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Ovarian Cyst

GENERAL OBJECTIVES: At the end of the case presentation We will be enhanced with
the knowledge ,equipped with the skills and acquire positive attitude about ova
rian cyst, its effect to the individual as well as to their significant others,
its manifestation and prevention, necessary treatment and appropriate nursing ac
SPECIFIC OBJECTIVES: 1)The patient condition. State the patient profile, past he
alth history, personal as well as history of present illness. 2) Assess the phys
ical appearance of the patient and the recognizes the clinical manifestations of
the disease. 3) Identify, interpret and understand laboratory examination and d
iagnostic tests indicated and its significant finding. 4) Understand the anatomi
cal parts and explain the nature and identify the cause, disease process and man
ifestation of the disease. 5)Utilize the nursing process in the delivery of care
d based in the clients needs and concerns. 6) Enumerate and analyze the drugs th
at have been administered to the patient. 7) Provide information on the discharg
ed planning intended to the patient condition
Ovarian Cyst
Ovarian Cyst
y An ovarian cyst is any collection of fluid, surrounded by a very thin
wall, within an ovary. Any ovarian follicle that is larger than about two centim
eters is termed an ovarian cyst. An ovarian cyst can be as small as a pea, or la
rger than an orange. y Most ovarian cysts are functional in nature, and harmless
(benign).[1] In the US, ovarian cysts are found in nearly all premenopausal wom
en, and in up to 14.8% of postmenopausal women. y Ovarian cysts affect women of
all ages. They occur most often, however, during a woman's childbearing years. y
Some ovarian cysts cause problems, such as bleeding and pain. Surgery may be re
quired to remove cysts larger than 5 centimeters in diameter.
y Ovarian cysts form for numerous reasons. The most
common type is a follicular cyst, which results from the growth of a follicle. A
follicle is the normal fluid-filled sac that contains an egg. Follicular cysts
form when the follicle grows larger than normal during the menstrual cycle and d
oes not open to release the egg. Usually, follicular cysts resolve spontaneously
over the course of days to months. Cysts can contain blood (hemorrhagic cysts)
from injury or leakage of tiny blood vessels into the egg sac.
Risk Factors:
y y y y y y y
* History of previous ovarian cysts * Irregular menstrual cycles * Increased upp
er body fat distribution * Early menstruation (11 years or younger) * Infertilit
y * Hypothyroidism or hormonal imbalance * Tamoxifen therapy for breast cancer
Signs And Symptoms
y Dull aching, or severe, sudden, and sharp pain or
y y y y
discomfort in the lower abdomen (one or both sides), pelvis, vagina, lower back
or thighs; pain may be constant or intermittent -- this is the most common sympt
om Fullness, heaviness, pressure, swelling, or bloating in the abdomen Breast te
nderness Pain during or shortly after beginning or end of menstrual period. Irre
gular periods, or abnormal uterine bleeding or spotting
y Change in frequency or ease of urination(such as inability
y y y y y y y y y
to fully empty the bladder), or difficulty with bowel movements due to pressure
on adjacent pelvic anatomy Weight gain Nausea or vomiting Fatigue Infertility In
creased level of hair growth Increased facial hair or body hair Headaches Strang
e pains in ribs, which feel muscular Bloating Strange nodules that feel like bru
ises under the layer of skin
Diagnosis: Ovarian cysts are usually diagnosed by either Ultrasound or CT scan.
