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JENNIFER C.

HISOLER, RN

STATION 8B

DECEMBER 14, 2015

CASE STUDY
I. Nursing Health History
a. Biographic Data
b.
Date and Time Admitted: December 9, 2015 7:00 PM
Patients Name: Sampaga, Marissa Nobleza Date of Birth: October 12, 1974 PIN No.: 150022968546
Address: Corentians Subd., Masulok Basak, Lapu-Lapu City Age: 41 Sex: Female Room No.: B - 835
Previous Hospitalization: Cholecystectomy (2006)
Allergies: None
.
Religion: Roman Catholic
Citizenship: Filipino
Status: Married
.
SpO2
BP
HR
RR
Temp
Weight
Height(cm) Pain
Fall Risk
(kg)
Score
(Numeric)
100%
110/70
96
18
36.5
70.00
163.50
8/10
Low
Attending Physician: Panares, Belinda Noval
.
Admitting Diagnosis/Impression: G3P2 (2002) AOG 17 1/7 wks; Multiple Uterine Contraction, Premature
Uterine Contraction, Multiple Myoma
.
c. Chief Complaint: Hypogastric Pain
d. Histoy of Present Illness:
3 days PTA, noted onset off intermittent cramping hypogastric pain with pain score of 8/10
occurring every 5-10 mins lasting 30-40 secs. No vaginal bleeding, no watery discharges. Patient
self medicated with Paracetamol 500mg/tab tid po, with relief. No consult on the day of admission.
Condition persisted. Prompting consult with attending physician and advised admission.
(-) dysuria, (-) foul smelling, (-) pruritic, (-) vaginal discharges,
II. Patterns of Functioning (Gordons Functional Health Pattern)
1. Health Perception - Health Management Pattern
The patient says that she is healthy because she is happy and she lives her life to the fullest, she rated
her health as 8 out of 10. She also said that the most important thing to keep her healthy is to eat proper
diet with regular exercise, and that would the patients perception of health. The patient consults to a
private doctor every time she feels that there something wrong with her health and strongly believes that
with following the doctors prescription, proper intake of medicines and doing regular exercises, the
illness will be treated, but with no exact schedule. The patient does perform a breast self exam and not
even use alcohol, tobacco drugs and caffeine as she believes that she wont get a good benefit as form it.
2. Nutritional - Metabolic Pattern
The patient eats three times a day. She doesnt follow a certain type of diet and usually she chooses food
which can be easily cooked. The patient doesn't find any difficulties when regards to eating the meals on
time because she eats her meal three times a day at 8 in the morning for breakfast, 12 in the afternoon
for lunch and 7 in the evening for dinner.
The patient drinks water every time she feels thirsty with 3-4 glasses a day or 1.5L/day and doesnt find
any difficulties in chewing or swallowing the food. She also stated that she has no allergy for a certain
kind of foods.

3. Elimination Pattern
The patient usually moves her bowel once a day with a light brown color and soft consistency of the
stool and doesnt notice any recent changes of her bowel pattern.
Her last bowel movement is on December 11, 2015
The patient usually voids 6-8 times a day with light yellow color urine with no bleeding present or any
abnormalities found.
4. Activity - Exercise Pattern
The patient doesnt have a regular routine for exercise.
Her leisure activities include doing house chores and watching tv.
5. Sleep and Rest Pattern
She usually wakes up at 5 am and sleeps at about 10 pm.
Her sleeping aids would include 1 pillow and a blanket.
She does not use any medications or pills to fall asleep but she cannot sleep when it is so hot and needs
the aid of the electric fan.
6. Cognitive Perceptual Pattern
As of now, the patient is not suffering from any impairment and she can use her senses very well.
The patient can understand some of our questions and can comprehend our questions.
7. Self Perception Self Concept Pattern
The patient is a friendly person; she loves to socialize with her friends in their neighborhood. She
considered herself as a holistic human being as long as her complete, healthy and her family are always
there for her. She wants to have good health and live her life to the fullest.
She considers her strengths as healthy and considers her illness as her weakness.
8. Role Relationship Pattern
The patient has a sister, As the Eldest, it is her responsibility to look for her younger sister.
9.

