PATIENT’S PROFILE

NAME: Patient “x” ADDRESS: Alano extension, Pagadian City SEX: Female BIRTHDATE: May 18, 1968 AGE: 41 y/o BIRTHPLACE: Davao del Sur NATIONALITY: Filipino RELIGION: Roman Catholic CIVIL STATUS: single FATHER’S NAME: Juanito Pantullana MOTHER’S NAME: Remedios Pantullana ADMISSION: DATE: February 28, 2010 TIME: 10:40 am Room/Ward: OB-WARD Chief complain: Hypogastric pain ADMISSION DIAGNOSIS: Uterine Myoma ATTENDING PHYSICIAN: Dr. Chandra Salvador HISTORY OF PAST ILLNESS: The patient was never been hospitalized before and had not experienced any kind of diseases. She only had mild illness such as cough, fever and headache. She also experienced dysmenorrhea in the 1st – 2nd day of her menstruation . HISTORY OF PRESENT ILLNESS: 3 years prior to admission, the patient noticed a mass on hypogastric area of her abdomen. She thought that it was only due to her loaded works and stress and so, she only consulted a “hilot”. She didn’t mind to have a consultation on a doctor because of lack of financial budget. 1 year prior to admission, the patient had undergone free medical check up from the company where she was working with and so, the UTZ’s result found out that she had an enlarged uterus with intramural myoma uterine.

PHYSICAL ASSESSMENT

GENERAL SURVEY: Received lying on bed conscious and coherent without IVF. Patient is conscious and coherent, and also responsive to certain questions and instructions given to her. Tension and increased alertness was noted on the patient upon receiving her. VITAL SIGNS: T = 36.3oC P = 70 bpm R = 26 cpm BP = 120/70 mmHg

SKIN

warm to touch on upper extremities like in the palm of her hands cold temperature on the sole of the client Fair skin and brown in color Has a good skin turgor upon palpation Presence of scars on both upper and lower extremities

• • • •

HAIR • Equally distributed hair • • • • Black with some white hair in color Slightly coarse No nodules, lumps and tenderness noted upon palpation Absence of lice and dandruff

NAILS • Nail beds are pinkish in color • •

Smooth texture short nails with dirt noted good capillary refill, less than 2 seconds

EYES • symmetrical • • • • pupils are equally round and reactive to light accommodation pupils are black in color sclera is white eyebrows and eyelashes are equally distributed

• •

eyelashes are slightly curve pupils constricts symmetrically when lighted with a penlight Blurred vision on her both eyes

EARS • no deformities • • • • • • symmetrical no cerumen and dirt noted uniform in color no discharges noted mobile, firm, and not tender upon palpation helix of ears are in line with the outer canthus of the eye

NOSE AND SINUSES • nose is located in the midline of the face • • • • • • • • • symmetrical proportionate to the face absence of discharges no nasal flaring uniform in color no skin breakdown nasal septum intact nasal hairs are evenly distributed no tenderness and pain upon palpation on facial sinuses

MOUTH • dry lips • • pinkish colored gums uvula is located at the midline of the soft palate

• • • • • •

teeth are yellowish in color with dental caries on his upper teeth hard palate is light pink in color tonsils are not inflamed buccal cavity is pinkish in color restricted tongue movement

NECK AND THROAT • neck muscles are equal in size • • • • • • absence of swollen lymph nodes trachea is centrally aligned no tenderness noted no thyroid gland enlargement noted thyroid gland ascends during swallowing equal strength during the assessment for his muscle strength

ANTERIOR AND POSTERIOR CHEST •

quiet respiration no palpitations, no deformities symmetrical in shape absence of adventitious breath sound upon auscultation vesicular breath sound was present heart is not enlarged spine is vertically aligned absence of masses right and left shoulders are at same height full and symmetric chest expansion percussion notes resonate except over the scapula no visible pulsations on anterior and posterior areas of thorax from observing them to the side

• • • • • • • • • •

AXILLA • presence of axillary hair


skin is intact little perspiration noted no nodules and tenderness noted

ABDOMEN • has an enlarge mass noted on hypogastric area • • • • • uniform in color no skin problems absence of bruits on all 4 quadrants no evidence of enlargement of liver and spleen liver is not palpable as well as the bladder

MUSCULOSKELETAL • • • • • •

has 10 fingernails and toenails uniform in color presence of scar in his calf and elbow presence of dirt in the fingernails and toenails no contractures noted Absence of tremors Has good muscle gait

NEUROLOGIC • • • • Able to talk with sense Oriented Able to remember past events in life Coordinated and verbally responsive