Treatment: y About 95% of ovarian cysts are benign, meaning they are not cancero
us. y Treatment for cysts depends on the size of the cyst and symptoms. For smal
l, asymptomatic cysts, the wait and see approach with regular check-ups will mos
t likely be recommended. y Pain caused by ovarian cysts may be treated with:
* pain relievers, including acetaminophen (Tylenol), nonsteroidal anti-inflammat
ory drugs such as ibuprofen (Motrin, Advil), or narcotic pain medicine (by presc
ription) may help reduce pelvic pain.NSAIDs usually work best when taken at the
first signs of the pain. y * a warm bath, or heating pad, or hot water bottle ap
plied to the lower abdomen near the ovaries can relax tense muscles and relieve
cramping, lessen discomfort, and stimulate circulation and healing in the ovarie
s. Bags of ice covered with towels can be used alternately as cold treatments to
increase local circulation. y * combined methods of hormonal contraception such
as the combined oral contraceptive pill -- the hormones in the pills may regula
te the menstrual cycle, prevent the formation of follicles that can turn into cy
sts, and possibly shrink an existing cyst. (American College of Obstetricians an
d Gynecologists, 1999c; Mayo Clinic, 2002e)
y Also, limiting strenuous activity may reduce the risk of cyst rupture or
torsion. y Cysts that persist beyond two or three menstrual cycles, or occur in
post-menopausal women, may indicate more serious disease and should be investiga
ted through ultrasonography and laparoscopy, especially in cases where family me
mbers have had ovarian cancer. Such cysts may require surgical biopsy. Additiona
lly, a blood test may be taken before surgery to check for elevated CA-125, a tu
mor marker, which is often found in increased levels in ovarian cancer, although
it can also be elevated by other conditions resulting in a large number of fals
e positives.[18] y For more serious cases where cysts are large and persisting,
doctors may suggest surgery. Some surgeries can be performed to successfully rem
ove the cyst(s) without hurting the ovaries, while others may require removal of
one or both ovaries.
y Oral contraceptives: Birth control pills may be helpful to
regulate the menstrual cycle, prevent the formation of follicles that can turn i
nto cysts, and possibly reduce the size of an existing cyst.
y Pain relievers: Anti-inflammatories such as ibuprofen (for
example, Advil) may help reduce pelvic pain. Narcotic pain medications by prescr
iption may relieve severe pain caused by ovarian cysts.
y * Laparoscopic surgery: The surgeon fills a woman's abdomen with a
gas and makes small incisions through which a thin scope (laparoscope) can pass
into the abdomen. The surgeon identifies the cyst through the scope and may remo
ve the cyst or take a sample from it.
* Laparotomy: This is a more invasive surgery in which an incision is made throu
gh the abdominal wall in order to remove a cyst. * Surgery for ovarian torsion:
An ovarian cyst may twist and cause severe abdominal pain as well as nausea and
vomiting. This is an emergency, surgery is necessary to correct it.
CHIEF COMPLAINTS: Patient A.S, 28 years old, female, residing at Malitbog, South
ern Leyte was admitted at SOYMPH, last Feb. 27 2010, 5:00 o clock in the morning
due to abdominal pain. PRESENT ILLNESS: 5 years PTA pt. A.S experienced abdomin
al pain, after she feels pain, she decided to have checked up then after that, t
he doctor found out that she has an ovarian cyst, then she just keep it because
she s scared to tell her husband that she has ovarian cyst, and ignored it. 5 da
ys PTA patient started to feel abdominal pain again but she just ignored it. 30-
45 minutes PTA patient experienced severe abdominal pain so she decided to be ad
mit at SOYMPH.
PAST HEALTH HISTORY: Patient A.S had already encountered measles, mumps, and chi
cken pox, she has been fully immunized. HEIRERDO FAMILIAL DISEASE: Patient s pat
ernal side has a heredity of being hypertensive.
hypertensive patient decease
Alex Erlinda 28 y/o
the past. The most important thing of the patient to keep healthy is to have a p
roper diet and family bonding. She doesn t use cigarettes and not an alcohol dri
nker. For her its not easy to find ways to follow things that her doctor suggest
. She said that the most important thing for her while she s in the hospital is
her medications, like pain relievers, because of the onsets of her abdominal pai
n cause by her growing ovarian cyst. She has no traditional concepts of health a
nd illnesses.