Sexuality Reproductive Pattern


The patient Menarche was on the year 1990 at the age of 16.
Her Menstrual cycle is regular for 7-8 days without dysmenorrheal and consumes 6 pads/day.
Her LMP is on August 5, 2015, AOG of 17 1/7 and EDC of May 11, 2016 or May 17, 2016 (EUTZ).
Obstetrical History of G3P2(FT 2 PR 0 AB 0 LS 2).
She had her Pap Smear on Oct 2015 and a result of negative.
She had her Mammogram on 2014 and a result of negative.
She does not perform Breast Self Exam.
She does not use any birth control measures.

10. Coping Stress Tolerance Pattern


The patient reduces her stress and copes with her disease by sleeping and watching tv.
11. Value Belief Pattern
The most important people in her life were her family or specifically her parents are the factors that
influence her in decision-making and the source of her hope and strength.
She does pray a lot such as thanking God for the blessings she receives and when someone is ill or
hospitalize.

III. Physical Examination:


1. INTEGUMENTARY SYSTEM
A. Skin
Color: brown
Texture: smooth
Moisture: warm & dry
Turgor: good turgor
Lesions: no skin
lesions/breakdown
B. Hair
Color: black
Amount and Distribution: evenly
distributed
Texture: smooth
Parasites: no pediculosis
C. Scalp
Symmetry: symmetrical
Texture: smooth
Lesions: no lesions
D. Nail
Color: pinkish
Shape: convex
Texture: firm
Condition of the Nail bed: normal
Capillary Refill Test: <2 seconds
2. HEAD AND NECK
A. Head
Size: normal/norm cephalic
Shape: rounded/symmetrical and
Contour rounded
Consistency: symmetrical contour
B. Face
Symmetry: symmetrical
Facial Features: symmetrical
C. Neck
Appearance: symmetrical
ROM: rotates head without
Tenderness
Trachea Position: midline
Lymph Node: no lumps or
masses
3. EYES
Position & Appearance: clear
and bright; in parallel alignment
Blinking: able to perform
Lacrimal Apparatus: no swelling,
redness, or drainage
PERRLA: NA
Visual Acuity: NA
Peripheral Vision: normal
Extraoccular Movement: present

4. EARS
External Ear Size: symmetrical
Shape: helix/normal
Location: in line with inner and
outer canthus
Lesions: no lesions
Tenderness: non tender
Cerumen: NA
Color: NA
Consistency: NA
Hearing acuity: normal
5. NOSE AND SINUS
A. External Nose
Skin appearance: consistent with
the facial skin
Nares: able to flare
Tenderness: non tender
B. Internal Nose
Appearance: nose flaring noted
Septum: NA
Sinuses: not fluid-filled
Tenderness: NA
6. MOUTH AND OROPHARYNX
A. Lips
Color: pinkish
Consistency: soft
B. Buccal Mucosa
Color: pinkish
Consistency: soft
C. Gums
Color: pinkish
Consistency: rubbery
D. Teeth
Number: NA
Condition: NA
Color: NA
E. Tongue
Symmetry: NA
Movement: NA
Color: pinkish
Consistency: NA
F. Tonsils
Position: NA
Tenderness: NA
Color: NA
7. BREAST
- INSPECTION
A. Breast:
Size: NA
Symmetry: symmetrical

Shape: NA
Color: NA
B. Areola & Nipple:
Size: NA
Color: NA
Shape: NA
Texture: NA
Discharges: No discharges
-PALPATION
Temperature: warm
Turgor: NA
Tenderness: NA
Mass: negative
Lymph Nodes: not palpable
8. ABDOMEN
-INSPECTION
Color: consistent with other body
Venous pattern: NA
Umbilicus: NA
Contour: rounded, Gravid
Symmetry: symmetrical;
-AUSCULTATION
Bowel Sounds: no bruits/normal;
with FHT of 140-150 bpm
9. GENITOURINARYREPRODUCTIVE SYSTEM
Female Genitalia
Labia: NA
Swelling: NA
Lesions: NA
Inguinal Lymph Nodes: NA
Pubic hair Pattern: N/A
Color: N/A
10. ANUS AND RECTUM
Appearance: N/A
Swelling: NA
Lesions: NA
Redness: NA
11. MUSCULOSKELETAL
SYSTEM
Gait: N/A
Symmetry: symmetrical
Strength: full ROM
ROM:
Upper Extremities: full ROM
Lower Extremities: full ROM
12. NEUROLOGIC SYSTEM
Level of consciousness: conscious

Mood: cooperative
Speech: within normal limits

IV.

