1

UNIVERSITY OF THE EAST

RAMON MAGSAYSAY MEMORIAL MEDICAL CENTER INC.
#64 Barangay Dona Imelda Aurora Boulevard Quezon City 1113

Total Abdominal Hysterectomy with Bilateral Salpingo-oophorectomy

Or

TAHBSO

Submitted by:

Beatrice Asuncion

Chantal Caragan

Lyra Angely Marquez

Acknowledgement
2

We would like to express our gratitude to those who have helped us make this surgical case study
possible:

To Almighty God, who has never let us down in guiding our every step throughout the
process.

To our friends and family, who was always present to encourage and support us. We
would have had a hard time accomplishing this process without the morale they had given.

To Ma’am M.C., our client, for allowing us to attend to her needs and conduct our study
while being so accommodating and supportive.

To Professor Castro and Flores, for imparting their knowledge and expertise throughout
our study so we may be able to become better nurses and reach our goals.

To Sir Arnel Embellado, the scrub nurse for the procedure, for allowing us to scrub in and
conduct our study.

To Sir John Christian Dizon, the circulating nurse for the procedure, for allowing us to
conduct our study and assist in intraoperative tasks.

To our university, University of the East Ramon Magsaysay, for molding our foundations
that transformed us into great students.

To the authors included in the citations, for providing us references that formed the
cornerstone in this book.

Table of Contents
3

A. Introduction.…………………………………………………………………………….....5
B. Patient’s Profile……………………………………………………………………………6
C. Present Health History……………………………………………………………...……..7
D. Past Health History…………………………………………………………………..……7
E. Genogram………………………………………………………………………………....8
F. Family Health History………………………………………………………………….....9
G. Psychosocial History…………………………………………………………………..….9
H. Developmental History……………………………………………………………………9
I. Obstetrics and Gynecologic History….……………………………………………...…..10
J. Course in the Ward……………………………………………………………………....11
K. Gordon’s Functional Health Pattern..................................................................................26
L. Laboratory Examinations..................................................................................................35
M. Anatomy and Physiology………………………………………………………………..42
N. Pathophysiology………………………………………………………………………....46
O. Surgical Procedure………………………………………………………………………47
P. Surgical Equipment Used………………………………………………………………..51
Q. Drug Analyses
a. Pre-Operative Medications………………………................................…………52
b. Intra-Operative Medications…………………........................…………………..52
c. Post-Operative Medications…………………………………...................……...52
R. Nursing Care Plans
a. Pre-Operative Nursing Care Plan………………………….…………..………...65
b. Intra-Operative Nursing Care Plan…………………………………..…………69
c. Post-Operative Nursing Care Plan…………………………………..................75
S. Journals
a. Journal # 1……………………………………………………………………....88
b. Journal # 2……………………………………………………………………...89
c. Journal # 3…………………………………………………………………..….89
T. Consent…………………………………………………………………………………85
U. The Authors…………………………………………………………………………….94
V. Bibliography...................................................................................................................95
4

Introduction

Our patient, M.C., is diagnosed with New Ovarian Growth, Left, Benign; Chronic Hypertension,
Controlled and Endometrial Polyp. Ovarian cysts are found on transvaginal sonograms in nearly
all premenopausal women and in up to 18% of postmenopausal women (Grabosch, 2018). On the
other hand, Endometrial Polyp can affect up to 25% of females presenting with abnormal uterine
bleeding (Unal, Dogan, et al., 2014) and has an increased incidence rate with hormone
replacement therapy, either estrogen-only or combined preparations (Wolmark, Vogel et al.,
2011). The most common risk factors in developing ovarian cysts are hormonal problems,
pregnancy and endometriosis and the most common risk factors in developing Endometrial
Polyp are hypertension and obesity.

Due to the physiologic complications and symptoms that arose from her condition, patient M.C.
was scheduled for Total Abdominal Hysterectomy with Bilateral Salpingo-Oophorectomy or
TAH-BSO under combined spinal-epidural anesthesia. TAH-BSO is the surgical removal of the
uterus including the cervix as well as the fallopian tubes and ovaries using the incision in the
abdomen. In contrast, “Combined Spinal Epidural technique, combined efficacy of spinal
anaesthesia and flexibility of epidural anaesthesia. This technique could both avoid general
anaesthesia and provide an excellent postoperative analgesia, according to the Boulay, Hamza, et
al. (2000, p.98-99). The procedure provided an excellent way to eliminate further gynecologic,
immunologic and cardiovascular complications from arising.
5

Patient’s Profile:

Name: M.C.

Age: 55

Address: San Mateo, Rizal

Birthdate: July 28, 1964

Civil Status: Married

Nationality: Filipino

Occupation: Elementary Teacher (Grade 5)

Chief complaint: No subjective complaints ; 3 years prior to admission patient was advised

for surgery due to a palpable, soft, non-tender mass

Final Diagnosis: for TAHBSO due to Ovarian new growth, Left, Benign

Date of admission: October 20, 2019

Surgical Procedure: Total Abdominal Hysterectomy with Bilateral Salpingo-Oophorectomy

Date of surgery: October 20, 2019 at 12:52 PM

6

Present Health History

3 years prior to admission patient complained of left flank and no other associated symptom. She
sought consult at Sta. Lucia, Marikina where in ultrasound was done which revealed a cyst. She
was advised for surgery but patient refused due to

In the interim, patient was apparently well.

1 year prior to admission patient complained of increasing abdominal girth and noticed a
palpable mass in the right lower quadrant approximately the size of a 5 peso coin. The mass was
soft and non-tender.

In the interim, patient noticed the progression of her increasing abdominal girth and increasing
palpable, soft, non-tender mas.

1 month prior to admission, patient sought consult in the UERM OPD wherein blood tests and
ultrasound were done. She was still advised for surgery.

On the day of admission, patient was apparently well with no subjective complaint.

Past Health History

Patient verbalized that she experienced chicken pox during her childhood and was diagnosed of
Hypertension last September 2019. Patient doesn’t recall any diseases from their family except
hypertension and diabetes, has no known allergies to any medications, and patient has completed
all necessary immunizations at a local health center. One of her child died due to miscarriage.
7

Genogram

Paternal Maternal

Patient could not recall their illnesses

“Old Age” Diabetes

78 82
96

HTN

HTN A&W A&W HTN A&W A&W

Legend:

- Points to patient

HTN – Hypertension

A&W – Alive and Well

- Deceased
8

Family Health History

Patient has a history of hypertension and diabetes on the paternal side, her father is already
deceased while on the maternal side she has no any history of illnesses and she could not recall
the cause of death of her grandmother and grandfather. Patient verbalized that she and her eldest
brother has hypertension and patient doesn’t recall any diseases from their family such as
hypertension and diabetes. Patient is married with 6 children but only 5 are living because her 5th
child died due to miscarriage.

Psychosocial History

Patient does not smoke, drink alcohol and use of illicit drugs. Patient is married and has 5
children. Their family’s main income come from his husband who is an Aluminum and glass
installer. Patient has a good relationship with her children, she does not have fights with them.
Patient’s support is from her family, mainly from the income of her husband and her job. Patient
works as an elementary teacher for DepEd, patient graduated high school and college in
Catanduanes. Patient is a Roman Catholic and goes to church every week. Patient’s hobbies
included doing household chores, watching T.V., chatting with neighbor, and taking care of her
grandkids.

Developmental History

Patient is 55 years old, according to Erik Erikson’s developmental theory patient is in

Generativity vs. stagnation (adulthood, 40–64 years) where in this stage the adult stage of
generativity has broad application to family, relationships, work, and society. “Generativity, then
is primarily the concern in establishing and guiding the next generation the concept is meant to
include, productivity and creativity”. During middle age the primary developmental task is one
of contributing to society and helping to guide future generations. When a person makes a
contribution during this period, perhaps by raising a family or working toward the betterment of
society, a sense of generativity a sense of productivity and accomplishment results. In contrast, a
person who is self-centered and unable or unwilling to help society move forward develops a
feeling of stagnation- dissatisfaction with the relative lack of productivity. The dominant trait
between Generativity Vs. Stagnation in regards to the patient is Generativity. This because the
patient was able to achieve generativity because patient was able to maintain good relationship
9

with her husband, and able to help her children to grow to a responsible individual, she was able
to adjust to physical changes, and be able to create a comfortable home for her family.