B. NUTRITIONAL AND METABOLIC PATTERN Patient s typical daily food intake is rice
and vegetables. Her typical daily fluid intake is only 500ml of water daily. Sh
e sometimes drink softdrinks . Patient takes vitamins such as MAMA WHIZ capsule,
a prenatal vitamins. Patient said that she gains weight cause of her being preg
nant but she forgot the amount of her weight gained. Her appetite is good. She d
oesn t have any food allergies and diet restrictions, but she said that when he
got pregnant she doesn t like to eat sphaggetti. No skin problems like lesions a
nd dryness
C. ELIMINATION PATTERN Patient s bowel elimination pattern is it s frequency is
once daily, its characteristic is soft and color is brown. No discomforts in bow
el eliminating. Her urinary elimination pattern frequency is 4 times a day, it s
characteristic is bright yellow color. Patient s has no discomforts and problem
controlling urinating. Patient does not have excess perspiration, no odor probl
y y y y y y y y y y y y y y y y y y y y y y y
The patient has sufficient energy for her desired activities. Her exercise patte
rn is walking together w/her child every morning. For her leisure time she only
watches T.V and nap less than an hour. Perceived Ability for: Feeding Bathing To
ileting Bed mobility Dressing Grooming General mobility Cooking Home maintenance
Shopping 0 0 0 0 0 0 0 0 0 0
Level 1- full self-care Level 2- requires use of equipment or device Level 3- re
quires assistance or supervision from another person or device Level 4- is depen
dent and does not participate
E. SLEEP-REST PATTERN Approximately the patient sleeps 10 hours at night. Patien
t doesn t have any problems in falling asleep and didn t take any sleeping pills
. Her sleep at night is not continuous because of her baby awakes late at night.
For her relaxation she watches T.V, take some naps, read novels and window shop
F. COGNITIVE-PERCEPTUAL PATTERN Pt. doesn t have any hearing difficulty. She wea
rs eyeglasses. No changes in memory. Her easiest ways to learn things is to have
focus on what she wants to do. Pt. doesn t have any difficulty in learning thin
gs. She managed it by taking her medicines, her pain relievers and take a nap fo
r her to relieved the pain.
G. SELF-PERCEPTION AND SELF-CONCEPT PATTERN She described herself as a happy mot
her and happy being pregnant. Most of the time she feels not so good because of
her cyst at her ovary. PT. said that her body changes because of being pregnant
and PT. also said that there are also some changes in the things she wants to do
because of being pregnant. PT. said that there are changes the way she feels ab
out herself and her body when illness was started. When she got angry and depres
sed her husband and her baby helps her through bonding.
H. ROLE-RELATION PATTERN The pt. lived together with her family, her husband and
her two years old baby. Pt. said that she has no difficulties in handling her f
amily. Her family does not depend on her for their things. Pt.s family feels bad
when she was hospitalized because she s pregnant and it is very risky for them
to have a surgery. She has the difficulty handling with her first baby because h
er husband has no time to handle their child because of its out of town occupati
on. She doesn t work in a company, Pt. was only a housewife. Her husband was the
one who supports the needs of their family.
SEXUALITY REPRODUCTION PATTERN PT. sexual relationship has a problem cause and h
er husband is out of town work. She doesn t use any contraceptives because its h
ard for her and her husband to have a baby because of their long distance relati
onship. She said that her last menstruation was last December 2009. She has no m
enstrual problems.
J. COPING-STRESS TOLERANCE PATTERN When PT. encounter big problems she handle it
by calling her husband through cellphone and her husband were the most helpful
and available to talk with, in talking things over. PT. said that the biggest ch
anges happened to her for the past years was when she and her husband had a baby
K. VALUE-BELIEF PATTERN Pt s most important things in her life is her family. Pa
tient is a Roman Catholic and she said that her religion helps her when difficul
ties arise through prayers.
