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I.

INTRODUCTION

Condyloma acuminata refer to all epidermal manifestation attributed to


epidermotropic vulvar papilloma virus. Condyloma acuminata are also referred to as
venereal warts, genital warts and papilloma acuminatum. Approximately 90% of the
cases of condyloma acuminata are related to HPV 6 and 11. These 2 types are benign
and/or the least likely to have neoplastic potential. Certain types such as HPV 33, 35,
39, 40, 43, 45, 51-56, 58, have moderate potential for neoplastic conversion, and
some have high potential for dysplasia such as HPV type 16 and 18. Condyloma
acuminata is a sexually transmitted disease. It is manifested by the presence of warts
in the vulvar, genital, and anal area. If left untreated in pregnant women, it could
cause complication to the baby because the warts could be propagated to the airway
passages of the child. Even if the disease is treated initially, it has a high chance of
recurrence.
In the hospitals we were affiliated, condyloma acuminata cases are very
limited. In the first week of our exposure in Jose B Lingad Memorial Regional
Hospital (JBLMRH), we were given a chance to handle a case of condyloma
acuminata. We chose the disease for our study for several reasons. First, cases of this
kind of venereal disease are very rare. Although we had encountered other types of
sexually transmitted disease such as syphilis and gonorrhea in our previous exposure,
we never encountered such derange this kind of manifestations. Second, because of
the limited cases, we do not have much knowledge about the disease, and the
curiosity that we had motivated us to conduct a case study regarding the ailment.
Lastly, we chose condyloma acuminata because of the increasing number of cases of
sexually transmitted diseases.
In the United States of America, annual cases of condyloma acuminata is 1%.
Prevalence had reported to exceed 50%. Health experts estimate there are more cases
of genital HPV infection than any other STI in the United States. According to the
American Social Health Association, approximately 5.5 million new cases of sexually
transmitted HPV infections are reported every year. At least 20 million people in this
country are already infected.
In this study, we are to deal with the pathophysiology of condyloma
acuminata, the interpretation of abnormal results based on the diagnostic and
laboratory procedures done to the patient. We will also deal with the appropriate
interventions, nursing diagnosis for clients with the said disease condition, the
suggested medical and surgical management including the diet, exercise, and
medication we are to administer when caring for the patient. This case study warrants
to widen our knowledge of the occurrence of the specific disease. It will also assist
us in developing our clinical and academic competence by giving us a new array of
knowledge about nursing interventions, and responsibilities appropriate for clients
having, not only condyloma acuminata, but other STD’s as well. The study will also
enable us to enhance our resourcefulness as nurses, and our critical thinking
considering the limited client information that are available and presented. It will
also help us develop our leadership skills and the flexibility that we have if we are
presented with different unexpected situations by widening our knowledge and
developing our nursing judgment. Most importantly, this study will enable us to
show and evaluate the effectiveness and productiveness that we have as student
nurses in applying preventive, curative, and rehabilitative measures for the patient
with this disease.
II. NURSING ASSESSMENT
1. Personal Data
a. Demographic Data
Ms JS is a 29 year old female Filipino patient. She was born
on December 28, 1976 in their home at Paligui Apalit, Pampanga. Her parents
are Mr. Leonardo Santos and Mrs. Melisa Santos. She is the 5th child in the
family of 12 children. Years back, she was living together with Mr. Alfred
Ocampo. They were able to raise a family of 6 children even though they are
unmarried. Their eldest child is 12 years old and youngest are the twins
wherein one of the twins died on the date of July 18, 2006. Due to an
undelivered baby boy in transverse lie (one of the twins) she was brought/
rushed to Jose B Lingad Memorial Regional Hospital (JBLMRH) on the same
date (July 18, 2006) with a hospital number of 149044..

b. Socio-economic and cultural factors


A year ago, Ms JS is employed in a school canteen earning about
P120 per day. Her partner is a jeepney driver and is earning P300/day. In one
month, they earn estimately P12, 600. Their monthly earnings is not being
consumed only for food and daily needs. A portion of the income is meant for
their monthly bills (electricity and water) and a portion for other necessities
such as replacement for damage parts of their jeepney and mostly payment for
their rented apartment in Apalit Pampanga. When it comes to dietary habits,
the patient is fond of eating salty foods. They occasionally eat meat and
preserved foods, in most cases of family financial crisis they simply eat rice
with soysouce and salt. She is also fond of drinking coffee at least 3 cups per
day and is able to consume the required 8-10 glasses of water/day.She also
smokes at least1pack a day.
Ms JS also believe in some superstitions and sayings, she does not
take a bath or shower during her menstrual period believing that doing so
could lead to insanity. After performing sexual intercourse, she does not take
a bath either because of her misconception that it could result to what is
known as “pasma” and lastly, she believe in “hilot”.
c. Environmental factors
The patient was raised in Paligui Apalit, Pampanga. The said place
nearly situated beside a creek (“sapa”). Upon living together with Mr. Alfred
Ocampo, they rented an apartment in the same area in Apalit, Pampanga.

2. Maternal-Child Health History


She had her menarche at the age of 12 years old and lasted for a
week. Form then on, she had regular menstrual period every month and each
period and lasted for 5-7 days. She also experience premenstrual
dysmenorrhea and has heavy menstrual flow on the fist 2 days of onset. She
started to engaged in sexual activity at the age of 16 y/o. She gave birth to her
first baby at the age of 17. From then on, they decided to live together not
bounded by marriage/matrimony. When she was still living together with
partner, they perform sexual intercourse twice weekly. Ms JS does not take
oral contraceptives, neither her partner practice the use of condoms.
a. Maternal-obstetric record
Ms JS has an obstetric record of gravida 7, partum 6. She has
TPAL record of 6, 1, 0, 6. Her children were born via NSD except for the
latest twin pregnancy. Two of which are twin pregnancies. The first twin
pregnancy is the fifth pregnancy, both of the babies died due to premature
delivery. They were born via vaginal birth but survived only for a short period
of time. All the births she had was performed at home by a “hilot”. Her latest
twin pregnancy was in full term. One of the twins was delivered at home with
the midwife’s assistance. She was unable to deliver the second of the twins
due to a transverse lie. Unfortunately, the second baby did not survive and
was diagnosed to be an intrauterine fetal death (IUFD).
b. Antepartal/ Prenatal preparation
The patient had her monthly check-up for the latest twin pregnancy
in a barangay health center with the attending registered midwife. There were
circumstances, especially at the second trimester, wherein she was unable to
completely comply with her prenatal monthly check-ups. She received 3
doses tetanus toxoid vaccine in the barangay health center.
c. Significant Trimester changes (1st to 3rd trimester)
On the first trimester of the latest pregnancy (twin pregnancy),
experienced episodes of nausea and vomiting. She is knowledgeable that
nausea and vomiting is a natural discomfort of pregnancy. She neither did nor
performed any home remedy/management in order to relive the discomfort.
She also felt/experienced early fatigability and manage it through rest.
Straining to defecate or constipation is also experienced by Ms JS on the third
month. This was a result of the compression of the large intestine, restricting
normal bowel movement. She was advised to drink an ample amount of
liquid (8-10 glasses of water) and high fiber food such as papaya in order to
relieve the discomfort. She accepted and followed the said advice and
constipation was gradually relieved.
On the second trimester of her pregnancy, she had complained of
frequent episodes of backache which was caused by the weight of the
developing babies. She also experience early fatigability and headache which
is a result of hindered maternal blood flow caused by the fetal growth and
development. These second trimester discomforts were managed by the
patient through bed rest.
Third trimester pregnancy discomforts the patient experienced
shortness of breath and manage it by rest and proper ventilation.
3. Family Health Illness History

Lolo Lola Lolo Lola


Santos Santos Lopez Lopez

Died of natural cause Binangungot Asthma, Smoker Stroke, paralysis, & HPN

Leonardo Melisa
Santos Lopez

HPN

Lolita Vilma Tony Bernadette Luisa Bernardo Leonardo Aileen Maricel Eunice Michael
Santos Santos Santos Yang Santos Santos Santos Santos Santos Santos Santos

HPN (+) TB, (+) DM


Smoker
Janet Alfred
Santos Ocampo

HPN, condyloma
acumintata, UTI

Daisy Mark Rodel Ronald Joshua Jaira Judith Baby Boy


Santos Santos Baby Boy
Santos Santos Santos Santos Santos Santos
(10-24-99) (08-12-00) Santos
(08-29-93) (05-14-95) (09-04-05)
(12-30-04) (07-18-06)

Deceased- premature Deceased


4. History of Past Illness
Ms JS is unknowledgeable of the vaccination that she had during
her childhood. She had a history of having chicken pox at the age of 8. She
acquired german measles at the age of 14. She had a history of urinary tract
infection at the year 2004 and was prescribed to take antibiotics (ofloxacin).
Aside from the major illnesses she experienced, she usually have cough and
colds, and fever. The patient also self medicate upon experiencing simple
health discomforts like such and never seek medical attention.
5. History of Present Illness
During the nurse patient interaction, the patient stated that she had
relationship problem with her partner. She accuses her partner of infidelity
months before they separated, and there was even one circumstance of having
her problem caught/seen with another woman. This is the reason of their
separation. This is a significant information because her disease condyloma
acuminata is caused by the Human Papilloma Virus which is a sexually
transmitted disease. She also mentioned experiencing pain in the urinary
meatus during urination but she was unaware of having genital warts until she
was brought to JBLMRH.
6. Physical Examination (IPPA-Cephalocaudal Approach)
Physical assessment done by the doctor

Vital signs
BP- 180/100 mmhg
PR-92bpm
RR-24bpm
Temperature- 36.0oC

Skin
- (+) pallor
- (-) rashes
- (-) cyanosis
- (-) jaundice

Head (EENT)
- anicteric sclera
- palpebral conjunctiva
- pale
lymphnodes
- lymphadenopathies

Chest
- symmetrical
- chest expansion (-) retractions

Lungs
- slow breath sounds

Cardio
- (-) murmur

Breast
- (+) engorgement

Abdomen
- NABS
- Soft non-tender

Rectum
- (-) hemorrhoids

Genitals
- Cervix open and fully

Physical Assessment done by the student nurse (07-21-06)

• SKIN
- Temperature 36.4 oC
- Medium brown in color
- with poor skin turgor
- (+) pallor
- (+) dryness
- (-) edema

