is her second hospitalization. Her chronological age is directly proportional to her developmental age as she is open and approachable, and is able to converse with the student nurses without any observable signs or significant inconsistencies such as speech defects, stuttering or inability to understand or follow the conversational framework with difficulty. II I. E nvironm ental Status The patient is in need of assistance when standing and going to the comfort room. There are two more patients in the room. There is adequate lighting and ventilation. The comfort room is approximately less than 10 feet away from the patient’s bed. Side tables are located at the right and left upper head of the bed where her things are readily accessible. There was no presence of side rails but there are head and foot rails. The patient is with an intravenous line on her right hand. An IFC was inserted last June 14, 2008 in preparation for her operation and was ascetically removed after her surgery on June 15, 2008. IV. S ensory Status a. Visual status: the patient has no known visual deficits. She also has no unusual sensations like blurring of vision. The patient does not use any corrective like contact lenses or eyeglasses or prosthetic devices like artificial eyeballs. She has pale palpebral conjuctiva and 2-3 mm pupils, equally round and reactive to light and accommodation. Her eyes are normally symmetrical and in level with each other. There are also symmetrical eye movements. b. Auditory status: the patient is able to distinguish and respond to voices. She verbalized that she has no known auditory deficits and unusual sensations like ringing or buzzing. She has no auditory corrective devices. The patient’s pinnae are bilaterally symmetrical with the lateral canthus of the eyes and in line with each other. c. Olfactory status: the patient is able to discriminate odors and there are no unusual sensations. The patient has no colds. d. Gustatory status: the patient is able to discriminate sweet, salty, bitter and sour tastes. She has no unusual sensations. She verbalized that there was no change in her appetite. e. Tactile status: the patient is able to discriminate different tactile sensations and has no unusual sensations.
Speech formulation and perception: the patient has intact speech organs. The patient verbalized that her whole set of upper jaw teeth is a denture. The patient is able to understand and initiate speech and has no deficits in phonation.
g. Sensory environment: the hospital setting and routine such as vital signs taking are tolerated well by the patient. V. Motor St atus Upon admission, the patient was weak. Upon assessment, the patient is unable to ambulate properly and needs assistance when standing and going to the comfort room. There was good body coordination as well as stability. The patient can tolerate range of motion exercises. There are no muscular abnormalities and there is good muscle tone and mass. The patient’s muscle strength is as follows: 5/5 5/5
The patient was instructed to remain flat on bed for a few hours after the surgery. However, there were no further medical restrictions on activity and early ambulation was encouraged. The patient has an abdominal binder over her wound dressing and is patient is right handed. VI. Nutritio nal Status The patient usually has three main meals and two snacks. She prefers vegetables (highland or lowland), coffee, and soda drinks particularly coke. She also prefers bread for snacks. According to her, she has good appetite prior to and even during hospitalization. However, prior to and after her surgery, she was on NPO. On the morning of June 15, 2008, she had already passed flatus and stool. There was no further physician’s order regarding her diet. The patient has a medium structured body. She has moist skin as well as moist buccal cavity. She has good capillary refill and good skin turgor. The patient has a denture. She has intact oral cavity. The patient is awake and is able to swallow but was remained on NPO, a day after her surgery. VII. Elim ination Status
The patient has been diagnosed with urinary tract infection as seen and implied by increased pus cells in her urinalysis. During her operation last June 14, 2008, she was inserted with an IFC draining yellowish urine and is adequate with urine output of more than 30cc/hour. The IFC was eventually removed on June 15, 2008 in the presence of flatus. During the night shift of her 1st day post operatively, the patient was however observed to have decreased urinary output and was then therefore referred to the resident on duty for further management. The patient had remained on bed for a number of hours and was hesitant to ambulate due to the discomfort and pain she felt hence reported that she had defecated once. VIII . Fl uid an d Electrolyte St atus
On average, she drinks for about 8-10 glasses of water a day. She also drinks additional coffee and carbonated drinks. The patient was maintained on NPO after her operation but her presence of flatus and that she already defecated may indicate progress on her nutritional intake. The patient has good skin turgor. IX. Circu latory St atus Pulse rate is of regular rhythm, ranging from 70 – 75 beats per minute. Blood pressure range is from 110/70- 120/80. Her capillary refill was 2 seconds. Client manifests good, adequate and effective circulation as seen by the absence of cyanosis and dizziness. In addition the client is awake and alert which manifests good level of consciousness. X. Temp eratur e Status Before and upon admission, patient’s temperature is within normal (range of 36.4 – 37.5 C). The patient’s temperature was stable during hospitalization; no fever was experienced. XI. Integum entary St atus The patient has a fair complexion. The patient had a dry and intact binder over wound dressing on the abdominal area due to her appendectomy and salphingectomy. No signs of muscle wasting or clubbing nails were observed. The patient has a good skin turgor. XII. Comfort and Rest Status
Normally, she sleeps for about 8 hours. During hospitalization, she verbalized that she does not have any concern regarding her hours of sleeping but was observed to be awakened from sleep on several occasions to converse with the other patient beside her. She was maintained flat on bed immediately after her operation but already advised and assisted to be on her desired comfortable position as ordered by her physician. She claimed to feel post-operative pain over her abdomen. She described it to be non-radiating and of moderate intensity. XIII . Respiratory Status The patient has no problems regarding her respiratory status. Her respiratory rate has a range of 20-25 breaths per minute. She has an effective airway clearance and has an effective breathing pattern which provides adequate gas exchange and results to a good level of consciousness and non-cyanotic peripheral status.