Obstetrics and Gynecological History

Patient M.C. is a G6T5P1A0L5M0, had her menarche at 12 years old, estimated of 2-3 pads per
day, fully soaked with a duration of 4-6 days, regular, every 28 days and has no history of
dysmenorrhea. Patient had her 1st coitus at the age of 20 and has only one sexual partner. Her
first pregnancy was when she was 21 years old via normal spontaneous delivery at home through
“hilot” by a traditional birth attendant at 1985; 2nd child was born in 1987 via normal
spontaneous delivery at home; 3rd child was born in 1991 via normal spontaneous delivery by a
midwife; 4th child was born in 1992 via normal spontaneous delivery by a midwife; 5 th child was
born in 2000 via normal spontaneous delivery, preterm, 8 months, was delivered by a physician
at East Avenue and deceased; 6th child was born in 2004 via normal spontaneous delivery at
home by a midwife. No history of dysuria, UTI, and AUB. Patient did use contraceptives during
the year of 1991 to 1992.
10

Course in the ward

Day 1 – PREOPERATIVE PHASE

Date: October 21, 2019

Time Location Activities

6:00am OB Gyne SIGN- IN: Student nurse Asuncion, Caragan, Marquez

Ward

6:15am OB Gyne Student nurses Asuncion, Caragan, Marquez listened and noted

Ward the endorsement

8:00am OB Gyne Student nurses interviewed patient:

9:10am Ward
o Demographic profile

o Chief complaint

o Present health history

o Past health history

o Family history
11

o Developmental history

o Psychosocial history

9:30am- OB Gyne Student nurses assessed the following:

11:00 am Ward
Physical assessment:

general: awake, alert, coherent

vital signs: 120/80, 79,18,36.7

Chest/ lungs : equal lung expansion, clear breath sounds,

CVS: normal heart rhythm, (-) murmurs

12

Abdomen: non-tender abdomen, normal bowel sounds with 9

normo-active abdominal sounds

Extremities: full equal pulse, (+)2 reflexes on the right

extremities, (+2) on the left extremities, 5/5 muscle strength on

the right ,5/5 muscle strength on the left extremities , (-) edema

Neuro Assessment:

CN I – patient was able to identify different odor

CN II – 20/20

CN III,IV, VI – 3-2 PERLA

CN V – Intact sensation

CN VII- No facial asymmetry

CN VIII- Intact hearing

CN IX X – Uvula at midline, good swallowing (+) gag reflex

CN XI –Good shoulder shrug

CN XII – Tongue midline

Motor: 5/5 muscle strength

13

Sensory: intact pain sensation

Balance: falls out during walking of standing, needs assistance

when walking

12:00nn OB Gyne Signed-out

Ward

DAY 2– OPERATION DAY (PREOPERATIVE – INTRAOPERATIVE)

14

Date: October 22, 2019

PREOPERATIVE PHASE

time Location Activities

4:00am OB Gyne Signed-in

Ward

6:03 am OB Gyne Student nurses listened to the endorsement

Ward

8:00am OB Gyne Student nurses assessed the following:

Ward
Anxiety level: mild

o “medyo kinakabahan kasi di ko alam yung pwedeng

mangyare during operation.” as verbalized by the patient.

o Patient was uneasy and restless.

Vital signs: 120/80, 79,18,36.7

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8:15am OB Gyne Pre-operative teaching regarding the surgical procedure,

Ward importance of removal of dentures, jewelries, nail polishes,

taking a bath and voiding before going to the operating room

8:30am- OB Gyne Bed Side, Assisting the patient.

10:30am Ward

10:30am OB Gyne Student nurse Caragan and Marquez took a break for 15 minutes.

Ward

10:45am OB Gyne Student nurse Asuncion took a break for 15minutes.

Ward

11:00 am- OB Gyne Bed Side, Assisting the patient.

11:40 Ward
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11:40 OB Gyne Instructed to Transfer the patient to OR

Ward

11:40 OB Gyne Signed out

Ward

INTRAOPERATIVE PHASE

Time Location Activities

11:48 am Operating Arrived at Operating Room

room

11:50 pm Operating Signed-in

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room

11:51 pm Operating Preparation of patient, tools and equipments

room

12:10 pm Operating Student nurse Marquez performs hand washing then gloving

room

12:11 Operating Pre-operative medications given

room

12:12 Operating The operation started

room

12:15pm Operating Shaving of Abdomen

room
18

12:24 pm Operating Applying Beatadine on the back of the patient.

room

12:25 pm Operating Anesthesia Given

room
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12:41 pm Operating Positioning the patient

room

12:42 pm Operating Applying Betadine on the peritoneal area

room

12:45 pm Operating Insertion of Catheter

room

12:49 pm Operating Applying betadine on the patient’s abdomen

room

12:54 pm Operating Incision started

room
20

1:02 pm Operating Peritoneal fluid removed

room

1:08 pm Operating

room

1st Specimen found (Left Ovary)

1:11 pm Operating Cutting of the 1st specimen

room

11:16 pm Operating 1st Specimen out

room
21

2:09 pm Operating 2nd specimen out (Uterus)

room

2:52pm Operating Closing time

-3:15 pm
room

3:15 pm Operating Operation was done successfully.

room

3:26 pm Operating Transfer to PACU

room

3:27 pm Operating Arrived at PACU

room

4:53pm Operating Instructed to Transfer to OB Ward

room

5:13 pm Operating Signed out

room

5:19 pm OB Gyne Arrived at OB Ward

Ward
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5:19 pm OB Gyne Signed in

Ward

5:22 pm OB Gyne Patient transfer to bed

Ward

5:30 pm OB Gyne Signed out

Ward

DAY – OPERATION DAY (POST-OPERATIVE PHASE)

Date: October 23, 2019

6:00 am OB Gyne Sign in

Ward

6:05 am OB Gyne Student nurse listened to the endorsement

Ward

8:00 am OB Gyne Student nurse assessed and discovered the following:

-8:30 am Ward
Vital Signs: 120/80, 69, 19, 36.6

Awake, coherent
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GCS: 14

Painscale: 6/10 on the surgical site

CN I – patient was able to identify different odor

CN II – 20/20

CN III,IV, VI – 3-2 PERLA

CN V – Intact sensation

CN VII- No facial asymmetry

CN VIII- Intact hearing

CN IX X – Uvula at midline, good swallowing (+) gag reflex

CN XI –Good shoulder shrug

CN XII – Tongue midline

Motor: 5/5 muscle strength

Sensory: intact pain sensation

9:00 am OB Gyne Signed-out

Ward

*Patient was discharged on October 24, 2019*

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Gordon’s Functional Health Pattern and Physical Assessment

Health Pattern Before Surgery After Surgery Nursing Diagnosis

1. Health S: “Ang nararamdaman S: “Wala naman akong Ineffective Health

Perception - ko lang ay lower back nararamdaman ngayon. Maintenance r/t
Health pain madalas yan. Pati Walang masakit sa akin. insufficient
Management yung sa dito sa puson Hindi masyadong resources
nahahawakan ko yung naexplain ng doctor yung
parang bukol tapos gagawin sa kin eh pero
nacucurious talaga ako pinapainom nila ko ng Risk for Fall
ano ito kasi di naman Aprovel Amlodipine kasi
masakit eh. Tapos sabi daw high blood ako pero
sakin dati noong 2016 ngayon ko lang mismo Risk for Infection
pa-operahan ko daw nalaman noong nagpa r/t Anesthetic-
pero kelangan ko kasi confine ako. Tapos yung Induced loss of
mag ipon muna wala tahi ko medyo masakit bladder distention
kami masyadong pera lang mga siguro nasa 6/10
marami pang gastusin ang sakit pero nilalakad
kaya natagalan ako lakad ko na siya kasi yun
magpa-opera” As sabi ni Doc.” As
verbalized by the verbalized by the patient.
patient.

O:
O:
 Vital signs at 8AM:
 Awake, alert,  BP: 110/80
coherent  HR: 79 BPM
 Vital signs at
 RR: 20 BPM
8AM:
 Temp: 37 C  Temp: 36.3 C
 BP: 130/90  Height: 150 cm
 HR: 68 BPM
 Weight: 49.5 kg
25

 RR: 17 BPM  BMI: 21.8

 Abdominal
 Pain Scale: 6/10
girth: 96 cm
 Patient is alert, awake,
oriented and lying
down in bed.
 Patient is not showing
any facial grimace.
S: “150cm at 49.5 kg S: “Yun pa rin naman ang Readiness for
ang height at weight ko timbang ko 49.5 kg simula enhanced
2. Nutrition –
na kinuha nila sa akin nung nagpa check up ako nutrition
Metabolic
dito sa hospital, hanggang sa ngayon
pumayat nga ako ng 1 matapos ang operasyon.
kilo eh. Naka soft diet Naka soft diet pa rin ako
ako ngayon bago ako pero ngayon mas marami
operahan tapos sa na akong prutas. Mamaya
bahay naman paborito mag tatanong tanong pako
naming yung isda, sa doctor ano mga
gulay, at kanin. Tatlong kelangan ko kainin para
beses sa isang araw rin healthy at mabilis yung
naman kami kumakain pag galling.” As
ng pamilya ko” As verbalized by patient.
verbalized by the
O:
patient.
- Temp: 36.3 C
- Input – 300 mL
O: - Output – 150 mL
- Skin is smooth,
 Temp: 37 C
intact, light to dark
 Input – 250 mL
pink and no
 Output – 350 mL
lesions.
 Skin is smooth, - IV: DSNR 1L
26

intact, light to dark - Height: 150 cm

pink and no lesions. - Weight: 49.5 kg
 Height: 150 cm - BMI: 21.8
 Weight: 49.5 kg - CN V:

 BMI: 21.8 - Patient’s sensation

on light object
(Makeup brush) is
 CN IX: normal on each
- Patient has good side (Right and
Gag reflex Left hands.)
- intact taste - Patient’s sensation
- Non-movable, on sharp object
non-tender and (Paper clip) is
non-movable sharp on both sides
+18cm mass on (Right and Left
the RUQ of the hands.)
Abdomen
 Patient’s skin is
- CN IX:
intact, smooth, light
- Patient has good
to dark pink and has
Gag reflex.
no lesions.
 Patient’s skin is
 Oral mucous
intact, smooth,
membrane is moist,
light to dark pink
smooth, shiny and
and has no lesions.
pink.
 Oral mucous
 Teeth has no decay,
membrane is
white with shiny
moist, smooth,
enamel and smooth
shiny and pink.
surfaces and edges.
 Teeth has no
decay, white with
shiny enamel and
27

smooth surfaces
and edges.
- CN V:
- Patient has facial
sensation equal to
pinprick in all 3
divisions
bilaterally.