• HEAD
- skull symmetrical in shape
- (-) lumps or masses
- (-) tenderness
- (-) pain when palpated
• EYES
- Eyelids are equal in movement
- Anicteric sclera
- Palpebral conjunctiva pink in color
- (+) PERRLA
- (-) external lesion
- Able to move up and down and right to left

• EARS
- With adequate responses to normal sounds
- Presence of dry wax buildup
- (-) external lesions

• NOSE AND SINUSES


- Regular breathing with mouth closed
- Can breath using both nostrils
- (-) pain upon palpation of sinuses
- (-) discharge

• MOUTH AND THROAT


- Teeth- with dental caries on almost all teeth
- with plaque deposition
- Oral mucosa dry and yellowish in color
- Tonsils- not inflamed
- (-) dysphagia

• NECK
- nontender lymph nodes
- Can turn the head from side to side without difficulty
- (-) stiffness
- (-) pain
- (-)lumps

• RESPIRATORY
- RR= 23 breaths/ minute
- Chest - relaxed breathing; rib cage moves symmetrically with
respiration
- equal expansion noted
- (-) retractions
- (-) adventitious breath sounds upon auscultation
- (-) colds
• CARDIAC
- PR= 73 beats/ min.
- BP= 120/80 mmHg
- Peripheral pulses (radial and brachial) easily palpated
- (-) chest pain
- (-) murmur

• GATROINTESTINAL
- no bowel movement occurs
- (-) diarrhea
- (-) food intolerance

• URINARY
- urinates 2x during the shift
- (-) dysuria
- (-) urinary retention
- (+) pruritus

• GENITALS
- (+) warts (looks like a cauliflower) spread around the vulvar area
- Reddish or almost dark in color
- (+) foul odor
- (+) lochia serosa

• MUSCULOSKELETAL
- (-) pain
- (-) cramps
- Slow in movement

• NEUROLOGIC
- Alert, mood appropriate to situation
- Responds to verbal command
- Speaks clearly

• HEMATOLOGIC
- Hgt and Hct low (hgt= 77, hct=0.33)
- With lochia serosa

• ENDOCRINE
- (-) history of diabetes
- (-) thyroid problem
- (-) excessive sweating and thirst

• PSYCHIATRIC
- (-) history of psychiatric disorder
7. Diagnostic and Laboratory Procedures

Hematologic Examinations- test/procedures done to patients to determine the ranges/count of blood components.

Diagnostic Date Ordered Indication/Purpose Results Normal Values Analysis and Interpretation
Procedure
Hemoglobin Count July 18, 2006 Used to determine Hgb 77g/L Female: The hemoglobin content of the blood of the patient is
content of blood. 115-155 g/L below the normal range. This is indicative of anemia
Hemoglobin is the iron which is a result of the patient’s blood loss during the
containing and the oxygen surgical procedure she underwent (CSIII & BTL).
carrying pigment/CO2 Another reason of the deviation from the normal values
carrying pigment of the is the post partum condition of patient. During her
blood/RBC formed in the latest/last pregnancy, there was a higher/increase
bone marrow. demand of nutrients because of the growing baby in her
womb. Due to the inadequate intake of nutrients
>evaluates blood loss, including Fe, the maternal absorption of Fe was
erythropoietin compromised by fetal development causing inadequacy
activity/ability, anemia, and resulting to anemia. The patient’s intake of medications
therapy response. such as antibiotics (Cefuroxime) also precipitated to
reduce levels of hemoglobin.
Diagnostic Date Ordered Indication/Purpose Results Normal Values Analysis and Interpretation
Procedure
Hematocrit Count July 18, 2006 Hematocrit count evaluates 0.23/23% Female: .Blood hematocrit content is directly proportional to the
blood loss, anemia, food 0.38 (38%) to 0.48 hemoglobin count. The decrease in the patients
replacement therapy, and (48%) hemoglobin count is directly related of the increase in
fluid balance, and screens the hematocrit counts. The decrease in hematocrit is
RBC status. It measure the also caused by the same factors namely:
concentration of RBC within 1. blood loss related to intra-operative period.
the blood volume and is 2. Decrease Fe absorption related to increase
expressed in percentage. demands secondary to pregnancy (altered
maternal absorption)
3. inadequate Fe intake
4. medications specifically antibiotics
5. the patients significant increase in WBC levels
(findings of WBC: 23.0[NV: 5-10 x 10 3/L])
White Blood Cell with differential count
Indication
This evaluates the number of conditions and differentiation causes of alterations in the total WBC count including inflammation, infection, and
tissue necrosis. The differential white cell count identifies the 5 specific types of WBC present in blood. These reflect the integrity of the client’s immune
system.

Diagnostic Date Ordered Indication/Purpose Results Normal Values Analysis and Interpretation
Procedure
WBC count July 18, 2006 This is used to 23.00x103/L 5-10,000/cumm The increased in the patient’s WBC count (leukocytosis)
determine/detect the is caused by an skin integrity as evidenced by lower
presence of infection or abdominal midline incision (Due to CS & BTL
inflammation and to monitor procedure) and excision sites in the vaginal area.
the patient’s response to > also caused by the inflammation reaction of the
antibiotic/anti-microbial patient’s body as a cardinal sign of infection.
therapy.
Diagnostic Date Ordered Indication/Purpose Results Normal Values Analysis and Interpretation
Procedure
Neutrophil Count July 18, 2006 Used to evaluate/detect the 0.87 0.45-0.65 The increase in the neutrophil count is caused by the
presence of bacterial inflammatory response of the body of the patient due to
infection, STD’s such as infection. It is also caused by the presence of syphilis
gonorrhea, syphilis, and (HPV) as manifested by genital warts (condyloma
other inflammatory acuminata)
condition. > also, neutrophil count is directly proportional/related
to the WBC count. The increase in neutrophil count is
also caused by the following factors:
1. tissue trauma as evidenced by surgical incision and
excision site
2. poor response of the patient’s body to anti-microbial/
antibiotic therapy (cefuroxime).
Lymphocyte July 18, 2006 A test used to determine 0.13 0.20-0.35 The patients decrease in lymphocyte count is indicative
lymphocyte count. of/caused by immunodeficiency secondary to inadequate
Lymphocytes count is an nutrition caused by the following factors:
indicator of immune 1. altered maternal nutrient absorption secondary
function, provides a gross to recent pregnancy/ postpartal status.
Diagnostic Date Ordered measures of nutritional
Indication/Purpose Results Normal Values 2. inadequate intake
Analysis andofInterpretation
foods rich in vitamins
Procedure status. This is obtained by minerals, & calories
Platelet Count July 18, 2006 venous blood
Measures the sample.
number of 359 x 109 /L 150-400x109 /L > Normal
thrombocytes per cubic
milliliter in order to
determine if the patient
have abnormal blood
clotting capabilities and to
obtain data if patient is at
risk for bleeding tendencies
specially in her post
operative condition/state.
Diagnostic Date Ordered Indication/Purpose Results Normal Values Analysis and Interpretation
Procedure Date Results In
Venereal Disease July 21, 2006 This test was indicated for Non reactive Non reactive/ > Normal
Research July 23, 2006 the patient in order to negative
Laboratory (VDRL) determine if the patient,
aside from the HPV
infection, has syphilis, with
blood as a specimen.
Nursing Responsibilities:
Pre-Procedure:
- Explain the procedure to the client.
- Place the patient in a comfortable position.
- Properly clean the skin of the selected puncture site with alcohol.
- Tourniquet the distal site.
During:
- Gently extract/collect blood specimen using a collecting media (syringe).
- Remove the tourniquet before withdrawing the needle.

Post:
- Apply firm gentle pressure on the extraction site to avoid bleeding/hematoma.
Urinalysis
- is one of the oldest and most common laboratory test. It is economical and results are obtained immediately. The procedure is non-invasive with urine as
specimen.

Diagnostic Date Ordered Indication/Purpose Results Normal Values Analysis and Interpretation
Procedure
Urinalysis 01-08-06 Urinalysis screens for Color: yellow Color: clear to The patient’s urinalysis indicated both normal and
abnormalities with the Sugar: positive slightly hazy, abnormal results in different aspects. The patient had
urinary system as well as Protein: ++ amber yellow, normal values in the following: (1) color of urine; (2)
systemic problems that Transparency: yellow to deep urine pH, & (3) specific gravity. On the other hand,
may manifest symptoms in clear amber considerable deviation were evident in the urinalysis
the urine. Visual Urine pH: 6 Sugar: negative results. The following are the abnormal results in the
examination, microscopic Specific: 1.020 Protein: (-) urine test together with their analysis:
examination, regent strip (+) albumin Transparency: 1. sugar:
testing, and refractometry trace clear > The patient has positive sugar in the urine because
are various methods used Analysis Urine pH: 4.5-8 lactation may occur a false positive due to the lactose or
01-21-06 in performing complete WBC-1-2 Specific: 1.002- galactose. As a supporting detail, researcher show a
urinalysis. Epithelial cell: 1.035 temporary glycosuria that appears to be no clinical
none (-) albumin trace significance, could be present in post partal women and in
RBC: over 10 Analysis intrapartal women. (_booktitle _)
WBC-none-4 > The client’s intake of multivitamins also may produce a
Epithelial cell: false positive because of the ascorbic acid content of the
none multivitamins.
RBC: none
2. transparency/ appearance
Color: > The turbid/slightly turbid appearance is caused by the
Appearance: disease condition of the patient which lead to vaginal
Albumin: contamination. Vaginal contamination is a common cause
Reaction: of turbid or cloudiness.