GENERAL APPEARANCE: seen patient conscious, weak and coherent sitting on her bed
side. SKULL: -Round -No deformities and lesions -No tenderness noted upon palpat
ion SCALP: -Free from lesions and scars -No tenderness or masses upon palpation
INTEGUMENTARY: Skin: -tan -no lesions -With birth mark on her left arm and a sev
eral moles on her face -Has a warm temperature -Skin pinches easily and immediat
ely returns to its original position
Nails: -Nails are clean -Pink tones -Hard and immobile -Nailplate is firmly atta
ched to the nailbed HAIR: -Long, black, shiny and wavy -Thin hair -No lice and d
andruff EENT EYES: - Symmetrical -Sunken eyeballs -Upper and lower lids close ea
sily and meet completely when closed -Skin on both eyelids is without redness, s
welling, or lesions -Non protruding eyes -Iris is typically round, flat, and eve
nly colored -Pupils are equally round and equal in size -Eyelashes are black in
color and evenly distributed -No yellowish discoloration of the sclera
NOSE: -Nasal structure is smooth and symmetric -No lesions, discharges, and tend
erness -Color is the same as the rest of the face -Frontal and maxillary sinuses
are nontender EARS: -Color is consistent with facial color -No lesions, swellin
g, and masses noted -No pain upon palpation -No discharges -Symmetrical and equa
l in size -Small amount of ear wax is visible -Both ears has no hearing problems
-Not wearing any hearing aides MOUTH: -Lips are pale, smooth and moist, without
lesions or swelling -Not complete whitish teeth -Tongue is pink, moist, moderat
e size with papillae present -Visible tonsils -Throat is pink and without lesion
s or redness
FACE: -Shape is round -Symmetrical -No involuntary muscles movement -Can move fa
cial muscles NECK: -Symmetric with head centered and without bulging masses -Tra
chea is midline -No bruits are auscultated THORACIC AND LUNG: -Scapulae are symm
etric and no protruding -Shoulders and scapulae are at equal horizontal position
s -Client doesn t use accessory muscles to assist breathing -Client is relaxed u
pon breathing -No tenderness, pain, or unusual sensations -No palpable crepitus
-No swelling, masses, and lesions -No adventitious sounds, such as crackles or w
heezes are auscultated
CARDIOVASCULAR: Cardiac rate is 83 bpm No murmurs heard upon auscultation No pul
sations or vibrations are palpated in the areas of the apex, left sterna border,
or base Radial and apical pulse rates are identical MUSCULOSKELETAL: Body types
: Round Limited ROM Temporomandibular Joint: Jaw moves laterally and retracts an
d protrudes easily Mouth opens normally Sternoclavicular Joint: No visible bony
overgrowth, swelling, or redness Joint is nontender Cervical, Thoracic, and Lumb
ar Spine: Nontender spinous processes Well developed, firm, and smooth No report
ed pain upon bending
Shoulders, Arms, and Elbows: Shoulders are not symmetrical No redness, swelling,
or deformities No tenderness Elbows has no deformities, redness, or swelling No
masses and nodules Wrists are symmetric without redness or swelling Nontender a
nd free of nodules Hands and Fingers: Symmetrical, nontender, and free of nodule
s Hips: Buttocks are equally sized Stable, nontender, and without crepitus Knees
: Symmetric Lower leg in alignment with upper leg Nontender and free of nodules
Patella rests firmly on femur Client reported no pain or clicking Ankles and Fee
t: Toes point forward and lie flat Skin is smooth and free of calluses No pain,
heat, swelling, or nodules
ABDOMEN: pain, 8 in pain scale where 1 is the lowest and 10 is the highest skin
color is consistent with body s color Small scars noted Contour is rounded ELIMI
NATION: Voiding pattern: 4 to 5 times a day (depending on the weather) Color: ye
llow Defecating pattern: 1 to 2 times a day Color: brown
NEUROLOGIC: Client is alert and awake Appears to be relaxed with shoulders and b
ack erect upon sitting down CN-I: No problem with identification of scent CN-II:
Client is farsighted (wears eyeglasses) CN-III, IV & VI: Eyes move in a smooth
and coordinated motion in all directions Bilateral illuminated pupils constrict
simultaneously CN-V: Correctly identifies a sharp and dull stimuli and light tou
ch to the forehead, cheeks, and chin CN-VII: Client can smile, frown, shows teet