3. Elimination S: “Nako lagi akong S: “Nakakaihi naman na Urge Urinary

A. Urine naiihi mga pitong beses ako. Medyo hirap lang Incontinence r/t
sa isang araw.” As gumalaw dahil sa tahi kasi increased pelvic
verbalized by the masakit pero nilalakad pressure as
patient. lakad ko naman na kasi manifested by
yun yung sabi ng doctor” urinary urgency
As verbalized by the
O: patient.

 Patient’s urine O:
color is yellow
 (+) Foley Catheter
 Input – 250 mL
 Total urinary
 Output – 350
output: 150 mL
mL
 Urine is light
yellow in color.

S: “ Normal naman pag

dumi ko minsan mga 1- S: “Hindi pa ako
2 times sa isang araw dumudumi sumila noong
B. Elimination ako.” As verbalized by inoperahan ako.” As
the patient. verbalized by the patient.
28

O:

 Few bruits in the

Epigastric region.
Abdominal Sounds:

 RUQ – 6
 LUQ – 7
 RLQ – 10
 LLQ - 6

4. Sleep – Rest S: “Maaga ako S: “Wala namang Disturbed

natutulog sa amin tapos problema sa pag tulog ko Sleeping Pattern
ang haba ng tulog ko, ngayon dito. Pero minsan related to pain,
minsan depende kung kumikirot kirot yung tahi unfamiliar
may inuuwi pa akong ko pag gabi habang tulog surroundings and
trabaho bale mga 4-6 ako kaya medyo hospital
hours.” As verbalized nagigising din ako. Tapos interruptions as
by the patient. yung mga baby sa manifested by
Rooming-in iyak ng iyak restlessness and
kaya nagigising talaga lack of interest in
ako.” As verbalized by the activities.
patient.
O:
O:
 Patient is alert,
awake and oriented  Patient is alert, awake
and was in a lying and oriented and was
position in bed. in a lying position in
bed.
 Patient seems restless
29

and lacks interest in

patient interview.

5. Activity – S: “Wala naman akong S: “Pinapaglakad lakad Acute Pain related

Exercise exercise lakad lakad nako ng doctor para daw to surgical
lang dito sa ward. Wala gumaling na agad yung incision as
rin akong high blood tahi ko kaso masakit sakit manifested by
noon pero nung nagpa kasi hindi ko kaya mag pain scale of 7/10
confine ako sabi nila lakad ng matagal.” As
may hypertension ako. verbalized by the patient.
Pakiramdam ko kaya
tumataas BP ko dahil sa
Activity
darating kong O:
Intolerance
operasyon.” As
 Patient is rested in related to surgical
verbalized by the
bed, awake, alert and incision
patient.
oriented.
O:  Patient spends
majority of her time in Risk for Fall
 RR: 16 BPM
 HR: 68 BPM a lying position in bed
 RR: 17 BPM and asleep.
 (-) Murmurs
 (-) Murmurs
30
 (-) Crackles
 (-) Wheezing
 (-) Nasal flaring
6. Cognitive – S: “Hindi naman siya
Perceptual Gumagamit ako ng
reading glass at ang
grado ng left and right
ay 375. Medyo dko
lang maintindihan
gagawin sa akin.” As
verbalized by the
patient.
O:
 Patient is alert,
awake and oriented
and was in a lying
position in bed.
 Good immediate,
recent, remote
memory.
 Patient is able to
hear watch tick
from 1-2 inches.
 Patient can read
print at 12 inches
without difficulty.
 Able to spell “bola”
 (-) Crackles
 (+) Wheezing
 (-) nasal flaring
 HR: 79 bpm
 RR: 20 bpm
S: “Ito dko pa rin Acute Pain related
ginagamit kagi reading to surgical
glass ko pag tingin ko lang incision as
na kelangan ko talaga manifested by
tsaka masakit sakit yung pain scale of 7/10
tahi ko dko matagalan
mag lakad lakad kahit yun
inadvice sakin pano ba Impaired Tissue
naman kasi kumikirot” As Integrity related
verbalized by the patient. to surgical
insicion
O:
Readiness for
 Patient is alert,
enhanced comfort
awake and
oriented and was
in a lying position
in bed.
 Follows command,
good fluency, good
insight and
judgment.
 Good immediate,
recent, remote
memory.
31

forward and back  Patient is able to

ward. hear watch tick
 Able to answer from 1-2 inches.
simple math  Patient can read
problem. print at 12 inches
 Language spoken: without difficulty.
Filipino  Able to spell
 Patient’s attention “bola” forward and
span is average,and back ward.
can always  Able to answer
comprehend and simple math
maintains eye problem.
contact.  Language spoken:
Filipino
 Patient’s attention
span is
average,and can
always
comprehend and
maintains eye
contact.
7. Self S: “Ready naman na S: “Mas nagging okay ang Anxiety secondary
Perception – ako sa surgery ko kasi pakiramdam ko to Fear of
Self Concept matagal ko na tong pagkatapos ng operasyon Surgical
pinaplano di lang ko”As verbalized by the Procedure as
natutuloy kasi kulang patient. manifested by
pa kami sa pera.” As blood pressure of
verbalized by patient. 130/90

O: Disturbed Body
32

 Patient’s O: Image r/t

attention span is permanent

 Patient was relaxed alteration of
average and can
and rested in bed. mutilating surgery.
always
 Patient’s attention
comprehend and
span is average and
maintains eye
can always
contact.
comprehend and
 Patient has a
maintains eye contact.
positive attitude
 Patient has a positive
towards herself
attitude towards
but seems
herself and is in a
anxious and
good mood.
presence of
guarding
behavior
towards
abdomen.
8. Role – S: “Masaya ako sa S: “Ganoon pa rin naman. No alterations
Relationship buhay ko, buhay asawa Bumibisita sila dito araw- needed in this
at buhay pamilya. Close araw para lang pattern.
kami lahat ng mga anak siguraduhin na okay ako.”
ko lagi lagi kami mag As verbalized by the
kakasama para patient
mapatibay yung
O:
pamilya namin.” As
verbalized by the  The patient has
patient. visitors.

9. Sexuality – S: “Isa lang naman ang S: “Sa tingin ko naman No alterations

Reproductive partner ko ang asawa hindi maapektuhan ang needed in this
ko. Dalawa o kaya pagtatalik naming ng pattern.
tatlong beses sa isang asawa ko, wala rin naming
33

linggo kami nag tatalik. sinabi ang doctor ko na

Unang regla ko ay 17 bawal ako makipagtalik sa
years old ako, hindi ko Asawa ko.” As verbalized
na gaano maalala ilang by the patient.
taon ako nag
menopause. Apat ang
anak ko, lahat buhay.” O:
As verbalized by the
 Breast is symmetrical
patient.
in size, shape, no
prominent pores and
areolas are dark pink
O:
to brown color and no
 Breast is discharges were
symmetrical in size, present.
shape, no prominent
pores and areolas
are dark pink to
brown color and no
discharges were
present.
10. Coping – S: “Sa edad kong ito S: “Wala namang naka No alterations
Stress wala na akong stress. stress sa akin dito sa needed In this
Tolerance Kung meron man pinag buong stay ko sa ospital.” pattern.
dadasal ko ito.” As As verbalized by the
verbalized by the patient.
patient.

O:
O:
 Behavior and thought
 Patient sleeps from process appropriate to
34

time to time and age and intellectual

would cover her capability.
entire face.
11. Value – S: “Catholic kami at S: “Nag dadasal kami dito No alterations
Belief nag sisimba tuwing kami ng anak ko, nako needed in this
linggo. Nagpapray kami lalo na ako.” As pattern.
lagi bago kumain at verbalized by the patient.
may altar din kami sa
O:
bahay. Maka – diyos
kami ng pamilya ko.”  Presence of
As verbalized by the religious articles
patient. and rosary by bed
side.

Laboratory Examinations

GYNECOLOGIC ULTRASOUND REPORT

Type of Examination: Transvaginal.