DOCTOR’S ORDER

Date & Time
2-28-10  Pls. admit  TPR every 4H  Soft diet  Labs: CBC FBS ECG CXR

Order

 for TAH once cleared  refer to Dr. Uy for CP clearance  Secure unit of FWB properly 2-28-10  Start Bisacodyl @ HS  Metronidazole 500mg 1 tab TID  Seen and axamined  History reviewed  No previous admission  BP: 100/60 HR= 76 RR= 16 3-01-10  Soft diet  Tea and crackers for lunch and dinner  NPO post midnight  For elective TAH  Secure Consent  Inform anesthesia on care OR personel  Start IVF D5LR @ 30gtts @6H Cefuroxime 750mg IVTT every 8H ANST Bisacodyl suppository II/ rectum @ 6pm SS enema @ 9pm or 6 Cleaning enema @ 5am until rectum is clear  All prep  FF up blood for standby  Continue V/S monitoring    

3-01-10 1:00pm

DIAGNOSTIC TEST Ultrasound Report Date: 04-13-09 Examination Performed: Pelvic ultrasound Impression: Enlarge uterus w/ intramural myoma Laboratory Result:
Hematology
WBCHemoglobin13.4 gms % Differential count: Segmented neutrophilsLymphocytesEosinophils74% 20 % .6 % 55-66% 20-35% 0.5-1% Bacterial infection Within normal range Within normal range

Date: 0225-10
3, 250 cu/mm

Normal Values
5,00010,0000/cumm 14-17gms%

Indication
infection anemia

Hematology Hemoglobin-

Date: 0302-10
12.4 gms %

Electrocardiogram Report 2-28-10 Analysis: 801 sinus rhythm, 401 short P-R internal DRUG STUDY

Doctor’s Order: Metronidazole 500mg 1tab q 8 hrs P.O. Generic Name: Metronidazole Brand name: Metrocream, MetroGel, Vaginal, Metrolotion, Noritate Classification: Anti-infectives. Antiprotozoals, Anti-ulcer Indication: Inflammatory papules and pustules of acne rosacea, bacterial vaginosis Mechanism of action: Unknown. May cause bacterial effect by interacting with bacterial DNA Dosage: 500mg P.O. Adverse Effects: dizziness, headache, cramps,pain, nausea, diarrhea, constipation, rash Contraindication: Contraindicated in patients hypersensitivity to the drug. Nursing Responsibilities: • Take full course of drug therapy; take the drug with food if GI upset occurs. • Do not drink alcohol • Your urine may appear dark; this is expected. Doctor’s Order: Cefuroxime 750mg q 8hrs ANST(-) Generic Name: Cefuroxime sodium Brand name: Kefurox, zinacef Classification: antibiotic, second generation cephalosporin Indication: pharyngitis, tonsillitis, infection of urinary and lower respiratory tract Mechanism of action: hinders and kills susceptible bacteria Adverse Effects: dizziness, headache, malaise, diarrhea, nausea Contraindication: hypersensitivity to cephalosporin Nursing Responsibilities: 1. Asssess pt’s infection before therapy and regularly thereafter 2. Be alert for adverse reactions and drug interactions Generic Name: Ranitidine Brand Name: Zantac Classification: Histamine 2 antagonist Mode of Action: Competitively inhibits the action of histamine at the H2 receptors of the parietal cells f the stomach, inhibiting basal gastric acid secretion and gastric acid secretion that is stimulated by food, insulin, histamine, cholinergic agonist, gastrin, and pentagastrin. Dosage: Ranitidine 50mg q8 IVTT Indication: Post surgery antacid to prevent ulcer formation Contraindication: Hypersensitivity to ranitidine, lactation. Adverse Effects: malaise, insomnia, somnolence, urticaria, tachycardia, bradycardia, leukopenia, pancytopenia, thrombocytopenia, gynecomastia, impotence, hepatitis Nursing Responsibilities: Instruct patient to take his meal if nausea or vomiting occurs. metoclopramide Apo-Metoclop (CAN), Maxeran (CAN), Maxolon, Nu-Metoclopramide (CAN), Drug classes: GI stimulant, Antiemetic, Dopaminergic-blocking agent
Therapeutic actions

Stimulates motility of upper GI tract without stimulating gastric, biliary, or pancreatic secretions;
Indications

Relief of symptoms of acute and recurrent diabetic gastroparesis

• • •

Short-term therapy (4–12 wk) for adults with symptomatic gastroesophageal reflux who fail to respond to conventional therapy Parenteral: Prevention of nausea and vomiting associated with emetogenic cancer chemotherapy Prophylaxis of postoperative nausea and vomiting when nasogastric suction is undesirable

Contraindications: Contraindicated with allergy to metoclopramide; GI hemorrhage, mechanical obstruction or perforation; pheochromocytoma Adverse effects