LIS T O F P RI OR ITIZ ED P RO BL EM S
Actual problems 1. Acute pain related to tissue trauma secondary to surgery 2. Impaired skin integrity related to trauma secondary to surgical incision 3. Impaired tissue integrity related to trauma to integumentary and subcutaneous tissues secondary to abdominal surgery 4. Activity intolerance related to temporary immobility secondary to previous surgery 5. Impaired physical mobility related to discomfort upon movement secondary to surgery 6. Impaired transfer ability related to trauma and discomfort upon moving secondary to effects of surgery 7. Self-care deficit: bathing/hygiene, and dressing related to discomfort upon moving secondary to effects of surgery 8. Acute urinary retention may be related to use of a medication (opioid) with side effects of urinary retention 9. Ineffective role performance related to physical health alterations 10. Interrupted family process related to situational changes secondary to physical health alterations 11. Disturbed sleeping pattern related to interruptions for therapeutic, monitoring and other generated awakening Potential problems 1. Risk for constipation related to insufficient physical mobility 2. Risk for infection related to inadequate primary defenses (broken skin integrity)
3. Risk for injury related to altered mobility status secondary to surgery 4. Risk for imbalance nutrition: less than body requirements related to decreased volume of ingested food during hospitalization 5. Risk for imbalanced body temperature related to trauma affecting temperature regulation
PRI OR ITI ZA TIO N OF PRO BL EM S
Abraham Maslow (1954) attempted to synthesize a large body of research related to human motivation. Prior to Maslow, researchers generally focused separately on such factors as biology, achievement, or power to explain what energizes, directs, and sustains human behavior. Maslow posited a hierarchy of human needs based on two groupings: deficiency needs and growth needs. Within the deficiency needs, each lower need must be met before moving to the next higher level. Once each of these needs has been satisfied, if at some future time a deficiency is detected, the individual will act to remove the deficiency. The first four levels are: 1) Physiological: hunger, thirst, bodily comforts, etc.; 2) Safety/security: out of danger; 3) Belonginess and Love: affiliate with others, be accepted; and 4) Esteem: to achieve, be competent, gain approval and recognition. According to Maslow, an individual is ready to act upon the growth needs if and only if the deficiency needs are met. The fifth level is Self-actualization. It means to find self-fulfillment and realize one's potential. Self-actualized people are characterized by: 1) being problem-focused; 2) incorporating an ongoing freshness of appreciation of life; 3) a concern about personal growth; and 4) the ability to have peak experiences.
LIST OF PRIORITIZED
PROB LEMS CLASSIFICATION (Actual/Potential) Actual Actual Actual
PRIORITIZED PROBLEMS 1. Acute pain related to tissue trauma secondary to surgery 2. Impaired skin integrity related to trauma secondary to surgical incision 3. Impaired tissue integrity related to trauma to integumentary and subcutaneous tissues secondary to abdominal surgery
4. Activity intolerance related to temporary immobility secondary to previous surgery 5. Impaired physical mobility related to discomfort upon movement secondary to surgery 6. Impaired transfer ability related to trauma and discomfort upon moving secondary to effects of surgery 7. Acute urinary retention may be related to use of a medication (opioid) with side effects of urinary retention 8. Disturbed sleeping pattern related to interruptions for therapeutic, monitoring and other generated awakening 9. Self-care deficit: bathing/hygiene, and dressing related to discomfort upon moving secondary to effects of surgery 10. Ineffective role performance related to physical health alterations 11. Interrupted family process related to situational changes secondary to physical health alterations 12. Risk for constipation related to insufficient physical mobility 13. Risk for imbalance nutrition: less than body requirements related to decreased volume of ingested food during hospitalization 14. Risk for infection related to inadequate primary defenses (broken skin integrity) 15. Risk for imbalanced body temperature related to trauma affecting temperature regulation 16. Risk for injury related to altered mobility status secondary to surgery
Actual Actual Actual Actual Actual Actual Actual Actual Potential Potential Potential Potential Potential
NU RS IN G C ARE P LAN S
Explanation of the problem
P: s/p Salpingectomy, The patient had undergone an Elective Appendectomy abdominal ultrasound with the following results: Left adnexal S: “ Complained to have mass suspicious of ectopic pain felt over the pregnancy and Mild abdominal; area, Hydrosalpingitis, Right characterized as stabbing in nature, with no radiation, rated as 7/10, aggravated by movement, and Salpingectomy, and Elective alleviated by rest” Appendectomy was performed to repair the assessed damage O: >Appears weak >Confines self to bed and moves minimally A Surgical incision was done >Groans upon movement
Objectives LTO : After hospitalization, the patient will a) assume ADLs without pain or discomfort b) verbalize that she is completely pain free
Interventions Diagnostics: 1.Monitor vital signs
Rationale Diagnostics: > For establishment of baseline data and an objective parameter/ indication of increasing pain.