h, purses lips, and raises eyebrows Symmetrical movements CN-VIII: client respon
ds to sounds Can hear whispers CN-IX & X: Intact gag reflex Swallows without dif
ficulty CN-XI: Symmetric, strong contraction of the trapezius muscles
Ultrasound Report
Note: y Anterosuperior and to the right of the uterus is a thick wallet, multise
ptated, cystic structure with mixed echoes measuring 7.8x8.2x6.7 cm with an echo
genic core measuring 3.5x3.5x3.2 in suggestive of an ovarian newgrowth, right. R
emarks: y Multicystic structure anterosuperior to the uterus as described. Impre
ssion: y Intrauterine pregnancy 9W 3D by crown to rump length, live, singleton,
corpus loteum, left. y Consider ovarian newgrowth, right y Anterior myometrial c
ontractions y Please correlate clinically
Test Name Color Reaction(pH) Sp. Gravity Albumin Normal Yellow 6.0 1.030 g/ml Ne
gative Patient Yellow 7 1.oo2-1.030g/ml Negative Indication
Microscopic Exam
Test Name Normal Patient Indication
Epithelial Cells
Test Name Leukocytes Number Hemoglobin Mass Core Erythrocyte Volume Blood Type N
ormal 11.2x10 g/dl 116 g/dl 0-37 A+ 12-16 d/dl Patient Indication
Differential Count
Test Name Segmenters Normal 0.95 Patient Indication
The female reproductive system contains two main parts: the uterus, which hosts
the developing fetus, produces vaginal and uterine secretions, and passes the ma
le's sperm through to the fallopian tubes; and the ovaries, which produce the fe
male's egg cells. These parts are internal; the vagina meets the external organs
at the vulva, which includes the labia, clitoris and urethra. The vagina is att
ached to the uterus through the cervix, while the uterus is attached to the ovar
ies via the Fallopian tubes. At certain intervals, the ovaries release an ovum,
which passes through the Fallopian into the uterus. If, in this transit, it meet
s with sperm, the sperm penetrate and merge with the egg, fertilizing it. The fe
rtilization usually occurs in the oviducts, but can happen in the uterus itself.
The zygote then implants itself in the wall of the uterus, where it begins the
processes of embryogenesis and morphogenesis. When developed enough to survive o
utside the womb the cervix dilates and contractions of the uterus propel the fet
us through the birth canal, which is the vagina. The ova are larger than sperm a
nd are generally all created by birth. Approximately every month, a process of o
ogenesis matures one ovum to be sent down the Fallopian tube attached to its ova
ry in anticipation of fertilization. If not fertilized, this egg is flushed out
of the system through menstruation.
A female's internal reproductive organs are the vagina, uterus, fallopian tubes,
and ovaries. Ovaries this is the primary reproductive organ of a female. It pro
duces both an exocrine product (eggs or ova) and endocrine products (estrogens o
r progesterone) Vagina The vagina is a fibromuscular tubular tract leading from
the uterus to the exterior of the body in female mammals, or to the cloaca in fe
male birds and some reptiles. Female insects and other invertebrates also have a
vagina, which is the terminal part of the oviduct. The vagina is the place wher
e semen from the male is deposited into the female's body at the climax of sexua
l intercourse, commonly known as ejaculation. Around the vagina, pubic hair prot
ects the vagina from infection and is a sign of puberty.
Fallopian Tubes it forms the initial part of the duct system. They receive the o
vulated oocyte and provide a site where fertilization can occur. Each of the ute
rine tubes is about 10 cm long and extends medially from an ovary to empty into
the superior region of the uterus. The distal end of each uterine tube expands a
s the funnel-shaped infundibulum, which has fingerlike projections called fimbri
ae that partially surround the ovary. Cervix The cervix is the lower, narrow por
tion of the uterus where it joins with the top end of the vagina. It is cylindri
cal or conical in shape and protrudes through the upper anterior vaginal wall. A
pproximately half its length is visible; the remainder lies above the vagina bey
ond view. Uterus The uterus or womb is the major female reproductive organ of hu
mans. One end, the cervix, opens into the vagina; the other is connected on both
sides to the fallopian tubes.