• •

CNS: Restlessness, drowsiness, fatigue, lassitude, insomnia, extrapyramidal reactions, parkinsonism-like reactions, akathisia, dystonia, myoclonus, dizziness, anxiety CV: Transient hypertension GI: Nausea, diarrhea

Nursing considerations

• Take this drug exactly as prescribed. • Do not use alcohol, sleep remedies, sedatives; serious sedation could occur. • GENERIC NAME: BISACODYL BRAND NAME(S): Dulcolax, Fleet Bisacodyl, Magic Bullet Classification: stimulant laxative Action: It acts by irritating the digestive tract and stimulates intestinal activity Indication: . It is used to treat constipation or to clean out the intestinal tract before bowel examinations or bowel surgery Adverse Effects: stomach ache, cramping, weakness, sweating, irritation of the rectal area, diarrhea, or dizziness Contraindication: hypersensitivity to the drug Nursing Responsibilities: If the patient is under 6 years of age, consult child's doctor before using this medication. Generic Name: Ketorolac tromethamine Brand Name: Toradol Classification: NSAID, Nonopioid analgesic Mode of Action: Reduces the production of prostaglandins, chemicals that cells of the immune system make that cause the redness, fever, and pain of inflammation and that also are believed to be important in the production of non-inflammatory pain. It blocks the enzymes that cells use to make prostaglandins (cyclooxygenase 1 and 2). As a result, pain as well as inflammation and its signs and symptoms - redness, swelling, fever, and pain - are reduced. Dosage: Ketorolac 30mg q8 IVTT Indication: For short-term management (up to 5 days) of moderately severe acute pain that otherwise would require narcotics. It most often is used after surgery. Contraindication: Hypersensitivity to ketorolac, renal Impariment, aspirin allergy Adverse Effects: gastric or duodenal ulcer, renal impairment, liver failure, dysuria, bleeding, platelet inhibition, neutropenia, leukopenia, pancytopenia, thrombocytopenia, bone marrow depression Nursing Responsibilities: Infuse slowly as a bolus over no less than 15 seconds.
NALBUPHINE HYDROCHLORIDE NUBAINE Drug Class: Narcotic agonist-antagonist analgesic

Therapeutic Actions: Nalbuphine acts as an agonist at specific opioid receptors in the CNS to produce analgesia, sedation but also acts to cause hallucinations and is an antagonist at µ receptors Indications: Relief of moderate to severe pain. Preoperative analgesia, as a supplement to surgical anesthesia, and for obstetric analgesia during labor and delivery. Contraindications/cautions: Contraindications: hypersensitivity to nalbuphine, sulfites; lactation. Adverse Effects: Sedation. Clamminess, sweating headache, nervousness, restlessness, depression, crying, confusion, faintness, hostility, unusual dreams, hallucinations, euphoria, dysphoria, unreality.

ANATOMY AND PHYSIOLOGY

Vagina: A muscular passageway that leads from the vulva (external genitalia) to the cervix. Cervix: A small hole at the end of the vagina through which sperm passes into the uterus. Also serves as a protective barrier for the uterus. During childbirth, the cervix dilates (widens) to permit the baby to descend from the uterus into the vagina for birth. Uterus: A hollow organ that houses the baby during pregnancy. During childbirth, the uterine muscles contract to push out the baby. Each month, unless a fetus has been conceived, the uterine wall sheds its lining (see The Menstrual Cycle and Ovulation below). Ovaries: Two organs that produce hormones and store eggs. Each ovary releases one egg per month. Fallopian tubes: Muscular tubes that eggs released from the ovaries must traverse to reach the uterus.
Kinds of Fibroids/myoma depends on their orientation in the uterine wall

PATHOPHYSIOLOGY
Predisposing Factor: Age of Patient: 41 y/o Gender: Female Stress Precipitating Factor: Hyperestrogenic state Nulliparaty

Diagnostic Test: Ultrasound: Impression: Enlarge uterus w/ intramural myoma CBC Treatment: GnRH Analogs

Benign tumors originating in the smooth muscular uterine tissue. Stress within the myometrium S/S: Abdominal discomfort Urinary frequency Prolonged bleeding with period Heavy menstrual bleeding Sensation of fullness

Simple proliferation of smooth muscle cells Development of Leiomyomas (Fibroid)

Increased fibroid growth Myoma removed Complication : Infertility Anemia Infection Surgical Mngt: TAH

Decreased Fibroid growth

Patient recover

Blood clot Infection Damage to urinary tract or bladder during surgery Early onset of menopause Rarely death

Sign up to vote on this title
UsefulNot useful