3. RBC: Urine Hemoglobin


> The presence of urine hemoglobin in the patient is
caused by the urinary tracts ulceration particularly in the
urinary meatus which were caused by genital warts.
4. Urine Albumin (Albuminuria)
> The presence of urine albumin (albuminuria) in the
patient’s urine is caused by several factors. Enumerated
below are the factors contributing to patient’s
albuminuria.
1. Acute infection (blood result of 23.0 [5-
10x109/L
2. Trauma
3. Hypertension (180/100 mmHg)
4. Dehydration
5. Mixture of pus and urine Hgb/RBC due to
vaginal infection/UTI brought about by the
genital warts
Nursing Responsibilities
Mode of collection used in the patient: collection from an indwelling catheter
Before
1. If client is conscious and coherent, explain procedure, if sedated, explain the procedure to the significant others.
2. Drain the urine standing inside the collection bag because long standing will undergo chemical changes thus interfering with results.
During
1. Aspirate urine from the catheter itself using a sterile syringe slanting the needle towards the drainage tubing.
2. Place specimen in a sterile urine collection cup.
After
1. Immediately send the specimen collected to the laboratory.
2. Avoid exposing the urine to air and avoid making the urine stand for a long period of time in the cup.
3. Follow-up the results of urinalysis.
4. Document findings/place lab results in the patient’s chart properly.
Aside from the initial diagnostic tests that were performed to the patient, follow-up blood examinations and urinalysis were ordered by the patient’s
attending physicians in the date of July 19, 2006. But due to the patient’s lack of financial capabilities and deficient knowledge about their importance, the
patient did not comply with the follow-up laboratory and diagnostic procedures and was made to sign a Home Against Medical Advise (HAMA) on the same
date. The patient also refused to undergo HBs Ag reaction test screening and Chest Xray and also signed the HAMA form for her refusal.
12-Lead Electrocardiogram

Diagnostic Date Ordered Indication/Purpose Results Normal Values Analysis and Interpretation
Procedure
12-Lead - July 19, 2006 An ECG procedure was >Normal
Electrocardiogram (Refused and ordered to be performed to
Signed HAMA) the patient because of the
episode of hypertension
>July 21, 2006 and chest pains she > Cardiac Rate >Cardiac Rate 60-
experience. Aside from this 100 bpm 100
it was indicated to evaluate
the effectiveness of the >Normal QRS, >Normal QRS, PR,
medication given to PR, QT. QT.
manage the above
mentioned discomforts.
Lastly, it was indicated to
determine the underlying
factor causing chest pains
and hypertension results.

Nursing Responsibilities:

Pre-procedure:

- Record client age, height, weight, and if she take cardiac medication.
- Instruct patient to remove all metal materials/ other conductors such as jewelries, belt, coins, cellphones, metal dentures, and ask client if she did
not undergo heap replacement (other metallic implants, or if she have a cardiac pacemaker, for it may hinder the electrical flow of ECG.
- Place all valuables within clients supervision or in care of SO.
- Explain the test that it helps to evaluate the Heart Status by recording its electrical activity.
- Proper attach the electrical nodes/ electrodes in the patients skin
- Connect the electrodes properly to the ECG machine.

During:

- Monitor and ensure proper attachments of electrodes to the patient skin.


- Refrain form talking to the patient.

Post:

- Disconnect the equipment.


- Remove tapes or conductive gels use on the client skin.
- Place ECG strips to the patients chart properly and label accordingly.
Diagnostic Date Ordered Indication/Purpose Results Normal Values Analysis and Interpretation
Procedure
Chest X-ray > July 19, 2006 The CXR was performed in > Both lung > Both lung fields > Normal Chest findings.
order for the physician to fields clear clear
determine if the patient has > Heart and > Heart and great
cardiac enlargement and to great vessels vessels are within
determine if she has are within normal
existing pulmonary disease normal configuration.
or disorders. configuration. > Other chest
> Other chest structure not
structure not remarkable.
remarkable.

Nursing Responsibilities:

Pre-procedure:
- Ask client to remove any radio opaque objects such as jewelries (necklace) in order to obtain a clear CXR result.
- Position the patient properly to the x-ray board.
- Ask client to inhale/breath deeply and hold breath while she is instructed to release breath.

During:
- Ensure patient is properly position in front of the x-ray board.
- If the image is taken, instruct patient to release his breath.

Post:
-Follow up CXR result.
ANATOMY AND PHYSIOLOGY
The female reproductive organs consist of the ovaries, uterine tubes (or fallopian
tubes), uterus, vagina, external genitalia, and mammary glands. The internal reproductive
organs of the female are located within the pelvis, between the urinary bladder and the
rectum. The uterus and the vagina are at the midline, with an ovary to each side of the
uterus. The internal reproductive organs are held in place with the pelvis by a group of
ligaments. The most conspicuous is the broad ligament, which spreads out on both sides
of the uterus and to which the ovaries and uterine tubes attach.

Female External Structure

Mons Veneris- the mons veneris is a pad of adipose tissue located over the
symphysis pubis, the pubic bone joint. It is covered by a triangle of coarse, curly hairs.
The purpose of the mons veneris is to protect the junction of the pubic bone from trauma.

Labia Minora- just posterior to the mons veneris spreads two hairless folds of
connective tissue. The area is abundant with sebaceous glands, so localized sebaceous
cyst may occur here.

Labia Majora- the labia majora are two folds of adipose tissue covered by loose
connective tissue and epithelium, they are positioned lateral to the labia minora, serves as
protection for the external genitalia and the distal urethra and vagina.

Other external organs:

Vestibule- is the flattened, smooth surface inside the labia.


Clitoris- is a small (approximately 1 to 2 cm) rounded organ of erectile tissue at
the forward junction of the labia minora. Center of sexual arousal and orgasm in the
female.
Skene’s gland- located just lateral to the urinary meatus.
Bartholin’s gland- located just lateral to the vaginal opening on both sides,
secretions from both these glands help to lubricate the external genitalia during coitus.
Secretions from both these glands help to lubricate the external genitalia during coitus.
Fourchette- is the ridge of tissue formed by the posterior joining of the two labia
minora and the labia majora. This is the structure that is sometimes cut (episiotomy)
during childbirth to enlarge the vaginal opening.
Hymen- is a tough but elastic semicircle of tissue that covers the opening to the
vagina in childhood. It is often torn during the time of first sexual intercourse.

Female Internal Structure

Ovaries- the ovaries is approximately 4 cm long by 2 cm in diameter and


approximately 1.5 cm thick, or the size and shape of almonds. They are grayish-white
and appear pitted. The function of the two ovaries (the female gonads) is to produce,
mature and discharge ova (the egg cells). In the process, the ovaries produce estrogen
and progesterone and initiate and regulate menstrual cycles.
Fallopian Tubes- the fallopian tubes arise from each upper corner of the uterine
body and extend outward and backward until each opens at the distal end next to an
ovary. Their function is to convey the ovum from the ovaries to the uterus and to provide
a place for fertilization of the ovum by sperm.
Uterus- the uterus is a hollow, muscular, pear-shaped organ located in the lower
pelvis, posterior to the bladder and anterior to the rectum. It is approximately the size of
an olive. The function of the uterus is to receive the ovum from the fallopian tube;
provide a place for implantation and nourishment during the fetal growth, furnish
protection to a growing fetus; and at maturity of the fetus, expel it from the woman’s
body.
Cervix- a neck like part, especially the cervix uterine (neck of the uterus), which
projects into the vagina. The cervical canal passes through it, linking the cavity of the
uterus with the vagina. The canal normally contains mucus, the viscosity of its changes
through out the menstrual cycle. The cervix is capable of wide dilatation during child
birth.
Uterine and Cervical Coats- the uterine wall consists of three separate coats or
layers of tissue: an inner one of mucous membrane (the endometrium), a middle one of
muscle fibers (the myometrium), and an outer one of connective tissue (the perimetrium).
The endometrium layer of the uterus is important in terms of menstrual function
and childbearing. It is not a single structure but is rather formed by two layers of cells.
The layer closest to the uterine wall, or the basal layer, is not much influenced by both
estrogen and progesterone. This is the layer that grows and becomes so thick and
responsive each nth under the influence of estrogen and progesterone that it is capable of
supporting a pregnancy. If pregnancy does not occur, this is the layer that is shed as the
menstrual flow.
The mucous membrane lining of the cervix is termed the endocervix. The
endocervix, continuous with the endometrium, is also affected by hormones, but changes
are manifested in a more subtle way. The cells of the cervical lining secrete mucus to
provide a lubricated surface so spermatozoa can readily pass through the cervix; the
efficiency of this lubrication increases or wanes depending on hormone stimulation. At
the point in the menstrual cycle when estrogen productin is at its peack, as much as 700
ml of mucus per day is produced; at the point that estrogen is very low, only a few
milliliters are produced. Because mucus alkaline, it helps to decrease the acidity of the
upper vagina, aiding in sperm survival. During pregnancy, the endocervix becomes
plugged with mucus, forming a seal to keep out ascending infections.

The lower surface of the cervix and the lower third of the cervical canal are lined
not with mucous membrane but with stratifies squamous epithelium similar to that lining
the vagina. Locating the point at which this tissue changes from epithelium to mucous
membrane is important when obtaining a Papanicolaou smear (a test for cervical cancer)
because this tissue interfere is most often the origin of cervical cancer.

The myometrium, or muscle layer of the uterus, is composed of three interwoven


layers of smooth muscle, the fibers of which are arranged in longitudinal, transverse, and
oblique directions. This network offers extreme strength to the organ. The myometrium
serves the important function of constricting the tubal junctions and preventing
regurgitation of menstrual blood into the tubes. It also holds the internal cervical os
closed during pregnancy to prevent a preterm birth. When the uterus contractrs at the end
of pregnancy to expel the fetus, equal pressure is exerted at all points throughout the
cavity because of this unique arrangement of muscle fibers. After childbirth, this
interlacing network of fibers is able to constrict the blood vessels coursing through the
layers, thus limiting loss of blood in the woman. Myomas, or benign uterine tumors, arise
from the myometrium. The perimetrium, or outermost layer of the uterus, offers added
strength and support to the structure.

Vagina is a hollow musculmembranous canal located posterior to the bladder and


anterior to the rectum. It extends from the cervix of the uterus to the external vulva. Its
function is to act as the organ of intercourse and to convey sperm to the cervix so sperm
can meet with the ovum in the fallopian tube. Wtioh childbirth, it expands to serve as the
birth canal.

Cells in the body, such as skin cells, undergo cell division by mitosis, or daughter
cell division. In this type of division, all the chromosomes are duplicated in each new cell
just before cell division, giving every new cell the same number of chromosomes as the
original parent cell. Oocytes divide in intrauterine life by mitotic division. Division
activity then appears so halt until at least puberty, when a second type of cell division,
meiosis (cell reduction division), occurs. In the male, this reduction division occurs just
before the spermatozoa mature. In the female, it occurs just before ovulation. Following
this division, an ovum has 22 autosomes and an X sex chromosome; a spermatozoon has
22 autosomes and either X or a Y sex chromosome. A new individual formed from the
union of an ovum and an X-carrying spermatozoon will be female (an XX chromosome
pattern); an individual formed from the union of an ovum and a Y-carrying spermatozoon
will be male (an XY chromosome pattern)
IV. PATHOPHYSIOLOGY

Legend:
Precipitating factors: -smoking
-diet Predisposing Factors: - pathophysiology
-multiple sexual partners or partner -immunosuppression
with multiple sexual partners. -pregnancy - clinical manifestation
-early age of Sexual Intercourse -age 17-33
-previous/recurrent STD’s
-intake of oral contraceptives - complications

Sexual contact with infected person

Transfer of HPV

Innoculation in the Stratified


Squamous epithelium.