Risk Factors: -History of previous ovarian cysts -Irregular menstrual cycle -Ear
ly menstruation (11yrs. Or younger) -Infertility -Hormonal imbalance
Hormonal Imbalance
Irregular menstruation
Follicles failed to ovulate/ released and ruptured an egg
An egg may increased growth. Fluid remains and can form a cyst in the ovary Incr
eased abdominal girth
Lower quadrant pain
Hemorrhage and acute pain
Increased pelvic pain Ruptured of the cyst
Fatigue and feeling of heaviness in the pelvis,
urinary frequency and painful defecation.
DRUG Duphaston (Dydrogesterone)
Date ordered 02-27-10 02-28-10 03-01-10 03-02-10
Classification Progesterone without estrogens.
Uses/action Dydrogesterone is an orally active progesrerone which acts directly
on the uterus,producing a complete secretory endometrium in an estrogen-primed u
terus at therapeutic levels,dydrogesteronehas no contraceptive effect as it does
not inhibit or interfere with ovulation or the corpusluteum.Furthermore , dupha
ston is an non androgenic,nonestrogenic,noncorticoid,non-anabolic and is not exc
reted as pregnanediol.
Indications Irregular duration of cycles and irregular occurrence and duration o
f periods cause by progesterone deficiency.
Side effects Si side effects of duphaston may include gastrointestinal disturban
ces,allergic skin rashes or urticaria,chages in libido,acne,fluid retension ,mas
s gain,mental depression and breast changes which may include discomfort or gyna
ecomastia. Alterations in liver function test have been reported and less freque
ntly jaundice.
Nursing Implications
Multivitamins 02-27-10 (Berocca,Primaple 02-28-10 x) 03-01-10 03-01-10
Multivitamins with minerals.
Vitamins are building In multivitamin blocks of the body. They deficiencies. are
used to prevent or treat . a vitamin deficiency due to poor nutrition ,certain
illness or during pregnancy.
The medication may cause mild nausea or unpleasant taste.
Should be avoided in patients with alcoholic intolerance, hypersensitivity to pr
eservatives, colorants or additives including tartrazine, saccharin and aspartam
e (oral forms). .
DRUG Date ordered
Classificat ion
Side effects
Nursing Implications
Cephalexin (Keflex)
02-27-10 02-28-10
AntiThe medication is ineffective a cephalosporintype antibiotic used to treat a
wide variety of bacterial infections.
Cephalexin is used to treat urinary tract infections,res piratory tract infectio
ns,and skin and soft tissue infections. It also sometimes used to treat acne.
Side effects from cephalexin include-but are not limited to diarrhea, dizziness,
headache, ingestion, joint pain, stomach pain, tiredness.
Hypersensitivity to chephalosporins, pregnancy, hypersentivity to penicillin¶s, la
ctation, renal disease
ASSESSMENT Subjective: ³ sakit ahung tijan dong´as verbalized by the patient Objecti
ve: -Facial grimaces noted -pain scale of 8 were 10 is the highest and 1 is the
DIAGNOSIS Chronic pain related to increase pressure to ovary secondary to ovaria
n cyst Scientific basis: ovarian cyst symptoms may include persistent bloating,
swelling, or pain in the abdomen, difficulty eating or feeling full quickly, urg
ent or frequent urination, and vaginal bleeding not associated with menstruation
Source: Microsoft Student with Encarta Premium 2009 DVD
PLANNING After 4-5 hrs of nursing interventions patient verbalizes reduction of
INTERVENTIONS -Assess pain characteristics: *Severity( to 10, with 10 being the
most severe) -Asses for probable cause of pain. -Assess the Pt¶s willingness or ab
ility to explore a range of techniques aimed at controlling pain. -Eliminate add
itional stressors or sources of discomforts whenever possible. -Provide rest per
iods to facilitate comfort, sleep, and relaxation -Administer analgesics as indi
cated (morphine). Give doses to provide analgesia around the clock. Convert from
short-acting to longacting analgesics when indicated -Determine some pain relie
f method like relaxation and breathing exercises
RATIONALE -Assessment of the pain experience is the first step in planning pain
management strategies -Different etiologic factors respond better to different t
herapies. -Some pt. will feel uncomfortable exploring alternative methods of pai
n relief -Pt¶s may experience exaggeration in pain. -The pt¶s experiences of pain ma
y become exaggerated as the result of fatigue. -Pain is frequent complication of
cancer, although individual responses differ
E/O After 4-5 hours of nursing interventions patient verbalized reduction of pai
-Techniques are used to bring about a state of physical and mental awareness w/c
reduces pain.