ST O : Within the shift the patient will be able to
a) identify and describe pain felt
b )verbalize that her pain decreased from to
2. Use a pain assessment scale to Comprehensively assess and record pain using objective criteria such as location, characteristics, onset/duration, frequency, quality, severity and precipitating or aggravating factors before and after performing nursing interventions. 3. Note location of surgical Incisions
> baseline for assessing changes in pain level and evaluating interventions
c) enumerate at least 3 strategies of pain relief Nociceptors or free nerve correctly endings in the skin responded to >Asks for assistance in the potentially damaging stimuli d) perform deep breathing ADL’s (surgical cutting) exercises for pain management correctly >Facial Grimacing observed upon movement Nociceptive actions are > Seen holding abdomen transmitted to the peripheral nervous system >Vital signs: BP: 110/70 mmHg RR: 25 cpm PR: 75 bpm The brain receives the stimuli T: 36.5 C and interprets pain depending the type of fiber delivering the impulse A: Acute pain related to tissue trauma secondary to surgery Acute pain related to tissue trauma secondary to surgery >Hesitant movement to initiate
>Location of Surgical incisions can influence the amount of post operative pain felt, this also serves as a medium of comparison with the clients pain rating > Identify factors influencing the pain response Therapeutics:
4. Assess patient perception and beliefs about pain felt
1. Inform patient that the health worker acknowledges that the patient’s pain is real by: a. Listening to the patient’s subjective complaints b. Conversing therapeutically with the patient c. Anticipating and attending
>Promotes a feeling of assurance, therefore decreasing the burden >Distracts the patient from concentrating on the pain
>Decreases the patient’s
Reference: Smeltzer et. al.; Textbook of Medical Surgical Nursing;10th edition Doenges et. al; Nurses Pocket Guide; 9th edition
Assessment Explanation of the problem P: s/p Salpingectomy, The patient had undergone an Elective Appendectomy abdominal ultrasound with the following results Left adnexal S: “Kakatapos lang ng mass suspicious of ectopic operasyon ko kanina” pregnancy and Mild Hydrosalpingitis, Right O : >Status post Salpingectomy, and Elective Appendectomy , day 1 Salpingectomy, and Elective Appendectomy was performed >With dry and intact to repair the assessed damage abdominal dressing and binder
LTO After hospitalization:
Rationale Diagnostics: >infection, through production of toxins and wastes increases the probability of tissue damage. >Provides a baseline that allows quick recognition of deviations in subsequent measurements >Serves as baseline data to evaluate the efficiency of nursing intervention >early recognition of undesirable signs and symptoms such as profuse bleeding is vital in preventing further complications >these substances may cause irritation to the patient’s skin and oral mucous membranes and may cause complications in the healing process of the abdominal wound
>Monitor for signs of -the patient’s surgical site will not have any infection complications such as infection -the patient’s wound will heal normally and well approximated. >Monitor vital signs every ST O: 4 hours After 8 hours of nursing interventions: -the patient’s suture site will remain intact and free from contamination
>Assess skin integrity -the patient or a skilled significant other will be > No foul odor noted in Surgical procedure required able to demonstrate at least 4-7 steps of proper the surgical site cutting into her skin and tissue wound dressing techniques and removing her appendix >Assess wound dressing >(+) facial grimace and and affected fallopian tube for drainage guarding behavior noted when ambulating >Vital signs: BP: 110/70 mmHg RR: 25 cpm Skin and Tissue trauma PR: 75 bpm secondary to the surgery > Monitor dietary intake, T: 36.5 C and avoid irritant food and fluid intake Presence of abdominal wound A: >Impaired skin integrity (surgical site) related to trauma secondary to surgical incision >Impaired tissue integrity related to trauma to integumentary and subcutaneous tissues secondary to abdominal surgery >Impaired skin integrity related to trauma secondary to surgical incision >Impaired tissue integrity related to trauma to integumentary and subcutaneous tissues secondary to abdominal
>Avoid handling and >pressure predisposes placing direct pressure on skin breakdown the suture area >Ensure safety by >to maintain the patency constantly checking on the of the patient’s tubings patient and assisting when like the Epidural catheter