Cognitive Abilities: N/A


Sensory: within normal limit

Pathophysiology of the Uterine Myoma

Predisposing
Factors:
-Female
-41 years old
-G3P2(2002)

Etiology:
Unknown

Estrogen
Dominance or
increase in
Estrogen

Precipitating
Factors:
-Multiparity
-High Fat Diet
-Coffee/Caffeine
Intake
-Lifestyle

IF NOT
TREATED

Proliferation of
cells in uterus

Overgrowth
the
endometrial

Diagnostic:
Refer to Pelvic
Exam
Ultrasound

Myoma:
Development
of uterine
fibroid
Uterine Cavity:
Begins to
stretch or
increase in
Interference in
the vascular
supply
Degeneration
of the interior
part of fibroid

Signs/Symptoms:
-hypogastric pain
-Pain Score: 8/10
(Numeric)
-increased pelvic
Signs/Symptoms:
- Episodes of passage
blood clots
-refer to lab
results (HGB and
HCT )

V. Pertinent Laboratory/Examination Results


a. CBC Result
Date Release: 12/9/15
COMPLETE BLOOD COUNT RESULT
Blood Count
WBC
13.05
RBC
5.12
HGB
11.0
HCT
34.3
PLATELET
247
Blood Indices
MCV
67.1
MCH
21.5
MCHC
32.1
Relative Differential Count
Neutrophil
74.6
Lymphocyte
12.1
Monocyte
7.3
Eosinophil
4.7
Basophils
0.2
LUC
1.0
Absolute Differential Count
Neutrophil
9.74
Lymphocyte
1.58
Monocyte
0.96
Eosinophil
0.62
Basophils
0.03
LUC
0.13

REFERENCE
4.8 10. 8
4.2 -5.4
12.0 16.0
37.0 47.0
130 400
81 99
27.0 31.0
33.0 37.0
1.9 8.0
19 46
3.4 9. 0
0.0 7.0
0.0 1.5
0.0 4.0
1.9 8.0
0.9 5.2
0.16 1.0
0.0 0.8
0.0 0.2
0.0 0.4

b. Pelvic Ultrasound Pregnant (Fetal Biometry)


Date Release: 12/10/15

General Survey:
No. of fetuses: SINGLETON
Presentation: BREECH
Fetal Heartbeat: 151 bpm
SVP: 4.2 cm

There are well-circumscribed heterogenous structures in the uterus suggestive of myoma


uteri, measuring as follows:
M1 8.2 x 7.9 x 8.0 cm posterior, intramural with subserous component
M2 11.2 x 10.3 x 9.2 cm anterofundal, intramural with subserous component
M3 8.2 x 6.8 x 6.5 cm posterofundal, intramural with subserous component
M4 4.9 x 5.0 x 4.4 cm anterofundal, intramural
M5 6.8 x 6.8 x 5.2 cm left lateral, intramural

Impression

Pregnancy uterine, 17 weeks and 6 days & 2 weeks by fetal biometry, live, singleton, breech
presentation
Adequate amniotic fluid volume (SVP 4.2 cm)
Posterior placenta, grade 1, totalis
Multiple myoma uteri, as described

c. Urinalysis Report
Date Release: 12/10/2015
Routine Urinalysis
Result
Physical Characteristics
Color
Yellow
Transparency
Slightly Cloudy
pH
6.0
Specific Gravity
Protein
NEGATIVE
Gluscose
NEGATIVE
Ketone
NEGATIVE
Urobilinogen
Normal
Leukocytes
NEGATIVE
Blood / Hb
25
Bilirubin
NEGATIVE
Nitrite
NEGATIVE
Microscopic Findings
RBC
56
WBC
14
Bacteria
246
Squamous Epithelial Cells
15
Cast
0
VI.