ASSESSMENT DIAGNOSIS Subjective: ³mahadluk ko maka apekto sa bata ang operasyon´ as
verbalized by the patient. Fear related to threat of fetal death for the out com
ing surgical procedure
INTERVENTIONS -Acknowledge awareness of patient¶s fear -Advise SO to stay with the
patient to promote safety, especially during the procedure -Maintain a calm and
tolerant manner in interacting with the patient -Assist the patient in identify
ing strategies used in the past to deal with fearful situations
E/O After 3-4 hours of nursing interventions patient verbalized reduction of fea
After 3-4 hours of nursing interventions patient Scientific basis: breathing The
factors that pattern will precipitate fear are , verbalizes to some extent, red
uction of Objective: universal; fear of fear -facial feeling of death, pain, and
fear and anxiety bodily injury are noted common to most people. Source: Nursing
Care Plan 6th edition Gulanick/Myers Page 68
-This validates the feelings the patient is having and communicates an acceptanc
e of those feelings. -The presence o a trusted people increases the patient¶s sens
e of security and safety during a period of fear -The patient¶s feeling of stabili
ty increases in a calm and nonthreatening atmosphere -This helps the patient foc
us on fear as a real and natural part in life that has been and can continue to
be dealt with successfully -Recognition and explanation of actors leading to ear
are -As the patient¶s fear significant in developing subsides, encourage alternat
ive responses him or her to explore -Rest improves ability to cope specific even
ts -This information will help preceding the onset of minimize fear the fear -En
courage rest periods
-Give positive information about the incoming surgical procedure
ASSESSMENT Subjective Data: ³magpahungit na gani ko sa ako asawa dong´ as verbalize
by the Patient Objective Data: -weak -facial grimaces -limited ROM noted
EXPECTED OUTCOME Self-care deficit After 5-6 -Asses ability to carry -The patien
t may only require After 5-6 hours related to hours of out activities of daily a
ssistance with some self-care of nursing abdominal pain nursing living, such as
measures. interventions intervention feeding, dressing, -Self-care deficit is re
cent, the patient Scientific basis: s patient and ambulating on a patient may ne
ed to grieve performed self Patient may be will regular basis. before accepting
that care activities. immobilized by pain, performs/se -Assist the patient in de
pendence is necessary. muscle weakness or lf care accepting necessary -Assisting
the patient to set they may be activities. amount of realistic goals will decre
ase immobilized for dependence frustration therapeutic reasons -Set short-range
-This help the patient organize when mobility is goals with the patient and carr
y out self-care skills impaired the well known -Use consistent -This provides th
e patient with consequences may routines and allow an external source of positiv
e include activity adequate time for the reinforcement and promoter intolerance,
loss of patient to complete ongoing efforts muscle mass, task -Assistance can r
educe energy strength and self -Provide positive expenditure and frustration car
e deficit reinforcement for all activities attempted ; Source: note partial Lint
on, A, et al, achievements (2007) Matteson and -Provide assistance McConnell¶s nur
sing when patient in concepts and practice 3rd ed. feeding, dressing, Pp.284-285
hygiene, transferring/ambulatio n and toileting.
Assessment Subjected Data ³kapoy ahu lawas kay kuwang2 man pud ahu 2g lage´ as verba
lized by the patient.
Diagnosis Fatigue related to sleep deprivation Scientific Basis: One of area cau
ses fatigue is Lifestyle problems. Feelings of fatigue often have an obvious cau
se, such as sleep deprivation, overwork or unhealthy habits. Source: © 1998-2010 M
ayo Foundation for Medical Education and Research (MFMER). All rights reserved.