Incubation period
(6-8 months)

Latent Viral Phase


Months to years

WBC, Production of viral DNA and capsids VDRL


neutrophils, examination
hyperthermi / HPV exam
a, (X) Infections of Host Cells
presence of
Morphological Atypical
Koilocytosis of Condyloma
Acuminata
Males: Pruritus in the: Females: pruritus in the Uncommon Sites: Mucosal
Lessions in the:
Abnorm Penis
al Vulvar
-activation of Oropharyn
area x
numerous
large cells.
Penile Cancer
Vulvar
Cancer - in lesions

Pubic Larynx
Area Anus/ - difficult
Perineal vaginal
delivers

Rectum Trache
Anal Cancer - easy
bleeding a

Urethra / Cervix - easy bleeding


Bladder Extremiti
es HPV-6

Purulent Discharge Cervical - spontaneous


Cancer rupture of
lesions after
delivery
Polyuria

Anus/
Perineal
Area
Oral Cancer
In Pregnant Women with Condyloma Acuminata

Transfer of Human Papilloma Virus to the


child via Birth canal, During Pregnancy

Laryngeal
Papillamotomasis

Breathing Passage
Obstruction

Infant Death
V. PATIENT AND HIS CARE
1. Medical Management
a. IVFs, BT, NGT feeding, Nebulization, TPN, O2 Therapy, etc.

Medical Date Ordered General Description Indication(s) or Purposes(s) Client’s response to the treatment
Management Date(s)
Treatment Performed Date
Changed/discontinue
Intravenous fluid: a. July 18, 2006 - Lactated Ringer - - in the case of the patient, > the clients extracellular fluid volume was restored
D5LRS 1L x 31- Solution with 5 % D5LRS is indicated in order to as evidenced by normal skin turgor and normal vital
32 gtts/min b. July 18, 2006 dextrose is a replace ECF volume deficit signs. The calorie content of D5LRS also assisted in
hypertonic which was caused by bleeding gradually regaining the client’s energy.
c. Discontinued July intravenous fluid during the intraoperative
23, 2006 solution because it is phase and bleeding caused by
a combination of 2 retained dead baby boy and
solutions namely placenta in her uterus. It is
D5W and LR also indicated because of its
modest calorie content which
would be helpful in
decreasing/shortening the
course of the viral disease
(HPV) the patient has.

Nursing Responsibilities
Before
1. Assess for client’s level of dehydration, bleeding, and V/S
2. Explain to client the importance and indication of the treatment
3. In insertion of intravenous catheter, maintain aseptic/sterile technique
4. Secure the placement of the IV catheter by proper taping
5. Regulate IVF as ordered by the physician
During
1. Properly check the regulation and level of the IVFs and document findings
2. Monitor intake and output
3. Replace the IVF bottle if empty and change to the recently/latest prescribed IVF
4. Check patency of IV cath regularly
5. Watch for bulging on IV site
After
1. Apply firm gentle pressure on the insertion site after removing the IV catheter
2. Instruct patient to apply warm compress to site to relieve discomfort
Medical Date Ordered General Description Indication(s) or Purposes(s) Client’s response to the treatment
Management Date(s)
Treatment Performed Date
Changed/discontinue
Oxygen Inhalation a. July 18, 2006 - Delivery of oxygen via - O2 therapy is indicated for our > After the increase in O2 administration (from
@: b. July 18, 2006 nasal canula, facial mask, patient due to her postoperative 3L/min to 4L/min) the patient’s respiratory system
first, 2-3 L/min c. Disccontinued after venture mask and other contion. O2 therapy is necessary gradually compensated and was able to restore its
second, 4 L/min 2 days. forms of O2 delivery because of the temporary normal and optimal functioning.
medium. This is ordered respiratory depression caused by
by the physician in units anesthesia. The amount of O2
of Liter’s per minute. administered to the patient was
The mode of delivery as increased from 2-3L/min to
mentioned above are also 4L/min due to the slow
used based on the compensation of the patient’s
physician order. body which was a result of
decrease hemoglobin and
hematocrit count.

Nursing responsibility
Before
1. Check for patient respiratory status, monitor V/S especially RR.
2. Prepare all materials needed; cannula, O2 tube and O2 tank
3. Place O2 away from plugs and other materials that could initiate fire
4. Connect tubings properly form the O2, to the humidifier, the tubing/nose and the cannula
5. Administer O2 as prescribed by the physician
During
1. Monitor V/S especially RR
2. Ensure that there are no kinks in the tubings
3. Monitor level of administration
4. Monitor for sign of a need for more O2
5. Keep or maintain an ample amount of water in the humidifier to avoid drying of nasopharyngeal mucosa
6. Monitor/assess for signs of improve respiratory status
7. Place O2 tank away from materials that could initiate fire.
8. Avoid creating sparks/fire near O2 tank because O2 is flammable
After
1. Monitor V/S especially RR
2. Assess for improvement of respiratory status
Medical Date Ordered General Description Indication(s) or Purposes(s) Client’s response to the treatment
Management Date(s)
Treatment Performed Date
Changed/discontinue
Blood transfusion a. July 18, 2006 - Transfusion of blood - To replace the blood lost during > Refused and signed a Home Against Medical
(PRBC)- Pact Red units containing blood surgery and the blood loss caused Advise (HAMA) form.
Blood Cell contents particularly by retained placenta and DBB in
RBC, One unit of PRBC the patient’s uterus in order to
should increase prevent hypovolemia, shock or
hematocrit by 3% and anemia and other complications.
hemoglobin by 1 g/dL.

a. July 21, 2006 > Absence


b. July 22, 2006
c. Discontinued July
22, 2006.

Nursing Responsibilities
Before
1. Secure consent for BT.
2. Check for proper blood typing, cross matching and serial #.
3. Obtain baseline V/S data
4. Explain procedure to the client and its side effects
5. Double check blood product compatibility and cross matching
6. Prepare all materials needed
7. Administer pre BT meds such as Diphenhydramine or Antamin if prescribed
During
1. Monitor V/S frequently Q15 min/Q 30 min
2. Watch out for anaphylaxis reaction
3. Administer blood product as prescribed (gtts/min)
4. If anaphylaxis reaction occurs such as hypernatremia, immediately terminate transfusion and notify physician
After
1. Monitor V/S frequently
2. Assess for effectivity of treatment/management
Medical Date Ordered General Description Indication(s) or Purposes(s) Client’s response to the treatment
Management Date(s)
Treatment Performed Date
Changed/discontinue
Foley a. July 18, 2006 - Indwellling foley- - Foley catheterization is > Catheter was always in place and connected to the
Catheterization catheter is an indicated for our client urinary bladder.
b. July 18, 2006 alternative way of because of the following > the patient was able to adjust with mild discomfort
allowing urine to reasons: caused by the indwelling foley catheter.
c. Discontinued July flow from the- 1. Postoperative condition of > client was not resistant in the duration of the foley
20, 2006 bladder to a the client requiring a flat on catheter.
specimen/urine bag. bed status as ordered by the > no output abnormalities such as hematuria were
It has a long physician on the dates of July observed all throughout the duration of the indwelling
hose/tubing with 2 18 to July 19, 2006. catheter.
ports. The first port- 2. To avoid contact of urine > possible infections that urine may cause were
is for the attachment to the sites of genital warts avoided.
of the urine tube and excision in the vulvar and
urine bag, and the vaginal area and the area of
other port is the site urinary meatus, hence,
for the injection of avoiding infection.
sterile water in order- 3. The spinal anesthesia used
to secure and to during the surgery (CS &
avoid dislodging the BTL) caused suppression of
catheter from the normal bladder function
urinary bladder. resulting to urinary
incontinence.
Nursing Responsibilities

Before
1. Explain the procedure to the client and also explain the discomfort it may cause.
2. Place the client in a supine position with her knees flex and separated.
3. Wear sterile gloves before preparing the catheter.
4. Check the catheter balloon for appropriate filling, and then set aside on the sterile field.
5. Clean the labia and the meatal opening one side at a time using downward stroke.
6. Apply lubricant such as KY jelly on your hand and lubricate the foley catheter.
During
1. Ask patient to breathe deeply and insert the well lubricated catheter into the meatal opening.
2. When urine return (presence of backflows), insert another inch of the foley catheter.
3. Inflate the balloon with 5 to 10 cc of sterile water or saline solution using a sterile syringe.
4. Gently pull back to seal the catheter.
5. *** if accidentally inserted in the vagina never reused the catheter.
After
1. Assess the presence of blood in the urine.
2. Secure/reinforce the tapes to avoid dislodging the catheter.
3. Monitor intake and output.
4. Drain the urine bag as necessary or every shift.
5. Document all findings.
b. Pharmacotherapy

Name Action Contraindications Side effect Adverse reaction Nursing Responsibility


Generic Name: Drug class Contraindicated in: >CNS: Sedation, Seizures, • Assess blood pressure and
Tramadol Centrally • Hypersensitivit dizziness/vertigo, anaphylactoid respiratory rate before and
acting y headache, reactions, periodically during administration.
analgesic • Cross- confusion, tachycardia, • Assess type, location, and intensity
sensitivity with dreaming, bradycardia of pain before and 2-3 hr (peak)
• Binds to opioids may sweating, anxiety, after administration.
Brand Name: mu-opoid occur >CV: Hypotension, • Assess bowel function routinely.
Tramal receptors • Patients who >Dermatologic: Prevention of constipation should
• Inhibits are acutely Sweating, be instituted with increased intake
reuptake of intoxicated pruritus, rash, of fluids and bulk and with
serotonin with alcohol, pallor, urticaria laxatives to minimize constipating
and sedative/hypnot >GI: Nausea, effects.
norepineph vomiting, dry
ics, centrally • Tramadol is not recommended for
rine in the acting mouth,
pts. Who have previously received
CNS. analgesics, constipation,
opioids for more than 1 wk; may
opioid flatulence
cause opioid withdrawal
analgesics, or >Other: Potential
symptoms.
psychotropic for abuse,
• Monitor patient for seizures. May
agents occur within recommended dose
• Pts. Who are range. Risk is increased with
physically higher doses and in patients taking
dependent on antidepressants, opioid analgesics,
opioid or other drugs that decrease the
analgesic (may seizure threshold.
precipitate • Overdose may cause respiratory
withdrawal) depression and seizures.
• Not • May cause dizziness and
recommended drowsiness. Caution pt to avoid
for use during driving or other activites requiring
pregnancy or alertness
lactation. • Advise patient to change positions
slowly to minimize orthostatic
hypotension.
• Caution pt to avoid concurrent use
of alcohol or other CNS
depressants with his medication.