Reference Range

5-6
NEGATIVE
NEGATIVE
NEGATIVE
Up to 2
NEGATIVE
NEGATIVE
NEGATIVE
NEGATIVE
0-11
0-17
0-276
0-17
0-1

Treatment

a. Pharmacologic
IVF Therapy - implemented to maintain the fluid and electrolyte balance of the body which
sustains bodily functions on the optimum level.
D5LR a physiological solution used for infusion into the circulation. In addition to essential
ions it also contains glucose.
- With additives of Isoxsuprine HCL (Isoxilan Ampule 5mg/ml 2ml) give 2amp IV
Infusion at 20 gtts/min
D5Water raises total fluid volume it is also helpful in rehydrating and excretory purposes.
- With additives of Isoxsuprine HCL (Isoxilan Ampule 5mg/ml 2ml) give 2amp IV
Infusion at 20 gtts/min
Medications:
Isoxsuprine HCL (Isoxilan Ampule 5mg/ml 2ml) give 2amp IV infusion at 20 gtts/min
- Date order: 12/9/15
- Date & Time given: 12/11/15 at 7pm
- Action: produces uterine relaxation through a direct effect on smooth muscles
Pethidine HCL (Demerol Ampule 100mg/2ml) give 50 mg intramuscular now

Date order: 12/09/15


Date given: 12/10/15 at 3:34pm
Action: Relief of moderate to severe pain, obstetrical analgesia.

Bisacodyl (Dulcolax Adult Rectal Suppository 10mg) give 1 supp per rectum now
- Date order: 12/11/15
- Date given: 12/11/15 at 10pm
- Action: Relief of occasional constipation and irregular bowel movements.
Paracetamol (Biogesic Caplet 500mg) give 1 caplet oral every 4 hours, to avoid alcohol
- Date order: 12/09/15
- Date given: last given at 12/12/15 at 12pm
- Action: Relief of painful or febrile condition
Folic Acid (Purifol) give 1 tab oral once a day
- Date order: 12/11/15
- Date give: last given at 8am
- Action: is used for preventing and treating low blood levels of folate (folate
deficiency), as well as its complications, including tired blood (anemia)
and the inability of the bowel to absorb nutrients properly. Pregnant or
might become pregnant take folic acid to prevent miscarriage and neural
tube defects, birth defects such as spina bifida that occur when the fetuss
spine and back do not close during development.
Cevi Lactulose (Dulphalac) give 30 ml at bedtime
- Date order: 12/12/15
- Date give: last given at 9pm
- Action: treating constipation and, in higher doses, reducing a complication
Associated with liver disease called hepatic encephalopathy.
b. Non-pharmacologic
Vital Signs Monitoring to continuously monitor patients health status.
Nutritional Needs on Full Diet
Fluid Intake and Output to monitor hydration pattern of the patient whether it is too high or too
low than normal amount of hydration and check the function of the kidney through urine
output.
Comple Bed Rest - to minimize activity and help recovery from disease
Left side lying position - Left lateral position increases venous return and enhances placental
circulation. Position changes promote comfort, reduce muscle tension, relieve pressure and
promote fetal desce
Increase Fluid Intake Active and Passive Range of Motion Exercises - To prevent any aggravations of complications of
immobility such as thrombus formation.
Turning, Coughing, And Deep Breathing - To assist in loosening and expectoration of mucous
Pain Management:
-Divertional Activities
-Deep Breathing and Relaxation Techniques
-Ventilation of Feelings and Concerns

V. Discharge Planning
Medications:
Describe the importance of regularly taking of prescribed medications including the potential
unpleasant effects of non compliance
Remind patient to religiously take the discharged medicines as ordered by the physician.
Instruct the client to continue with follow up medical care.
Advise the patient not to miss the intake of medications given by her physician upon discharge.
Environment and Exercise:
Maintain a quiet, pleasant, environment to promote relaxation.
Provide clean and comfortable environment.
Encourage patient to continue deep breathing exercises, also instruct the significant others for the
exercise needed. This to promote circulation of blood, relaxation also.
Treatment
Continue home medications. For the follow up check-up repeat.
Encourage to have adequate rest periods by decreasing stimuli. Schedule activity to maximize sleep
periods.
Encourage patient to avoid significant labor and emotional stress.
Health Teachings:
Teach stress management techniques as indicated, including appropriate exercise program.
Encourage patient to monitor his weight daily to increase detect fluid retention (do this at the same
time each day)
Lifestyle change (proper food preference).
General health measures (adequate seep, proper diet, and maintain a clean surrounding). Instruct
patient to limit activity for 24 to 48 hours after discharge.
Out Patient
Patient will be advised to go back in the hospital in a specific date to have a follow-up check up
after discharge. Consult doctor for any problems or complication encountered.
Diet

Diet as tolerated

Spritual
Advise to continue prayingto God and hear mass on Sunday.