A single copy of these materials may be reprinted for noncommercial personal use
only. "Mayo," "Mayo Clinic," "," "EmbodyHealth," "Enhance your li
fe," and the triple-shield Mayo Clinic logo are trademarks of Mayo Foundation fo
r Medical Education and Research.
Planning After 3-4 hours of nursing interventi ons Patient will have sufficient
energy to complete desired activities
Interventions -Assess patient emotional response to fatigue -Encourage patient t
o have rest -Provide recommendations for nutritional intake for adequate energy
sources and metabolic requirements -Minimize environmental stimuli, especially d
uring planned times of sleep and rest -Teach the patient and family task organiz
ation techniques and time management strategies -Help the patient develop habits
to promote effective rest/sleep patterns -Encourage the pt. and SO to verbalize
feelings about the impact of fatigue
Rationale -These emotional state can add to the person¶s fatigue level and create
a vicious cycle -Periods of rest will help prevent adding to levels of fatigue -
The patient needs adequate balanced intake to provide energy sources like carboh
ydrates, fats, protein, vitamins and minerals. -Bright lighting, noise, visitors
, frequent distractions in the patient¶s environment can inhibit relaxation, inter
rupt rest/sleep. And contribute to fatigue -Organization and time management can
help the patient conserve energy and prevent fatigue. -Promoting relaxation bef
ore sleep and providing for several hours of uninterrupted sleep can contribute
to energy restoration. -Fatigue can have a profound negative influence on family
and social interaction.
E/O After 34 hours of nursing interven tions Patient have sufficien t energy to
complet e desired activitie s.
Objective Data -seen patient always yawning -sunken eyeballs
Assessment Subjective Data: ³di kayo ko makatarong ug tog´ as verbalized by the Pati
Diagnosis Disturbed sleep pattern related to fear for the out coming surgical pr
ocedure Source: The physical sym ptoms of anxiety and fear reflect a chronic ³read
iness´ to deal with some future threat. These symptoms may include fidgeting, musc
le tension, sleeping problems, and headaches. Microsoft ® Encarta ® 2009. © 1993-2008
Microsoft Corporation. All rights reserved.
Planning After 3-4 hrs of nursing interventions patient will verbalizes improvem
ent sleeping pattern
Intervention -Assess past patterns of sleep in environment. -Recommend an enviro
nment conducive to sleep or rest -Provide nursing aids( backrub, comfortable pos
ition, relaxation techniques. -Post a ³ Do not disturb¶ sign on the door. -Provide s
oft music or white noise -Organize nursing care: Eliminate nonessential nursing
activities -Teach about the possible causes o sleep difficulties and optimal way
s to treat them -Teach on nonpharmacological sleep enhancement techniques
Rationale -Sleep patterns are unique to each individual. -Many people sleep bett
er in cool, dark, quite environments -These aids promote rest. -This will alert
people to avoid entering the room and interrupting sleep -Reduces sensory stimul
ation by blocking out other environmental sounds that could interfere with restf
ul sleep -This promotes minimal interruption in sleep or rest -This allows patie
nts to participate in their care. -This techniques can be used throughout a life
time. Phar. Should be used for a limited time
E/O After 3-4 hrs of nursing interventio ns patient verbalized improvem ent slee
ping pattern
Objective Data: -Fatigue appearance noted -weak -always Yawning
Discharge Planning
y M- Medication y y y
Instruct the S.O. to complied strictly with the following medications given E- E
xercise y Encourage S.O. to make the patient mild ROM exercise T- Treatment y Ad
vice S.O. to avoid stress related factors to the patient H Health teachings y En
courage deep breathing exercise y Adequate bed rest O- Out patient y Teach S.O.
signs and symptoms that emphasizes worsening of the disease in order to have fol
low up check up D- Diet y Maintain diet low sugar and fat intake y Limit fluid i
ntake S Spirituality y Encourage the S.O. of the patient to pray for the Patient