Name Action Contraindications Side effect Adverse reaction Nursing Responsibility


Generic Name: Drug classes Allergy to >CNS: Headache, >GI: • Assess patient for infection (vital
Cefuroxime Antibiotic cephalosporins or dizziness, pseudomembra signs; appearance of wound,
Cephalosporin penicillins, renal lethargy, nous colitis, sputum, urine, and stool; WBC) at
(second failure, lactation, paresthesias liver toxicity beginning and during therapy.
Brand Name: generation) pregnancy >GI: Nausea, >GU: • Before initiating therapy, obtain a
Zinacef vomiting, Nephrotoxicity history to determine previous use
• Antimicro diarrhea, >Hematologic: of and reactions to penicillins or
bial drugs anorexia, Bone marrow cephalosporins. Persons with a
• Bind to abdominal pain, depression negative history of penicillin
bacterial flatulence, >Hypersensitivity sensitivity may still have an
cell wall >Local: Pain, at : Ranging from allergic response.
membrane, injection site, rash to fever to • Cefuroxime may also cause false-
causing phlebitis, anaphylaxis, negative blood glucose results with
cell death. inflammation at serum sickness ferricyanide tests. Use glucose
IV site reaction enzymatic or hexokinase tests to
>Hematologic: determine blood glucose.
decreased
• (IV) Change site every 48-72 hr to
WBC,
prevent phlebitis. Monitor site
decreased frequently for thrombophlebitis,
platelets, pain, redness, swelling).
decreased Hct • Administer slowly for 3-5 min.
>Other: • Advise pt to report signs of
Superinfections superinfection (furry overgrowth
, disulfiram-like on the tongue, vaginal itching or
reaction with discharge, loose or foul-smelling
alcohol stools) allergy.
• Instruct pt to notify health care
professional if fever and diarrhea
develop, especially if stool contains
blood, pus or mucus. Advise pt not
to treat diarrhea without consulting
health professional.

Name Action Contraindications Side effect Adverse reaction Nursing Responsibility


Generic Name: Hemostatics/ Patient predisposed >nausea, vomiting, >Ophtalmological • Monitor for Gastrointestinal
Tranexamic Acid Anti- to thrombosis. diarrhea problem disturbances (nausea, vomiting,
hemophilia Prophylaxis during diarrhea)
Brand Name: pregnancy and • Advise patients who are to be
Hemostan before delivery. treated continually for longer than
several days, an ophthalmological
examination, including visual
acuity, color vision, eye-ground
and visual fields, is advised, before
commencing and at regular
intervals during the course of
treatment. Tranexamic acid should
be discontinued if changes in
examination results are found.
Name Action Contraindications Side effect Adverse reaction Nursing Responsibility
Generic Name: > Iron >Contraindicated >GI: epigastric pain anorexia • Fe Preparation should be
Ferrous Sulfate Supplement to patients vomiting, administered with food to reduce
receiving repeated constipation, black gastric irritation through absorption
Brand Name: *Provides blood transfusions. stools, diarrhea, may be impaired.
Feosol, Fergan elemental iron, • Antacid and tetracyclines may
an essential > Use cautiously >Others: temporary impair absorption of Fe.
component in on long term basis. teeth staining if • Advice pt to take this medication
the formation in liquid form with a full glass (8 oz or 240 ml) of
of water, unless your doctor directs
hemoglobin. you otherwise. Do not lie down for
30 minutes after taking this
medication.
• This medication may cause mild
nausea or unpleasant taste. Consult
your doctor if any of these effects
persist or become severe.
• Do not crush or chew this
medication before swallowing.
This timed-release product must be
swallowed whole.

Name Action Contraindications Side effect Adverse reaction Nursing Responsibility


Generic Name: Drug classes >Use cautiously to >CNS: Dizziness, > angina, * Do not exceed a single dose of 30
Nifedipine Calcium patients with heart light-headedness, mg.
channel- failure or headache, asthenia,
Brand Name: blocker hypotension. Use fatigue, *Before increasing the dose, carefully
Calcibloc Antianginal extended release nervousness, sleep monitor BP.
agent tablets cautiously disturbances,
Antihypertensi in patients with GI blurred vision * No rebound effect noted when
ve narrowing. >CV: hypotension nifedipine is discontinued. However if
>Dermatologic: to were stopped decreased dosage
*Thought to Flushing, rash, gradually.
inhibit calcium dermatitis,
ion influx pruritus, * During initial therapy and when
across cardiac urticaria dosage is increased, may experience an
and smooth >GI: Nausea, increase in frequency, duration, or
muscle cells, diarrhea, severity of angina.
decreasing constipation,
contractility cramps, * Food may decrease the rate but not
and oxygen flatulence, the extent of absorption; can be taken
demand. Also hepatic injury without regard to meal.
may dilate >Other: Nasal
coronary congestion, * Advise patient to report any
arterioles and cough, fever, symptoms of any persistent headache,
arteries. chills, shortness flushing, palpitations, nausea, weight
of breath, gain, dizziness, lightheadedness, or
muscle cramps, lack of response.
joint stiffness,
* Keep log of BP reports. Perform
weekly weights and note any extremity
swelling.

Name Action Contraindications Side effect Adverse reaction Nursing Responsibility


Generic Name: > Anti- >Use cautiously to >CNS:dizziness, > angina > Monitor blood pressure regularly and
Methyldopa Hypertensive breastfeeding light headedness, >Musculo- note for hypotension.
Brand Name: women. headache,sedation, skeletal: > Patients who need blood transfusions
Aldomet, Novo- *Thought to weakness arthralgia should undergo Coomb’s test to avoid
medopa, inhibit the >CV: bradycardia, > Hematologic: problems in cross matching.
Dopamet central palpitations, Thrombocyto-
vasomotor orthostatic penia, hemolytic
centers, hypotension, anemia, bone
thereby >EENT: nasal marrow
decreasing congestion depression
sympathetic >GI:nausea,vomitin
outflow to the g, constipation, dry
heart, kidneys, mouth
and peripheral
vasculature. >Respiratory:
dyspnea
>Skin: rashes,
pruritus

Name Action Contraindications Side effect Adverse reaction Nursing Responsibility


Generic Name: Drug classes • Contraindic >CNS: Headache, > Severe, • Administer oral doses with
metronidazole Antibiotic ated with dizziness, disulfiram-like
Antibacterial ataxia, vertigo, interaction with food.
hypersensiti
Amebicide vity to incoordination, alcohol, • Instruct the patient regarding
Antiprotozoal metronidaz insomnia, candidiasis the side effects: dry mouth
ole; seizures, (superinfection) with strange metallic taste
Brand Name: *Bactericidal: pregnancy peripheral (frequent mouth care, sucking
Flagyl, inhibits DNA (do not use neuropathy, sugarless candies may help);
synthesis in for fatigue nausea, vomiting, diarrhea
specific trichomonia >GI: Unpleasant (small, frequent meals may
(obligate) sis in first metallic taste, help).
anaerobes, trimester). anorexia, • Instruct the patient that urine
causing cell • Use nausea,
death; may appear dark; this is
cautiously vomiting, expected.
antiprotozoal- diarrhea, GI
trichomonacid with CNS upset, cramps
al, amebicidal: diseases, >GU: Dysuria,
biochemical hepatic incontinence,
mechanism of disease, darkening of the
action is not candidiasis urine
known. (moniliasis) >Local: redness,
, blood burning,
dyscrasias, dryness, and
lactation. skin irritation
(topical)

Name Action Contraindications Side effect Adverse reaction Nursing Responsibility


Generic Name: Drug class Allergy to >CNS: Headache, > increase in • Instruct patient regarding the
famotidine Histamine 2 famotidine; renal malaise, total bilirubin, side effect of the drug:
(H2) antagonist failure; pregnancy; dizziness, sexual constipation or diarrhea; loss of
lactation. somnolence, impotence libido or impotence
insomnia (reversible); headache (adjust
* >Dermatologic: lights, temperature, noise
Brand Name: Competitively Rash levels).
Pepcid blocks the >GI: Diarrhea, • Instruct patient to report sore
action of constipation, throat, fever, unusual bruising
histamine at anorexia, or bleeding, severe headache,
the histamine abdominal pain muscle or joint pain.
(H2) receptors
of the parietal
cells of the
stomach;
inhibits basal
gastric acid
secretion and
chemically
induced
gastric acid
secretion.

Name Action Contraindications Side effect Adverse reaction Nursing Responsibility


Generic Name: Drug class • Contraindic >CNS: Headache, >Hematologic: • Administer oral drug with
Ranitidine Histamine 2 ated with malaise, Leukopenia, meals and at bedtime.
(H2) antagonist allergy to dizziness, granulocytopeni • Instruct patient regarding the
ranitidine, somnolence, a, side effect of the drug:
lactation. insomnia, thrombocytope constipation or diarrhea; loss of
* vertigo nia,
• Use libido or impotence
Brand Name: Competitively >Dermatologic: pancytopenia
cautiously (reversible); headache (adjust
Zantac blocks the Rash, alopecia >CV:
with lights, temperature, noise
action of >GI: Constipation, Tachycardia,
impaired levels).
histamine at diarrhea, bradycardia,
the histamine
renal or • Instruct patient to report sore
hepatic nausea, PVCs (rapid IV throat, fever, unusual bruising
(H2) receptors vomiting, administration)
function. or bleeding, severe headache,
of the parietal abdominal pain,
cells of the muscle or joint pain.
>Local: Pain at IM
stomach; site, local
inhibits basal burning or
gastric acid itching at IV site
secretion and
chemically
induced
gastric acid
secretion.
Name Action Contraindications Side effect Adverse reaction Nursing Responsibility
Generic Name: analgesic/ >Contraindicated >CNS:dizziness, , >Hematologic: > Correct hypovolemia before giving
Ketorolac anti- as prophylactic headache,sedation, Decreased ketorolac
inflammatory analgesic before drowsiness platelet
major surgery or >CV: edema, adhesion, > NSAIDs may mask the signs and
Brand Name: intraoperatively hypertension, purpura, symptoms of infection because of their
Toradol *Thought to when hemostasis is palpitations, increased antipyretic and anti-inflammatory
inhibit critical. arrhythmias bleeding time actions.
prostaglandin >GI:nausea,vomitin
synthesis, to g, constipation,
produce anti- flatulence
inflammatory, Skin: rashes,
analgesic, and pruritus, diaphoresis
antipyretic
effect.