UTERUS Anteverted

Homogenous

Size: 3.71x 3.18x 4.23cm

CERVIX Size: 1.97x 2.79x 2.31 cm

International Endometrial Tumor Analysis (IETA) Description of the Endometrium

35

ENDOMETRIUM: Thickness 0.41cm

Uniform Non-uniform Cycle Endometrial Junctional

Echogenecity Echogenecity Coompatibility Midline Zone

Hyperechogenic - Atrophic linear Regular

RIGHT OVARY LEFT OVARY

Size: 2.29 x 1.81 x 1.86cm Size: 18.94 x 13.06 x 15cm

Findings: Within is anechoic cyst measuring 1.59 Findings: Unilocular cyst with low level echoes
x 1.35 x 1.67 cm and no color flow on Doppler (vol: 2004.82ml)

IMPRESSION AND RECOMMENDATION:

- Atrophic Uterus and Endometrium.

- Ovarian New Growth, Left with 2 B Features and no M feature by IOTA simple rules.
- Suggestive of Benignity.
- Cystic Follicle, Right Ovary.
- No Uterine mass
- Fluid in the UL-DE-SAC

CBC TESST

TEST RESULT NORMAL INTERPRETATIONS/

RANGE INDICATIONS
HEMOGLOBIN 142 g/L 120-140 High hemoglobin levels
could be indicative of
the rare blood disease,
polycythemia. It causes
the body to make too
many red blood cells,
causing the blood to be
thicker than usual. This
can lead to clots, heart
attacks, and strokes. It is
36

a serious lifelong
condition that can be
fatal if it is not treated.
HEMATOCRIT 42 % 37-47 NORMAL
RBC 4.5 X10^12/L 4.5-5.5 NORMAL
MCHC 34% 32-27 NORMAL
MCH 31.7pg 27.5- 33.2 NORMAL
MCV 94fL 80-94 NORMAL
RDW 11.9% 11.0-15.0 NORMAL
WBC 6.1X10^9/L 5.0-10.0 NORMAL
NEUTROPHILS 61% 37-72 NORMAL
LYMPHOCYTES 37% 20-50 NORMAL
MONOCYTES 0% 0-14 NORMAL
EOSINOPHILS 2% 0-6 NORMAL
BASOPHILS 0% 0-1 NORMAL
PLATELETS 264 X10^9/L 150-440 NORMAL
MPV 9.3 Fl 7.5-11.5 NORMAL
RBC NORMOCHROMIC,
MORPHOLOGY NORMOCYTIC.

PROTHROMBIN TIME

TEST RESULT NORMAL RANGE NURSING

RESPONSIBILITIE
S
PROTIME 10.4 secs 10-13 NORMAL
Control 12.2 secs
INR 0.87
% ACTIVITY 130.0
37

APIT 27.2 secs 29-34 NORMAL

Control 27.8
Nursing Responsibilities:

1. Explain test procedure and why we need to do it.

2. Explain to patient that fasting is not necessary. However, fatty meals may alter some test
result as a result of lipidemia.
3. Preparing equipments
4. Preparing patient
5. Assist the patient during Testing
6. Monitor patient during testing
7. Reports the result of the test
38

Anatomy and Physiology

Uterus
39

The uterus (ū′ter-ŭs) is the size and shape of a medium-sized pear— about 7.5 cm long and 5 cm
wide (see figures 28.10 and 28.11). It is slightly flattened anteroposteriorly and is oriented in the
pelvic cavity with the larger, rounded part, the fundus (fŭn′dŭs), directed supe- riorly and the
narrower part, the cervix (ser′viks), directed inferiorly. The main part of the uterus, the body, is
between the fundus and the cervix. A slight constriction called the isthmus marks the junction of
the cervix and the body. Internally, the uterine cavity continues as the cervical canal, which
opens through the ostium into the vagina.
The uterus is supported by the broad ligament, the round ligaments and the uterosacral ligaments.
The broad ligament is a peritoneal fold extending from the lateral margins of the uterus to the
wall of the pelvis on either side. It also ensheathes the ovaries and the uterine tubes. The round
ligaments extend from the uterus through the inguinal canals to the labia majora of the external
genitalia, and the uterosacral ligaments attach the lateral wall of the uterus to the sacrum.
Normally, the uterus is anteverted, mean- ing that the body of the uterus is tipped slightly
anteriorly. However, in some women, the uterus is retroverted, or tipped posteriorly.
In addition to the ligaments, skeletal muscles of the pelvic floor support the uterus inferiorly. If
these muscles are weakened (e.g., in childbirth), the uterus can extend inferiorly into the vagina,
a condition called a prolapsed uterus.
The uterine wall is composed of three layers: the perimetrium, the myometrium, and the
endometrium. The perimetrium (per-i-mē′trē-ŭm), or serous layer, is the peritoneum that covers
the uterus. The next layer, just deep to the perimetrium, is the myometrium (mī′ō-mē′trē-ŭm), or
muscular layer, composed of a thick layer of smooth muscle. The myometrium accounts for the
bulk of the uterine wall and is the thickest layer of smooth muscle in the body. In the cervix, the
muscular layer contains less muscle and more dense connective tissue. The cervix is therefore
more rigid and less contractile than the rest of the uterus. The innermost layer of the uterus is the
endometrium (en′dō-mē′trē-ŭm), or mucous membrane, which consists of a simple columnar
epithelial lining and a connective tissue layer called the lamina propria. Simple tubular glands,
called spiral glands, are scattered about the lamina propria and open through the epithelium into
the uterine cavity.

Cervix
40

The cervix is a cylinder-shaped neck of tissue that connects the vagina and uterus. Located at the
lowermost portion of the uterus, the cervix is composed primarily of fibromuscular tissue. There
are two main portions of the cervix:

The part of the cervix that can be seen from inside the vagina during a gynecologic examination
is known as the ectocervix. An opening in the center of the ectocervix, known as the external os,
opens to allow passage between the uterus and vagina.
The endocervix, or endocervical canal, is a tunnel through the cervix, from the external os into
the uterus.
The overlapping border between the endocervix and ectocervix is called the transformation zone.

The cervix produces cervical mucus that changes in consistency during the menstrual cycle to
prevent or promote pregnancy.

During childbirth, the cervix dilates widely to allow the baby to pass through. During
menstruation, the cervix opens a small amount to permit passage of menstrual flow.

Ovaries

The two ovaries (ō′var-ēz) are small organs about 2–3.5 cm long and 1–1.5 cm wide (figure
28.11). A peritoneal fold called the mesovarium (mez′ō-vā′rē-ŭm; mesentery of the ovary)
attaches each ovary to the posterior surface of the broad ligament. Two other ligaments are
associated with the ovary: the suspensory ligament, which extends from the mesovarium to the
body wall, and the ovarian ligament, which attaches the ovary to the superior margin of the
uterus. The ovarian arteries, veins, and nerves traverse the suspensory ligament and enter the
ovary through the mesovarium.

Fallopian Tubes or Uterine Tubes

A uterine tube, also called a fallopian (fa-lō′pē-an) tube or oviduct (ō′vi-dŭkt), is associated with
each ovary and extends from the area of the ovary to the uterus. Each tube is located along the
41

superior margin of the broad ligament. The part of the broad ligament most directly associated
with the uterine tube is called the mesosalpinx (mez′ō-sal′pinks).
The uterine tube opens directly into the peritoneal cavity to receive the oocyte from the ovary. It
expands to form the infundibu- lum (in-fŭn-dib′ū-lŭm; funnel), and long, thin processes called
fimbriae (fim′brē-ē; fringe) surround the opening of the infun- dibulum. The inner surfaces of the
fimbriae consist of a ciliated mucous membrane.
The part of the uterine tube that is nearest the infundibulum is called the ampulla. It is the widest
and longest part of the tube and accounts for about 7.5–8 cm of the total 10 cm length of the
tube. Fertilization usually occurs in the ampulla. The part of the uterine tube nearest the uterus,
the isthmus, is much narrower and has thicker walls than the ampulla. The uterine part, or
intramural part, of the tube passes through the uterine wall and ends in a very small uterine
opening.
The wall of each uterine tube consists of three layers. The outer serosa is formed by the
peritoneum, the middle muscular layer consists of longitudinal and circular smooth muscle cells,
and the inner mucosa consists of a mucous membrane of simple ciliated columnar epithelium.
The mucosa is arranged into numerous longitudinal folds.
The mucosa of the uterine tubes provides nutrients for the oocyte or, if fertilization has occurred,
for the developing embry- onic mass as it passes through the uterine tube. The ciliated epithelium
helps move the small amount of fluid and the oocyte, or the developing embryonic mass, through
the uterine tubes.
 42

Pathophysiology

Non-modifiable Factors:
Modifiable Factors:
 Gender
 Diet
 Age: 55 years old
 Lifestyle
 Family History

HORMONAL IMBALANCE:
increased release of Human
Chorionic Gonadotrophin

Suppression of FSH and LH

that helps to mature ovarian
follicles

Altered maturation of
ovarian follicles
IETA Description of Endometrium:

Endometrium thickness: 0.41cm Failure of the follicles to

ovulate and continue to grow
Right Ovary:
Increased Abdominal girth:
 Size: 2.29 x 1.81 x 1.86 cm Cyst may grow in size up
96 cm
to 15cm diameter
Left Ovary:

 Size: 18.94 x 13.06 x 15 cm

43

Unruptured cyst but

Increased pelvic pressure
advised for TAHBSO

Heaviness in Urinary
pelvic frequency

Surgical Procedure

Total Abdominal Hysterectomy

The entire uterus, including the cervix, is resected. Normal ovaries are preserved for hormone
production.

The abdominal peritoneal cavity is entered through a vertical midline or a transverse Pfannenstiel
incision. Vertical incision facilitates exploration. The patient is placed in a deep Trendelenburg’s
position. Incision through the uterine peritoneum is carried out laterally. The Trendelenburg
position assists in maintaining the bowel out of the operative field.

The abdominal organs are retracted and protected with laparotomy packs moistened with warm
sterile normal saline solution.

The fallopian tubes and round and broad ligaments are clamped, cut, and ligated, The ovaries
when not removed, are suspended to avoid adherence to the vaginal vault. With the uterus
forward, posterior sheets of the broad ligaments are incised, the ureters are identified, and the
uterine vessels and uterosacral ligaments are clamped, divided, and sutured. All uterine-
supporting ligaments must be divided and ligated. The bladder is mobilized from the cervix and
vagina, the vaginal vault is incised, and the cervix is dissected from the vagina.
44

After the uterus is removed , the connective tissue ligaments are anchored to the vagina. The
vaginal mucosa and muscular wall are approximately by absorbable sutures or staples, and the
bladder, vault, and rectum.

Salpingo-oophorectomy

A Kelly clamp is placed immediately lateral to the uterus at each cornua and incorporates the
isthmic portion of the fallopian tube and the utero-ovarian ligament within its grasp. Bilateral
clamps in this position will allow for elevation, traction, and rotation of the uterus, which will aid
in visualization and dissection. The round ligament is grasped with a Kocher clamp midway
between the uterus and the internal inguinal ring. A transfixion suture of 2-0 delayed absorbable
suture is placed through the distal portion of the round ligament and tagged. A second suture
and/or large hemoclip may be placed across the proximal portion of the round ligament to
prevent back-bleeding. The round ligament is transsected and the anterior leaf of the broad
ligament is incised toward the level of the internal cervical os with Metzenbaum scissors. This
will begin the development of the bladder flap. The posterior leaf of the broad ligament may also
be incised parallel to the infundibulopelvic ligament toward the side wall. This exposure is
particularly helpful if the ovaries are to be removed. With traction of the uterus away from the
side wall and lifting the tagged, round ligament upward and lateral, the operator can separate the
areolar tissue within the broad ligament by spreading the index and middle fingers in a
scissorlike manner.

The round ligament is identified, clamped, and transfixion sutured. This procedure initiates the
hysterectomy and allows entrance into the broad ligament and retroperitoneum.

The anterior leaf of the broad ligament is incised toward the level of the internal os with
Metzenbaum scissors. Bilateral incisions meet in the midline.

The ureter is visualized on the medial leaf of the broad ligament in this space. If adhesive disease
impedes visualization here, the ureter can be identified at the pelvic brim where it crosses the
iliac vessels at their bifurcation. The ureter can then be followed downward through its course to
ensure that further dissection does not compromise its integrity. The ureter appears as a white,
45

nonpulsatile tubular structure with fine blood vessels noted longitudinally on the adventitia. It is
best identified by visualization of its characteristic peristaltic activity. It can also be palpated by
the operator's thumb being placed deep on the intraperitoneal side of the posterior medial leaf of
the broad ligament and the index finger deep on the retroperitoneal side of this medial leaf. As
the operator holds the index finger and thumb together with the peritoneum trapped between and
moves upward, the ureter will be palpable and demonstrates a “rubber band—like” twang as
released. This palpation can then guide the dissection to achieve adequate visualization.

The ureter crosses the iliac vessels at their bifurcation, continues below the infundibulopelvic
ligament on the posterior medial leaf of the broad ligament, and crosses under the uterine vessels
before turning anterior and medially to enter the bladder.

The Ovary and Fallopian Tube

The avascular portion of the posterior broad ligament lateral to the uterus, anterior to the ureter,
and posteromedial to the infundibulopelvic ligament is identified and tented upward with the
index finger. It can be bluntly or, if thickened, sharply entered. If the ovary and fallopian tube are
not being removed, this window allows isolation of the proximal fallopian tube and utero-ovarian
ligament. These structures are clamped with two Kelly clamps close to the uterus with care being
taken that the lateral clamp does not impinge on the ovarian capsule. The Kelly clamp on the
uterus can be replaced so that its tip extends into the window. The pedicle is cut, leaving two
clamps laterally. This allows the pedicle to be free tied as one clamp is released, then transfixion
sutured around the second clamp.

The posterior broad ligament is tented upward in the avascular space lateral to the uterus,
posteromedial to the adnexa and anterior to the ureter. This space is entered to create a window
in the broad ligament.

If the ovary and fallopian tube are to be conserved, two Kelly clamps are placed across the
fallopian tube and utero-ovarian ligament in close proximity to the uterus. The Kelly clamp at the
uterine cornua is advanced so that its tip extends into the window.
46

A free tie is placed with removal of the lateral clamp.A transfixion suture is then placed beneath
the second clamp.

When the ovary and fallopian tube are to be removed, the window produced in the broad
ligament serves to isolate the infundibulopelvic ligament, which is clamped with two Kelly
clamps above the level of the ureter. The most distal clamp is placed first. A third clamp
immediately adjacent to the ovary and fallopian tube prevents back-bleeding. The ligament is cut
above the two distal clamps. The distal end is free tied and then transfixion sutured with 2-0
delayed absorbable suture. The proximal end is also tied and may be suspended from the Kelly
clamp on the uterus to prevent the ovary and tube from obstructing the operative field.

If the ovary and fallopian tube are to be removed, three Kelly clamps are placed across the
infundibulopelvic ligament through the window in the broad ligament.

Abdominal layers are closed as for laparotomy.

47

Surgical Equipments

Total Abdominal hysterectomy with bilateral salpingo-oophorectomy tray:

 Schroeder tenaculum forceps

 Curved Heaney forceps (single toothed with horizontal serration)

 Curved Mayo uterine scissors

 Straight Heaney-Ballantine Hysterectomy forceps (double toothed with vertical serrations)

 Long angled #3 knife handle

 Crile/Kelly forceps

 Tonsil forceps

 Jorgenson scissors

 Foerster sponge forceps

 Self retaining retractor - Turner Warrick

48

Sutures:

 Skin stapler 3m: skin closure

 0 polyglactin 910: for uterus and vaginal cuff

 0 polyglactin 910: closure of peritoneum and fascia

 0 polyglactin 910 ties: ligaments and vessels

 2-0 polyglactin 910: ligament stumps

 2-0 Chromic SH: used for “bleeders”

 2-0 Silk: Drain

 4-0 absorbable suture: subcutaneous closure

Drug Analysis

PREOPERATIVE

Name of Mechanis Indicatio Contraindications Side Nursing

Drug m of ns Effects Responsibil
Action ities

Generic Inhibits Nonsteroi -Hypersensitivity A -Assess

Name: prostagland dal anti- common client's level
Ketorolac in synthesis inflammat (>10%) of pain for
by ory drugs -Allergies to the side baseline
competitive (NSAIDs) medication effect is data.
Brand Name: blocking of can be drowsine
Toradol the enzyme used for ss.
cyclooxyge pain relief -Cross-sensitivity to - -Assess
nase in other NSAIDs Infrequen vital signs
Classification: (COX). patients t (<1%) especially
Antiinflamma with side HR, RR and
49

tory, ovarian -Prior to surgery effects BP. Hold

Analgesia, growths. include administrati
-Inhibits
First NSAIDs, paresthesi on if they
both COX-
GenerationNS including -History of peptic ulcer a, are below
2 and
AID, ketorolac, disease and prolonge normal.
COX-1
Antipyretic, can be gastrointestinal d
making it
Non- used to bleeding bleeding
"Non-
Selective treat mild time, -Observe 10
Selective"
Cyclooxygena to injection Rights of
by nature.
se Inhibitor moderate -Alcohol intolerance site pain, medication
pain purpura, and
sweating, administer
Route: IV -Renal impairment abnormal analgesic as
thinking, ordered.
increased
Dosage: 30 Cerebrovascular productio
mg bleeding n of tears, -Inform
edema, patient of
pallor, purpose,
Frequency: dry possible
Q6 (x4 doses) mouth, side/adverse
abnormal effects and
taste, outcome of
Pregnancy urinary administrati
Category: D frequency on of
, medocation.

-Ensure
patient does
not have
50

hypersesitiv
ity and
allergy to
medication,
cross-
sensitivity
to other
NSAIDs,
and does
not take it
prior to
surgery.

-Ensure
Ketorolac is
not
prescribed
for longer
than five
days,due to
its potential
to cause
kidney
damage.