Name Action Contraindications Side effect Adverse reaction Nursing Responsibility


Generic Name: Drug classes • Contraindic >CNS: Headache >CV: Chest pain, > Monitor for temperature regularly
Paracetamol Antipyretic ated with >Hematologic: dyspnea,
Analgesic and report to physician if hyperthermia
allergy to Anemia myocardial
(non-narcotic) acetaminop >Skin: rash damage when does not subside.
hen. doses of 5–8
• Use g/day are ingested
*Antipyretic: daily for several
cautiously
Brand Name: reduces fever weeks or when
with
Biogesic by acting doses of 4 g/day
impaired
directly on the are ingested for 1
hepatic
hypothalamic year
function,
heat-regulating >GI: Hepatic
chronic
center to cause toxicity and
alcoholism,
vasodilation failure, jaundice
and sweating, pregnancy, >GU: Acute
which helps lactation. kidney failure,
dissipate heat renal tubular
Analgesic: site necrosis
and
mechanism of
action unclear
Name Action Contraindications Side effect Adverse reaction Nursing Responsibility
Generic Name: Drug classes  Contraindicated • CNS: extrapyramid  Monitor BP carefully during IV
 Metoclopram GI stimulant with allergy to Restlessness, al reactions, administration.
ide Antiemetic metoclopramid drowsiness, parkinsonism-  Monitor for extrapyramidal
Dopaminergic e; GI fatigue, like reactions, reactions, and consult physician if
blocking agent hemorrhage, lassitude, they occur.
mechanical insomnia,  Monitor diabetic patients, arrange
obstruction or akathisia, for alteration in insulin dose or
*Stimulates perforation; dystonia, timing if diabetic control is
motility of pheochromocyt myoclonus, compromised by alterations in
Brand Name: upper GI tract oma (may dizziness, timing of food absorption.
Plasil without cause anxiety
stimulating  Provide diphenhydramine injection
hypertensive • CV: on standby in case extrapyramidal
gastric, biliary, crisis); Transient reactions occur (50 mg IM).
or pancreatic epilepsy. hypertension  Provide phentolamine on standby
secretions  Use cautiously • GI: Nausea, in case of hypertensive crisis (most
with previously diarrhea likely to occur with undiagnosed
detected breast pheochromocytoma).
cancer (one
third of such
tumors are
prolactin
dependent);
lactation.

Name Action Contraindications Side effect Adverse reaction Nursing Responsibility


Generic Name: Anti-  Parenteral > drowsiness, >  Watch our for respirator depression
Magnesium convulsant administration hypothermia, Bradycardia, and sign and symptoms of heart
Sulfate contraindicated depressed circulatory block
in patients with reflexes, collapse,  Keep IV calcium gluconate
heart block or hypotension, flaccid available to reverse magnesium
myocardial flushing, paralysis, intoxication
damage diplopia, respiratory  Check Magnesium level after
 Contraindicated diaphoresis paralysis repeated doses. Disappearance of
in patients with knee-jerk and patellar reflexes is
Brand Name: toxemia of sign of impending magnesium
pregnancy toxicity.
during 2 hours  Monitor fluid intake and output.
preceding Make sure urine output is 100 ml
delivery. more in 4-hour period before each
dose.

c. Diet

Type of Diet Date ordered General Description Indication(s) or Purposes(s) Client’s response &/ or reaction to the activity/
Date started exercise
Date change
Nothing per orem July 18, 2006 - also known as - the patient is on NPO diet The NPO status was tolerated by the patient and was
(NPO) nothing by mouth diet status because of her compliant to the diet status prescribed/ordered by the
- the restriction of oral preoperative condition (CSIII physician. There were no complication such as aspiration
intake of foods, & BTL) on the date of July 18, and digestive tract upset because of the patient’s proper
liquids, or drugs. 2006. This diet is appropriate compliance.
for the patient because of the
presence of peristalsis and
bowel movement. It is also
indicated for the patient in
order to avoid aspiration or
worse, atelectasis. The patient
is at risk for aspiration because
of the absence of her gag and
coughing reflex secondary to
anesthesia induction.

Nursing Responsibilities
1. Instruct patient to avoid eating/drinking any food, liquid/beverages, or even meds by mouth prior to surgery and after surgery as ordered.
2. Explain the importance of NPO status and its relation to the patient’s current condition.
3. Enumerate to patient and SO the complications that may arise if NPO status is not followed strictly.
4. Constantly/repeatedly reinforce to the patient her NPO status.
5. Educate patient that she could wet her lips using wet cotton but avoid excessive amount.
6. Observe for restoration of GI function such as passage of flatus and presence of bowel sounds then document findings.
Type of Diet Date ordered General Description Indication(s) or Purposes(s) Client’s response &/ or reaction to the activity/
Date started exercise
Date change
General Liquid diet July 19, 2006 - A diet wherein the - On the date of July 19, 200 the The ordered diet was observed by the patient. She was
to soft diet client is allowed to patient was placed on general able to tolerate soft foods and general liquids such as
eat/take liquids, or liquids to soft diet because of gelatin, noodles/pasta, and other noncarbonated beverages
soft foods such as the presence of bowel and her oral meds as well. There were no untoward signs
gelatins, movement/ peristalsis, and of GI upset.
noodles/pasta, mash passage of flatus and
potatoes, and other restoration of gag reflex. It is
well-cooked soft indicated after NPO in order to
foods. allow the patient’s digestive
system to compensate for its
function depression caused by
the spinal anesthesia used
during her surgery (CSIII &
BTL).

Nursing Responsibilities
1. Assess for signs of restored GI function such as passage of flatus, and presence of bowel sounds. If positive, document findings and notify physician.
2. Inform patient of her general liquid to soft diet status and evaluate the possible foods she could eat such as water, juices, gelatin, and pasta/noodles and
her prescribed oral meds. Instruct her to eat only in ample/moderate amounts.
3. Reinforce patient to comply to her general liquid to soft diet status and educate her about the possible complications she might experience if she could
be noncompliant.
4. Assess for signs of GI upset such as epigastric pain/abdominal pain, etc.
5. Assess for bowel movement by asking the client about the frequency of defecation, then document.
Type of Diet Date ordered General Description Indication(s) or Purposes(s) Client’s response &/ or reaction to the activity/
Date started exercise
Date change
Diet as Tolerated July 21, 2006 - Diet as tolerated by - The patient is placed on a DAT The patient was placed on DAT status upon restoring
its name indicates that status because of the proper/normal GI function. The diet was well tolerated
the patient could restoration of all her normal by the patient, and her GI function remain normal and
eat/take all oral meds, digestive functions as stable all throughout.
and any type of food evidenced by normal BM (12-
without restrictions. 20 bowel movement/min),
It is ordered when all consecutive/ regular passage
normal digestive of flatus, complete recovery of
functions are restored. the patient’s gag reflexes.

Nursing Responsibilities
1. Inform patient she could eat/drink the food and beverages she desires.
2. Instruct patient to eat only as tolerated and gradually increase intake as preferred.
3. Assess for GI upset symptoms.
4. Instruct patient to report signs of GI discomforts.
5. Regularly ask patient about frequency of bowel movement.
6. Document findings.
c. Activity/Exercise

Type of Exercise Date ordered General Description Indication(s) or Purposes(s) Client’s response &/ or reaction to the activity/
Date started exercise
Date change
Flat on Bed July 18, 2006 - A non ambulatory status - The FOB status is indicated for > The patient was compliant with the FOB status there
July 18, 2006 commonly ordered for the patient because of her post was no onset of spinal headache postoperatively due to
July 19, 2006 postoperative patients. operative status. She was induced proper compliance.
Most commonly those with spinal anesthesia because of
induced with spinal the surgical procedures CS & BTL
anesthesia. This status, and was placed on FOB status to
the patient is placed 180o avoid spinal headache. This is also
or bed with no pillows. indicated to avoid incision bleeding
and other injuries.

Nursing Responsibilities
1. Maintain airway, breathing and circulation
2. Raise side rails or place pillows or both sides of bed to avoid falls and injuries (maintain safety)
3. Monitor patients V/S every 15 min until stable (related to post-op status)
4. Place patient flat on bed, 180o on bed with no pillow to elevate the patient’s head
5. Assess for return of consciousness
6. Assess for surgical site and incision dressings- reinforce or change as necessary
7. Instruct patient to maintain 180o position on bed until the doctors order change the status of exercise
8. Document significant findings and intervention performed
9. Notify physician for significant deviations

*** All nursing responsibilities and interventions enumerated are performed in relation to the post operative condition and post op exercise status of the patient

Type of Exercise Date ordered General Description Indication(s) or Purposes(s) Client’s response &/ or reaction to the activity/
Date started exercise
Date change
Complete Bed Rest July 19, 2006 - CBR is a non - Indicated for the patient due to > Patient complied with BCR status.
July 19, 2006 ambulatory status also her post-op condition but with the > Absence display of dehiscence and evisceration
July 20, 2006 ordered for post op absence of the effect of spinal > Absence of spinal headache onset
patients, patients with anesthesia. This is also indicated > Absence of postoperative complications
pregnancy disorder such to the patient in order to avoid
as placenta previa, post-op complications specially
preterm bleeding or dehiscence and evisceration.
uterine contractions. In
this status the patient
could assume semifowlers
position or elevate her
head with the use of a
pillow. If tolerated, the
patient could also assume
a high fowlers position.