Generic Paracetamo If ovarian Caloric undernutrition, Low Assess level

Name: l has a growths acute liver failure, fever of pain and
Paracetamol central causes liver problems with vital signs
analgesic pain, severe renal nausea, before
51

Brand Name: effect that paracetam impairment, stomach administrati

Panadol is mediated ol can be a condition where the pain, and on of
through administe body is unable to loss of medications
activation red. maintain adequate appetite; for
Classification: of blood flow called dark comparison
descending shock, urine, after
serotonergi acetaminophen clay- medication
Route: IV c pathways. overdose, colored administrati
Debate Acute Inflammation of stools; or on.
exists about the Liver due to jaundice,
Dosage: 600 its primary Hepatitis C Viru hypotensi
mg site of on, low Ensure
action, shallow paracetamol
which may breaths is
Frequency: be administere
Q6 (x6 dose inhibition d with
of adequate
prostagland caloric
Pregnancy in (PG) intake.
Category: B synthesis or
through an
active Do not
metabolite administer
influencing when
cannabinoi patient has
d receptors. acute liver
Prostagland failure or
in H2 liver
synthetase problems.
(PGHS) is
the enzyme
52

responsible Look for

for signs of
metabolism Acetaminop
of hen
arachidonic overdose. If
acid to the present,
unstable hold
PGH2. The administrati
two major on of
forms of Paracetamol
this .
enzyme are
the
constitutive
PGHS‐1
and the
inducible
PGHS‐2.
PGHS
comprises
of two
sites: a
cyclooxyge
nase
(COX) site
and a
peroxidase
(POX) site.

Generic Inhibition Inflamma NSAID hypersensitivity Stomach Obtain any

Name: of tory pain who have experienced pain, history of
Celecoxib cycloxgena from asthma, urticaria, or constipati allergic
53

se-2 (Cox- ovarian other allergic reactions on, reactions

2) growths after taking aspirin or diarrhea, from
Brand Name:
other NSAIDs. gas, NSAIDs or
Celebrex
heartburn ASA.
,
nausea,
Classification:
vomiting,
NSAIDs
dizziness,
headache,
respirator
Route: Oral
y tract
infection,

Dosage: 200
mg 1 cap

Frequency:
BID

Pregnancy
Category: D

Generic inhibits cell Peri- Hypersensitivity to Allergic

Name: wall operative cephalosphorins reactions
Cefazolin biosynthesi prophylax including
s by is skin
binding rashes,
Brand name: Penicillin urticaria
Cevafex binding and
proteins anaphyla
which stops
54

Classification: peptidoglyc xis

Antibiotics an
synthesis.
Penicillin
Dose: 1g binding
proteins are
bacterial
Route: IV proteins
that help to
catalyze the
Frequency: last stages
q12 of
peptidoglyc
an
Pregnancy synthesis,
Category: D which is
needed to
maintain
the cell
wall.

Generic Inhibits the Hypertens Hypersensitivity, Arrythmi

Name: movement ion hypersensitivity to a,
Amlodipine of calcium dihydropyridines, amlo Bradycar
ions into dipine or any of the dia, chest
vascular excipients listed in pain,
Brand Name: smooth section, severe nausea
Norvasc muscle hypotension. shock and
cells and (including cardiogenic vomiting,
cardiac shock). drowsine
Dose muscle ss,
cells which diarrhea,
55

Route inhibits the headache,

contraction
of cardiac
Frequency muscle and
vascular
smooth
Pregnancy muscle
Category: cells

Name of Mechani Indications Contraindic Side Effects Nursing

drug sm of ations Responsib
Action lities

Generic Stimulate This is used to Hypersensitiv This are the serious side -Assess
Name: s treat constipati ity. effects : patient for
Bisacodyl peristalsi on. It may also abdominal
s of the be used to distention,
colon clean out -persistent presence of
Brand and the intestines b nausea/vomiting/diarrh bowel
Name: promotes efore a bowel ea, muscle sounds,
Dulcolax accumula examination/s cramps/weakness, and usual
tion of urgery. irregular pattern of
water in heartbeat, dizziness, fai bowel
Classifica the nting, decreased function.
tion: colonic urination, mental/mood
Laxative lumen changes.
which -Assess
leads to color,
Route: stimulati consistency
Oral on of , and
56

defecatio amount of
n, stool
Dosage:
reduction produced.
of transit
time and
Frequenc
softening -Advise
y:
of stool. patient to
increase
fluid intake
to at least
1500–
2000
mL/day
during
therapy to
prevent
dehydratio
n.

-Do not
crush or
chew
enteric-
coated
tablets.
Take with
a full glass
of water or
juice.
57

-Do not
administer
oral doses
within 1 hr
of milk or
antacids;
this may
lead to
premature
dissolution
of tablet
and gastric
or
duodenal
irritation.

Name of Mechanis Indications Contraindicatio Side Nursing

58

drug m of ns Effects Responsibliti

Action es

Generic Is a Used to reduce Contraindicated -Give before

These
Name: selective the amount of to patients with food,
are the
Omeprazole. and acid in your weak bones, preferably
common
irreversibl stomach. It's broken bone. breakfast;
side
e proton used to treat Osteoporosis, capsules must
effects:
Brand Name: pump gastric or autoimmune be swallowed
inhibitor. It duodenal disease, liver whole (do not
Headach
suppresses ulcers, problems, low open, chew, or
e,
Classification: stomach gastroesophage amount of crush).
Stomach
Gastrointestin acid al reflux magnesium in
pain,
al Agent, secretion disease the blood.
Nausea,
Proton Pump by specific (GERD), - Monitor
Diarrhea,
Inhibitor inhibition erosive urinalysis for
Vomiting
of the esophagitis, hematuria and
.
H+/K+- and proteinuria.
Route: Oral ATPase hypersecretory
system conditions.
found at - Report any
Dosage: the changes in
secretory urinary
surface of elimination
Frequency: gastric such as pain
parietal or discomfort
cells associated
with
urination, or
blood in
urine.
59

- Report
severe
diarrhea; drug
may need to
be
discontinued

Nursing Care Plans

60

PREOPERATIVE

NCP #1

Assessment Analysis Plan of Interventions Rationale Evaluation

Care

Subjective: Anxiety After 2 Independent: To classify After 2

“Ready naman secondar hours of level of hours of
1. Assess the
na ako sa y to Fear nursing anxiety nursing
patient’s level of
surgery ko kasi of interventio identify interventio
anxiety. Hildegar
matagal ko na Surgical n, patient treatment n, patient
d E. Peplau
tong pinaplano Procedur will needed will
described 4 levels
di lang natutuloy e as demonstrat demonstrat
of anxiety: mild,
kasi kulang pa manifest e improved e improved
moderate, severe
kami sa pera.” ed by concentrati concentrati
and panic.
As verbalized by blood on and on and
patient. pressure accuracy of 2. Allow time to accuracy of
of 130/90 thoughts. express feelings. Application of thoughts.
Objective:
Restate patient's Therapeutic
 Patient’s
thoughts. Communicati
attention
on.
span is
average
3. Use
and can
presence, touch(
always
with permission),
compreh Being
verbalization, and
end and supportive
demeanor to
maintains and
remind patients
eye approachable
that they are not
contact. promotes
alone and to
 Patient communicatio
encourage
has a n
expression or
61

positive clarification of
attitude needs, concerns,
towards unknowns, and
herself question.
but
seems Dependent:
anxious 1. Administer
and anxiolytic drugs
presence if prescribed by
of physician.
guarding
behavior
Collaborative:
towards
abdomen 1.Educate
. patient's family
 BP is on Therapeutic
130/90. Communication.
Teach them to
accept patient’s To provide
defenses; do not comfort and
dare, argue, or trust.
debate

NCP #2
62

Assessme Analysis Plan of Interventions Rationale Evaluatio

nt Care n

S: “Wala Disturbed After 3 Independent: To identify cause After 3

namang Sleeping hours of and treatment. hours of
1. Assess level
problema Pattern nursing nursing
of sleep
sa pag due to interventio interventi
deprivation.
tulog ko unfamiliar ns, the 2. Provide a To make os, the
ngayon surroundin patient will quiet sleeping easier patient
dito. Pero gs and be able to environment for the patient. will be
minsan hospital discuss 3. Encourage able to
kumikirot interruptio measures daytime discuss
kirot ns as on how to physical Stress may be measures
yung tahi manifested improve activities but reduced by on how to
ko pag by sleeping instruct the therapeutic improve
gabi restlessnes pattern. patient to activities and sleeping
habang s and lack avoid may promote patter
tulog ako of interest strenuous sleep. However,
kaya in activities strenuous
medyo activities before activities may
nagigisin bedtime lead
g din ako. to fatigue and
Tapos may cause
Dependent: insomnia.
yung mga
baby sa 1. Administer
Rooming sedative-
-in iyak hypnotics, These act
ng iyak anti-anxiety through general
kaya drugs as central nervous
nagigisin ordered by system
g talaga physician. depression and
ako.” As disrupt the
63

verbalize Collaborative: normal stages of

d by the non-rapid eye m
1. Educate the
patient. ovement
family on the
(NREM) and
O: proper food
REM sleep.
and fluid
 Patien Long-term use
intake such as
t is may cause
avoiding
alert, daytime
heavy meals,
awak drowsiness,
alcohol,
e and rebound
caffeine,
orient insomnia, and
or smoking be
ed increased
fore bedtime.
and dreaming when
was discontinued.
in a
lying
positi For enhanced
on in health promotion
bed. of sleep.
Patient
seems
restless
and lacks
interest in
patient
interview.