Nursing Responsibilities
1. Monitor V/S
2. Instruct patient about the activities she could perform like elevation of head, assuring a semi-fowlers position, or high fowlers position as tolerated
3. Instruct patient to comply with ambulatory status and explain the complications that could occur if CBR is not observed
4. Check surgical site for signs of dehiscence or evisceration, purulent exudates or bleeding
5. Reinforce or change wound dressings as needed/necessary
6. Record significant findings and intervention preformed
7. Inform physician for abnormalities or S/Sx of infection or would dehiscence/evisceration
8. Administer post-op meds as prescribed

*** All nursing responsibilities and interventions enumerated are performed in relation to the post operative condition and post op exercise status of the patient

Type of Exercise Date ordered General Description Indication(s) or Purposes(s) Client’s response &/ or reaction to the activity/
Date started exercise
Date change
Ambulate as July 20, 2006 - Full privileged to - Indicated for the patient because > Ambulatory status was tolerated well
tolerated July 20, 2006 ambulate as tolerated by of the restoration of all the patients > The health teachings/education given to the client were
Until discharged the patient may be started system functions and consistent observed
form bedside exercises to stable vital signs. > Manifested stable V/S
walking 1 yard, then > Absence of wound dehiscence and evisceration
gradual increase in > Absence of post-op complications
activity until normal ADL
performance is restored.

Nursing Responsibilities
1. Monitor V/S
2. Instruct patient about ambulate as tolerated status
3. Instruct patient to avoid standing immediately. Instruct to first sit down at the edge of bed before standing up to avoid orthostatic hypotension
4. Instruct patient to start ambulating by performing bedside exercises then increase gradually
5. Monitor surgical incision site
6. Verify physician about significant findings
7. Administer medication as prescribed
8. Record/document all findings and intervention performed

*** All nursing responsibilities and interventions enumerated are performed in relation to the post operative condition and post op exercise status of the patient
Assessment Nursing Scientific Planning Nursing Rationale Expected Outcome
Diagnosis Explanation Intervention
Subjective Fluid As a result of After 40 of 1. Establish rapport - to gain patients trust and After 40 of Nursing
 Volume post operative Nursing establish good patient- Intervention the patient
Deficit R/T procedure of a Intervention nurse relationship has able to maintain
Objective excessive cesarean birth the patient fluid volume at a
2. Monitor and record - to note for the
The patient blood loss blood loss will be able to functional level as
vital signs alterations in V/S
may during occur at maintain fluid evidenced by increase
(decreased BP, Increased
manifest: surgical approximately volume at a in PR and temp) in urine output, with
increased procedure as 600 to 800 ml functional normal vital signs,
urine manifested of blood level as 3. Note for the -to assess what factor moist mucous
output, by a leading to evidenced by causative factors that contributes to fluid membrane, good skin
decreased decreased in changes in individually contribute to fluid volume deficit that may turgor and normal hgb
skin turgor, hgb & hct hgb and hct active urinary volume deficit be given prompt & hct count.
dry skin and count. ct. and cause output, stable intervention.
mucous a decreased in vital signs,
membrane, intravascular moist mucous 4. Assess for factor - to evaluate degree of
that could precipitate fluid deficit
decreased or membranes,
blood loss such as
hgb, hct intracellular and good skin bleeding on incision
count, fluid thus turgor. site and excessive
altered fluid volume lochia
serum deficient
sodium, occur. 5. Note patients - food rich with high fluid
decreased preferences regarding content replaces or
BP, fluids and foods with contributes for the
increased high fluid content correction of fluid loss
PR and
temperature 6. Provide TSB if - to decreased
patient has fever temperature and provide
comfort
7. Keep fluids within - replaces fluid loss and
client’s reach and provides hydration
encourage increased
fluid intake

8. Provide oral care - to prevent injury from


by moistening lips & dryness
skin care by
encouraging daily
bath

9. Change dressings - to protect skin and


frequently monitor losses

10. Provide safety - to prevent injury related


measures and assist to hypotension
patient when moving
especially if patient
has decreased BP

11. Administer IV -replaces fluid losses


fluid replacement as
ordered

12. Administer blood - replaces blood loss


products as ordered

13. Administer - to reduce body


antipyretic drugs if temperature
patient has fever as
ordered
ACTUAL SOAPIE

S - “Hindi ako nagpa-BT kase wala pang pera”- as verbalized by the patient
O - Received on bed on supine position conscious and coherent, with intact
and unsoaked incision dressing, (-) breast engorgement, urine (1), (-)BM,
unsoaked vagial/perineal pads with moderate amount of lochia serosa, (-)Homan’s
sign, ambulatory, pale buccal mucosa and conjunctiva, hgb count (77), hct (0.33),
with initial vital signs taken as follows: BP- 120/80 mmHg, PR-83 bpm, RR-26
bpm, Temp.-36.4 oC.
A - Altered Tissue Perfusion r/t decrease hgb(77), hct(0.33) counts
P - After 2o of nursing intervention, the patient will verbalize understanding
of the condition, treatment/therapy regimen, and will demonstrate behavioral
changes to improve circulation.
I - Assessed for physical manifestations of anemia
- Assessed for factors that could precipitate to anemia such as bleeding on
incision site, excessive lochia and diet.
- Assessed diet/food preference
- Encouraged to increase intake of food rich in iron such as animal liver &
green & leafy vegetables when in DAT status
- Instructed to watch for sign of bleeding on incision site (soaked dressing)
and increase in lochia
- Instructed compliance to oral iron supplement intake
- administered due medication
E - Patient verbalized understanding of condition and therapeutic regimen and
demonstrated behavioral changes to improve circulation

S - “Eku migalo masakit kasi, maghilab ya ing tiyan ku dati, tatakut naku”- as
verbalized by the patient
O - Received on bed on supine position conscious and coherent, with intact
and unsoaked incision dressing, (-) breast engorgement, urine (1), (-)BM,
unsoaked vagial/perineal pads with moderate amount of lochia serosa, (-)Homan’s
sign, ambulatory, pale buccal mucosa and conjunctiva, hgb count (77), hct (0.33),
with initial vital signs taken as follows: BP- 160/90 mmHg, PR-90 bpm, RR-23
bpm, Temp.-36.4oC.
A - Impaired Physical Mobility r/t pain and discomfort secondary to episodes
of uterine contractions: preterm labor
P - After 2 hours of nursing intervention, the patient will display increase in
activity level and will verbalize understanding to maintain safety.
I - Monitored V/S
- Assessed for episodes of preterm uterine contraction
- Assessed for degree of discomfort that limits patient’s movements
- Assisted in performing ADL
- Instructed to increase food rich in calorie sch as fruits, vegetables, rice,
bread, etc. to regain energy
- Instructed patient to perform ADL as tolerated
- Instructed adherence to presented meds
- administered due meds
E - After 2 hours of nursing intervention, the patient was able to display
increase in activity level and will verbalize understanding to maintain safety.
2. Surgical Management

Caesarean section

A caesarean section (cesarean section AE), or c-section, is a form of childbirth in


which a surgical incision is made through a mother's abdomen (laparotomy) and
uterus (hysterotomy) to deliver one or more babies. It is usually performed when a
vaginal delivery would lead to medical complications, although it is increasingly
common for otherwise normal births as well.

Etymology

There are several elements which contribute to a linguistic explanation of the word
caesarean.

• The term may be simply derived from the Latin verb caedere (supine stem
caesum), "to cut." The term caesarean section then would be a tautology.
• The caesarean is possibly named after Roman military and political leader Julius
Caesar who allegedly was so delivered. Historically, this is unlikely as his
mother was alive after he reached adulthood (extremely implausible if such a
procedure was performed with the technology of the day), but the legend is at
least as old as the 2nd century AD.
• Roman law prescribed that the procedure was to be performed at the end of a
pregnancy on a dying woman in order to save the life of the baby. This was called
the lex caesarea. Thus the Roman law may be the origin of the term.

Most likely the term is the product of a combination of these. The beginning of the story
is certainly the verb caedo: the phrase a matre caesus ("cut out of his mother") was used
in Roman times to describe the operation. The real etymology of the name Caesar (a
much older family name) is completely unrelated, but a very early folk etymology
invented the story of Julius Caesar's birth by section in order to suggest that his name is
derived from this verb. The title of the Roman law must be influenced by this legend,
since the form caesareus cannot be derived directly from caesus without some
interference of Caesar. The form of the modern English word caesarean may come
either from the law or from the name Caesar, but the modern German Kaiserschnitt
(literally: "Emperor's section") obviously comes directly from the legend of Julius
Caesar's birth.

Types

A caesarean section in progress. This is the view that the father can expect of their
newborn child. The mother's view is similar but from a lower angle.

There are several types of caesarean sections (CS):


• The classical caesarean section involves a midline longitudinal incision which
allows a larger space to deliver the baby. However, it is rarely performed today as
it more prone to complications.
• The lower uterine segment section is the procedure most commonly used today; it
involves a transverse cut just above the edge of the bladder and results in less
blood loss and is easier to repair.
• A crash caesarean section or emergency caesarean section is a CS performed in
an obstetrical emergency and is usually initiated within 30 minutes after
making the decision.
• A caesarean hysterectomy consists of a caesarean section followed by the
removal of the uterus. This may be done in cases of intractable bleeding or when
the placenta cannot be separated from the uterus.
• Traditionally other forms of CS have been used, such as extraperitoneal CS or
Porro CS.
• a repeat cesarean section is done when a patient had a previous section. Typically
it is perfomed through the old scar.

In many hospitals, especially in the United States, United Kingdom, Australia and
New Zealand the mother's partner is encouraged to attend the surgery to support the
mother and share the experience. The anesthesiologist will usually lower the drape
temporarily as the child is delivered so the parents can see their newborn.

[edit]

Indications

Obstetricians or other care providers recommend caesarean section when vaginal


delivery might pose a risk to the mother or baby. Possible reasons for caesarean delivery
include:

• prolonged labor or a failure to progress (dystocia)


• apparent fetal distress
• apparent maternal distress
• complications (pre-eclampsia, active herpes)
• catastrophes such as cord prolapse or uterine rupture
• multiple births (though this is controversial)
• abnormal presentation, (breech or transverse positions)
• failed induction of labour
• failed instrumental delivery (by forceps or ventouse)
• the baby is too large (macrosomia)
• placental problems (placenta praevia, placental abruption or placenta
accreta)
• contracted pelvis
• previous caesarean section (though this is controversial – see discussion below)
• prior problems with the healing of the perineum (from previous childbirth or
Crohn's Disease)
Note, however, that different providers may disagree about when a caesarean is required.
For example, one obstetrician may feel that a woman is too small to deliver her baby,
another might well disagree. Similarly, some care providers may be much quicker to cite
"failure to progress" than others. Disagreements like this help to explain why caesarean
rates for some physicians and hospitals are much higher than are those for others. The
medico-legal restrictions on VBAC, vaginal birth after caesarean, have also increased the
caesarean rate.