NCP #3
Assessment Analysis Plan of Care Interventions Rationale Evaluation
64

S: “Ang Ineffective After 4 Independent: To identify After 4

nararamdaman Health hours of patient's hours of
1. Assess
ko lang ay lower Maintenanc nursing goals and nursing
clients'
back pain e r/t intervention frustration intervention
perceptio
madalas yan. insufficient s, the patient s. s, the patient
n of their
Pati yung sa dito resources will be able will be able
current
sa puson to use to use
health
nahahawakan ko information information
problem
yung parang to develop to develop
s To
bukol tapos an 2. Ask an
facilitate
nacucurious individual preferred individual
learning
talaga ako ano plan to meet methods plan to meet
process.
ito kasi di naman health care of health care
masakit eh. goals. learning. goals.
Tapos sabi sakin 3. Provide
Promotes
dati noong 2016 additiona
learning at
pa-operahan ko l
own
daw pero mediums
phase.
kelangan ko kasi of

mag ipon muna learning

4. Identify
wala kami
available
masyadong pera
support
marami pang For
groups.
gastusin kaya additional
natagalan ako opportunit
magpa-opera” As y for
verbalized by the social
patient. interaction
s and
learning.
O:
65

 Awake,
alert,
coherent
 Vital
signs at
8AM:
 Temp: 37
C
 BP:
130/90
 HR: 68
BPM
 RR: 17
BPM
 Abdomin
al girth:
96 cm

INTRAOPERATIVE

NCP #1

Assessment Analysis Plan of Interventions Rationale Evaluation

Care

Objective: Decreased After 2 Independent: To assess After 2

66

Cold Cardiac hours of cardiac hours of

peripheries, Output nursing 1. Monitor output and nursing
BP is 80/60, related to interventions BP, HR, circulation interventions
Temperatur Surgical , patient will TEMP, , patient no
e is 34. 6, Bleeding no longer spO2, I & IV Infusion longer
RR is 13, and display cold O Sets often display cold
HR is 60, Anesthetic- peripheries 2. Ensure pauses from peripheries
spO2 is Induced flow of IV dripping due
100, Vasodilation Therapy to gravity,
diminished and Sterofundin kinks, etc.
peripheral Myocardial 100mL/hr) Ensuring all
pulses Depression is carried IV
as out. Therapies
manifested 3. Ensure are carried
by BP 80/60 there is no out
and compressio effectively
Temperatur n of replaces lost
e of 34.6 peripheral fluid/ blood
veins. from
Dependent: surgery.
1. Document
and notify To increase
surgical venous
team if return to
cardiac heart
values are
abnormal.
Collaborative:
1. Collaborate
To instill
with the
awareness
Anesthesia
67

team in of patient’s
knowing current
appropriate condition.
action
when The
cardiac Anesthesia
output Team are
decreases. responsible
for
Anesthetic-
Induced
Hypotension
.

NCP #2

Assessment Analysis Plan of Interventions Rationale Evaluation

Care

Objective: Risk for After 8 Independent: After 8

68

Introduction Infection hours of 1. Monitor for For early hours of

of surgical related to nursing signs and recognition to nursing
equipments in the interventio symptoms allow prompt interventio
body, Easy Introductio n, patient of treatment. n, patient
puncturability n of be free of infection. was free of
of latex Surgical infection, 2. Implement To prevent infection,
gloves Equipment as sterile entry of as
exposing skin s in body evidenced technique pathogens to evidenced
to surgical and by normal in handling the patient’s by normal
site, Exposure vital signs equipments body. vital signs
Occurrence of to and . and
accidents Pathogens absence of 3. Perform To reduce the absence of
causing signs and skin prep. resident and signs and
contaminatio symptoms transient symptoms
n in sterile of Dependent: microorganis of
field, infection. 1. Administer ms in the infection.
Presence of prescribed incision site.
open midline prophylacti
abdominal c To prevent
incision, medication infections
Crowding of s as from
OR by ordered. occurring.
personnel and
Collaborative:
students,
1. Inform
Presence of
surgical
exposed hair
team if
from surgical
sterile field To prevent the
cap of
has been surgical team
surgical team,
contaminat from moving
Presence of
ed microorganis
surgical
69

team’s ms towards
exposed the portal of
bodily fluids entry.
such as sweat
above
incision site

NCP #3

Assessment Analysis Plan of Interventions Rationale Evaluation

Care

Objective: Risk for After 4 Independent: To prevent After 4

Urinary hours of UTI and hours of
Patient is 1. Imement
Injury nursing other nursing
unconscious aseptic
related to interventions infections. interventions
, has been technique in
Anesthetic , patient , patient
administere administerin
- Induced maintains maintains
d Lidocaine g IUC.
Loss of balanced I & 2. Administer balanced I
either HCL,
Bladder O, with Indwelling and O with
Patient's
and clear odor Urinary clear odor
urine is
Sphincter free urine Catheter. To drain the free urine
light yellow,
Sensitivity free of 3. Monitor I bladder free of
presence of
as bladder and O. during bladder
IV and 4. Administer
manifested distention surgery distention
Blood perineal
by bladder and urinary and urinary
Transfusion care.
distention. leakage. leakage.
Dependent:

5. Administer To ensure
Antibiotic adequate
70

Prophylaxis fluids are

to prevent excreted.
UTIs as
ordered by
physician. To prevent
developmen
t of UTIs.

To prevent
developmen
t of
infection.

POST-OPERATIVE
71

NCP #1

NURSIN PLANNIN NURSING RATIONALE EVALUATION

ASSESSME G G INTERVENTI
NT DIAGNO ON
SIS
S: “Ito dko Acute At the end INDEPENDEN INDEPENDEN After 4 hours of
pa rin Pain of 4 hours T: T: nursing
ginagamit related to of nursing - Monitor Vital - To serve intervention the
kagi reading surgical intervention signs especially as baseline data patient reported
glass ko pag incision the patient the temperature and see if there that pain is
tingin ko lang as will be able and skin color. is possible controlled/
na kelangan manifeste to report - Assess quality infection. reduced.
ko talaga d by pain that pain is and severity of - To know
tsaka masakit scale of controlled/ pain. what pain
sakit yung 7/10 reduced. - Observe non management
tahi ko dko verbal cues and will be helpful
matagalan pain behaviors for the patient
mag lakad such as facial and to know the
lakad kahit expression and degree of pain.
yun inadvice how she walks. - Observat
sakin pano ba - Encourage ions may not be
naman kasi adequate rest congruent with
kumikirot” periods. verbal reports or
As verbalized - Provide may be only
by the comfort such as indicator present
patient. heat or cold when patient is
application. unable to
- Reposition the verbalized.
O: patient to semi - To

 Patien fowler/ lateral prevent fatigue

sims position. that can impair
72

t is DEPENDENT: ability to
alert, - Administer manage or cope
awake medications with pain.
and prescribed by - To
orient the physicians improve
ed such as circulation and
and analgesics. reduces muscle
was COLLABORA tension.
in a TIVE: - to relieve
lying Refer to medical abdominal
positi technologies to muscle tension.
on in perform DEPENDENT:
bed. laboratories. To help reduce
 Follo pain.
ws COLLABORA
comm TIVE:
and, To monitor labs.
good
fluenc
y,
good
insigh
t and
judgm
ent.
 Good
imme
diate,
recent
,
remot
73

e
memo
ry.
 Patien
t is
able
to
hear
watch
tick
from
1-2
inches
.
 Patien
t can
read
print
at 12
inches
witho
ut
diffic
ulty.
 Able
to
spell
“bola
”
forwa
rd and
74

back
ward.
 Able
to
answe
r
simpl
e
math
proble
m.
 Langu
age
spoke
n:
Filipi
no
 Patien
t’s
attenti
on
span
is
avera
ge,an
d can
alway
s
compr
ehend
and
75

maint
ains
eye
conta
ct.
76

NCP #2

ASSESSM NURSIN PLANNI NURSING RATIONALE EVALUATI

ENT G NG INTERVENTIO ON
DIAGNO N
SIS
Risk for At the end INDEPENDENT INDEPENDENT: After 1 hour
Infection of 1 hour : - To assess of nursing
of nursing - Note risk causative/contri intervention
interventio factor for buting factors. the patient
n the occurrence - Because it’s a identified
patient of first-line intervention
will be infection defense against s to
able to ( comprom nosocomial prevent/redu
identify ised host, infection/cross- ce risk of
interventio skin contamination. infection.
ns to integrity, - To
prevent/re environme prevent
duce risk ntal spread of
of exposure. bacteria
infection. - Stress - To
proper prevent
handwashi contamina
ng tion.
technique - To
by all prevent
caregivers infections.
between - To
therapies/c prevent
lients. infection
- Maintain and
sterile promote
77

techniques good care.

for
invasive
procedures
(urinary
catheter).
- Cleanse
incisions
sites daily
and prn
with
povidone
iodine or
other
appropriat
e solution.
- Change
dressings
as
needed/ind
icated.
DEPENDENT:
- Administer
prophylact
ic
antibiotics
and
immunizat
ion as
indicated.
78

COLLABORATI
VE:
- Refer to
medical
technologi
es to
perform
laboratorie
s.

NCP #3
79

ASSESSMEN NURSIN PLANNING NURSING RATIONA EVALUATI

T G INTERVENTI LE ON
DIAGNO ON
SIS
S: “Ito dko pa Impaired At the end of 4 INDEPENDE INDEPEND After 4 hours
rin ginagamit Tissue hours of NT: ENT: of nursing
reading glass ko Integrity nursing Monitor Vital -To serve as intervention
pag tingin ko related to intervention the signs especially baseline the patient
lang na surgical patient will be the temperature data and see displays
kelangan ko insicion able to display and skin color. if there is progressive
talaga tsaka progressive Inspect wounds possible improvement
masakit sakit improvement daily, or as infection. in wound
yung tahi ko in wound appropriate, for -Promote healing.
dko matagalan healing. changes ( signs timely
mag lakad lakad of infection, intervention
kahit yun complications, and revision
inadvice sakin or healing). of plan of
pano ba naman Encourage care.
kasi kumikirot” optimum -To promote
As verbalized nutrition tissue
by the patient. including health/heali
adequate ng.
protein, lipids, -To reduce
O: calories, trace and
minerals, and replenish
 Patient
multivitamins. cellular
is alert,
Encourage water loss
awake
increase fluid and enhance
and
intake. circulation.
oriented
Encourage -To limit
and was
adequate metabolic
in a
80

lying periods of rest demands,

position and sleep. maximize
in bed. Promote early energy
 Follows and ongoing available
comman mobility and for healing,
d, good Encourage/Assi and meet
fluency, st position comfort
good changes. needs.
insight Apply -To promote
and appropriate circulation
judgmen wound covering and prevent
t. and skin- excess
 Good protective tissue
immedia agents for open pressure.
te, wounds and -To protect
recent, stomas. the wound
remote DEPENDENT: and
memory. -Administer surrounding
 Patient medications tissues from
is able such as excoriating
to hear antibiotics as secretions/
watch prescribed by drainage
tick the physician. and to
from 1-2 COLLABORA enhance
inches. TIVE: healing.

 Patient Refer to DEPENDE

can read medical NT:

print at technologies to -To

12 perform facilitate

inches laboratories. prophylaxis

without of possible
81

difficult infection.
y. COLLAB
 Able to ORATIVE:
spell - To
“bola” monitor
forward labs
and back
ward.
 Able to
answer
simple
math
problem.
 Languag
e
spoken:
Filipino
 Patient’s
attention
span is
average,
and can
always
compreh
end and
maintain
s eye
contact.
82

Journals

Journal #1

Title: Causes and Management of Ovarian Cysts

Authors: Zina Abdulkareem Al Zahidy

83

Abstract: An ovarian cyst is a sac filled with liquid or semiliquid material that arises in an ovary.
While the discovery of an ovarian cyst causes considerable anxiety in women owing to fears of
malignancy, the vast majority of these lesions are benign. Most patients with ovarian cysts are
asymptomatic, with the cysts being discovered incidentally during ultrasonography or routine
pelvic examination. Some cysts, however, may be associated with a range of symptoms,
sometimes severe. Many patients with simple ovarian cysts found through ultrasonographic
examination do not necessitate treatment. In a postmenopausal patient, a persistent simple cyst
smaller than 10 cm in dimension in the presence of a normal CA125 value may be monitored
with serial ultrasonographic examinations. When ovarian cysts are large, persistent, painful or
have concerning radiographic or exam findings, surgery may be required, sometimes resulting in
removal of the ovary. We conducted this review using a comprehensive search of MEDLINE,
PubMed, EMBASE, Cochrane database of systematic reviews and Cochrane central register of
controlled trials from January 1, 1995, through January 1, 2017.

Summary: As per the clinical features of benign tumors, the benign tumors manifest in the
reproductive years. Most tumors are asymptomatic. The benign ovarian cysts or the benign
ovarian tumors will show complication like torsion and infection. Epithelial tumors are the most
common tumors.

Reflection: We learned that the prognosis of benign ovarian cysts are excellent. Malignancy is a
common problem among women who have ovarian cysts. Also, in complex multioculated cyst.
Whats interesting is that epidemiological studiess from 1970 to 1990 state that Oral
Contraceptive Pills reverde the growth of these cysts. Bilateral Oophorectomy are often
recommended for cysts due to increased ocurrence of neoplasms.

Journal #2

Title: Causes and Management of Ovarian Cysts

Authors: Zina Abdulkareem Al Zahidy

84

Abstract: The ovaries are paired sex glands or gonands in female and are concerned in germ cell
maturation.The ovaries are concerned with steriogenesis.During the period of 2 years. We have
oeprated with most of the cases with a laparotomy and laparoscopy..

Summary-Most patients with ovarian cysts are asymptomatic, with the cysts being discovered
incidentally during ultrasonography or routine pelvic examination. Some cysts, however, may be
associated with a range of symptoms, sometimes severe. When ovarian cysts are large, persistent,
painful or have concerning radiographic or exam findings, surgery may be required, sometimes
resulting in removal of the ovary.

Relflection: We learned that the functional cysts of the ovary are made from hormonal changes.
The functional cysts are different from a neoplastic cyst as they are 6-8 cm, asymptomatic,
regress spontaneously, unilocular, and contains clear fluid. We also learned that polystic ovarian
masses are commonly occurred ovarian tors in women. All you need to treat functional cysts are
3-6 months of OCP and it will help you differentiate them from physiologic or pathologic cysts.
Benign cysts exhibit a clinical and pathological patterns.

Journal #3

Title: Review of 244 cases of ovarian cysts

Authors; Kojah, Mohammed et al.

Abstract:

Objectives: To review cases of ovarian cysts managed at a University Hospital, and to identify
the factors necessitating the use of laparotomy over laparoscopy.

Methods: We carried out a retrospective chart review of all cases of ovarian cysts diagnosed and
managed at the Department of Obstetrics & Gynecology, King Abdulaziz University Hospital,
Jeddah, Saudi Arabia between January 2010 and August 2014. All data collected from medical
record charts, patents details, clinical presentations, ovarian cysts description, and pathology type
were recorded, and management by laparoscopy or laparotomy was identified. Ethical approval
was obtained from ethical hospital committee.
85

Results : There were 244 cases of ovarian cysts during the study period. The age ranged from 3
months to 77 years of age. The parity from 0-6. The height range from 37-180 cm. The weight
range from 3-161 kg, and calculated body mass index ranged from 12-47. Out of 244 patients
diagnosed, 165 were married (67.4%). Of those, only 16 patients were pregnant (6.6%). The
most common presentation was abdominal pain in 142 patients (58.2%). Only 79.9% were
ovarian cysts, and 17.5% were either para-ovarian or retroperitoneal. The right ovaries were
affected in 63.1%, and only 18.9% were bilateral. The types of ovarian cysts included functional
cysts 33.2%, benign cyst-adenoma 19.3%, and dermoid cysts 12.3%.

Conclusion: Factors associated with laparotomy management rather than laparoscopy included
older age >35, single, pregnant, or patients presenting with abdominal pain, and more than one
cyst.

An ovarian cyst is a common gynecological problem and is divided into 2 main categories;
physiological and pathological. Physiological cysts are follicular cysts and luteal cysts.
Pathological cysts are considered as ovarian tumors, which might be benign, malignant, and
borderline. Benign tumors are more common in young females, but malignant are more frequent
in elderly females.

Summary:

Patients admitted with a diagnosis of ovarian cysts and managed at KAUH were included.
Exclusion criteria cases were those transferred to another facility, or if we found their chart was
incomplete. The data collected was included including years, nationality, parity, weight and
height. Out of 244 patients diagnosed with ovarian cysts, 165 were married (67.4%), and of those
only 16 were pregnant (6.6%). The most common clinical presentation was abdominal pain in
142 patients (58.2%). Only 79.9% were ovarian cysts, and 17.5% were either para- ovarian or
retroperitoneal. The most common affected was the right ovaries (63.1%) and only 18.9% were
bilateral. The type of ovarian cysts were recorded accordingly; 33.2% were functional cysts,
19.3% benign cyst adenoma, and 12.3% dermoid cysts.
86

Reflection: We learned that the most common symptom was abdominal pain and the right ovary
that was most affected. Symptomatic patients only present with abdominal pain although most of
the patients are asymptomatic. Pain can occur in the lower back or the abdomen of the patient. To
me, this was very useful to our case because I always had a hard time figuring out why our
patient doesn’t have a lot of symptoms, not even pain sometimes.

Consent
87
88
89

Authors

LYRA ANGELI MARQUEZ CHANTAL CARAGAN

BEATRICE REYNA ASUNCION

This was personally published by the authors: Beatrice Reyna Asuncion, STN III, Chantal
Caragan, STN III, and Lyra Angeli Marquez III, STN III in Manila City, Philippines. This was
made in the year 2020, January 31.
90

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