For religious, personal or other reasons, a mother may refuse to undergo caesarean
section. In the United Kingdom, the law states that a labouring woman has the absolute
right to refuse any medical treatment including caesarean section "for any reason or
none", even if that decision may cause her own death, or that of her baby. Other countries
have different laws.

As scheduled caesarean sections have become a rather safe operation, there has been a
movement to perform caesarean delivery on maternal request (CDMR). There is also
a consumer-driven movement to support VBAC as an alternative for repeat caesareans in
the face of increased medico-legal restrictions on vaginal birth.

Risks

Statistics from the 1990s suggest that less than one woman in 2,500 who has a caesarean
section will die, compared to a rate of one in 10,000 for a vaginal delivery. [1] However the
mortality rate for both continues to drop steadily. The UK National Health Service
gives the risk of death for the mother as three times that of a vaginal birth. [2] However, it
is not possible to directly compare the mortality rates of vaginal and caesarean deliveries
as women having the surgery are often those who were at a higher risk anyway.

Babies born by caesarean sometimes have some initial trouble breathing. In addition,
because the baby may be drowsy from the pain medication administered to the mother,
and because the mother's mobility is reduced, breastfeeding may be difficult.

A caesarean section is a major operation, with all that it entails. Pain at the incision can
be intense, and full recovery of mobility can take several weeks or more. A prior
caesarean section increases the risk of uterine rupture during subsequent labour.

If a CS is performed under emergency situations, the risk of the surgery may be increased
due to a number of factors. The patient's stomach may not be empty, increasing the
anesthesia risk.[3] Obstetrical hemorrhage may lead to anemia or to a clotting disorder.

Anaesthesia

The mother usually receives regional anaesthesia (spinal or epidural), allowing her to
remain awake for the delivery and avoiding sedation of the infant.
In current practice, general anaesthesia for caesarean section is becoming less
common as scientific research has now clearly established the benefits of regional
anaesthesia for both the mother and baby. General anaesthesia tends to be reserved for
high-risk cases or emergencies. The risks of general anaesthesia for mother and baby are
still extremely small overall.

Anaesthetic care is not limited to the operation itself. Anaesthetic teams in the United
Kingdom and New Zealand are responsible for post-operative pain relief.

There seems to be a link between the use of anaesthesia during labour and birth, as a form
of pain relief for women planning a vaginal birth, and caesareans. Recent medical
research concluded that epidural anaesthesia did not lead to labour failure leading to a
caesarean, but medical practice is to use labour induction drugs after anaesthesia is
applied to counteract the obvious sedative effect that causes labours to slow down or
often stop.

Vaginal births after caesarean

Vaginal birth after caesarean (VBAC) is not uncommon today. The medical practice until
the late 1970s was "once a caesarean, always a caesarean" but a consumer-driven
movement supporting VBAC changed the medical practice. Rates of VBAC in the 80s
and early 90s soared, but more recently the rates of VBAC have dramatically dropped
due to medico-legal restrictions.

In the past, caesarean sections used a vertical incision which cut the uterine muscle fibers.
Modern caesareans typically involve a horizontal incision along the muscle fibers. The
uterus then better maintains its integrity and can tolerate the strong contractions of future
childbirth. Cosmetically the scar for modern caesareans is below the "bikini line."

Obstetricians and other caregivers differ on the relative merits of vaginal and caesarean
birth following a caesarean birth. Some still recommend a caesarean routinely, others do
not; still others respect the wishes of the expectant mother.

Twenty years of medical research on VBAC, support a woman's choice to have a vaginal
birth after caesarean. Because the consequences of cesareans include a higher chance of
re-hospitalization after birth, infertility, and uterine rupture in the next birth, preventing
the first caesarean remains the priority. For women with one or more previous caesareans,
as an alternative to major abdominal surgery, VBAC remains a safer option.[6]

Tubal Sterilization Overview

Tubal sterilization is surgery to block a woman’s fallopian tubes. Tubal sterilization is a


permanent form of birth control. After this procedure, eggs cannot move from the ovary
through the tubes (a woman has two fallopian tubes), and eventually to the uterus. Also,
sperm cannot reach the egg in the fallopian tube after it is released by the ovary. Thus,
pregnancy is prevented.

This procedure is also called tubal ligation or you are said to have your “tubes
tied.” More formally, it is known as bilateral tubal ligation (BTL).

Currently, about 700,000 of these procedures are performed each year in the United
States. Half are performed right after a woman gives birth. The rest are elective
procedures performed as a one-day operation in an outpatient clinic. Eleven million US
women aged 15-44 years rely on sterilization as a means of birth control to prevent
pregnancy. More than 190 million couples worldwide use surgical sterilization as a safe
and reliable method of permanent birth control.

Prior to the 1960s, female sterilization in the United States was generally performed only
for medical problems or when a woman was considered “too old” to have children or at
risk. The changing cultural climate in the 1960s resulted in safe, minimally invasive
female sterilization procedures.

During the Procedure

While you are under anesthesia, one or two small incisions (cuts) are made in the
abdomen (usually near the navel), and a device similar to a small telescope on a flexible
tube (called a laparoscope) is inserted.

Using instruments that are inserted through the laparoscope, the tubes (fallopian tubes)
are coagulated (burned), sealed shut with cautery, or a small clip is placed on the tube.
The skin incision is then closed with a few stitches. You are usually feeling well enough
to go home from the outpatient surgery center in a few hours.

Your health care provider may prescribe pain medications to help you manage the pain, if
any.

Most women return to normal activities, including work, in a few days, although you may
be advised not to exercise for several days. You may resume sexual intercourse when
you feel ready.

Tubal ligation can also be performed immediately after childbirth through a small
incision near the navel or during a Cesarean delivery.

Currently, laparoscopy (bipolar laparoscopy, Falope ring, Filshie clip) is the most
popular method of female sterilization in nonpregnant women. Periumbilical
minilaparotomy (Pomeroy, Parkland) is the most common procedure right after
childbirth.

A new device acts much like tubal sterilization by blocking the fallopian tubes. The Food
and Drug Administration has approved a small metallic implant (called the Essure
System) that is placed into the fallopian tubes of women who wish to be permanently
sterilized. Unlike other currently available tubal sterilization procedures for women,
placement of the device does not require an incision or general anesthesia.

During the Essure procedure, your health care provider inserts an obstructive device into
each of the 2 fallopian tubes at the time of hysteroscopy. This is done with a special
catheter that is inserted through the vagina into the uterus and then into the fallopian tube.
The device works by inducing scar tissue to form over the implant, blocking the fallopian
tube and preventing fertilization of the egg by the sperm.

Risks

As with any surgery, there is always a risk when you are given general anesthesia. You
may have a bad reaction to the medication used. Surgery itself may present problems with
bleeding or infection.

There is still a chance you may become pregnant after tubal sterilization. About 1 in 200
women become pregnant who have their tubes tied. This may be caused by an incomplete
closure of the tubes. If pregnancy occurs after the procedure, you are at increased risk for
an ectopic pregnancy in which the pregnancy develops in the fallopian tubes. This is a
dangerous situation.

Because the procedure is performed by tiny instruments inserted into your abdomen, you
may have injury to other organs in your body.

Results

Most women recover from the laparoscopic procedure with no problems. There are no
tests required to confirm that you are now sterile (that is, unable to become pregnant)
after a laparoscopic procedure.

During the first 3 months after the Essure procedure, you must use another form of birth
control. At the 3-month point, you must undergo a final x-ray procedure in which dye is
placed in your uterus and an x-ray is taken to confirm that the device is in place.

This procedure cannot be reversed.

Alternatives

If you feel you want a permanent solution to birth control, discuss your options with your
health care provider. Many younger women who choose this procedure regret their
decisions later. The younger the woman, the more likely she will regret choosing this
permanent form of birth control.
Your doctor will discuss your current number of children, your plans for your future and
family, and will want to talk with your spouse. This is an important decision. Women
with certain medical conditions may not be suited for this procedure.

Tubal sterilization is surgery. Many couples, in looking at their birth control options,
especially when they are ready to stop having children, weigh the benefits and risks of
whether the woman would undergo tubal sterilization or the man a vasectomy.

Tubal ligation is not temporary. Do not think of it as a procedure to be reversed. When


reversal is attempted, the operation becomes major surgery and is only successful about
50-80% of the time (meaning the woman is able to become pregnant after reversal).

Surgical removal of genital warts by excision

Surgery Overview

Visible genital warts on the penis or vagina or around the anus are removed by cutting
them off with a surgical knife (scalpel). Warts on the cervix may be removed by laser or
loop electrosurgical excision (LEEP).

The procedure is usually done in a health professional's office or clinic. You receive
medication that numbs the area around the warts (local anesthetic). Stitches (sutures)
usually close the incisions.

What To Expect After Surgery

Recovery time depends on the location and number of warts removed.

• Most people will be able to return to normal activities within 1 to 3 days.


• Healing takes 2 to 4 weeks.
• Scarring may occur.

For men and women who have had genital warts removed, call your health professional
for any of the following:

• Bleeding that lasts longer than 1 week


• A fever
• Severe pain
• Bad-smelling or yellowish discharge, which may indicate an infection

Avoid sexual intercourse until the treated area heals and soreness is gone (usually 1 to 3
weeks, depending on the size of the area treated).

Why It Is Done
Surgery is used to removal warts that continually return. It also may be used when warts
are widespread. A single treatment may be all that is needed.

How Well It Works

Surgery is effective in up to 72% of cases. Warts come back in 19% to 29% of people.1, 2

Risks

Risks of surgery are:

• Bleeding.
• Infection. You may receive antibiotics at the time of the procedure to reduce the
risk of infection.
• Pain. You may need medication for several days after the procedure.

What To Think About

Treating genital warts does not cure a human papillomavirus (HPV) infection. The virus
remains in the body in an inactive state after warts are removed. A person treated for
genital warts may still be able to spread the infection. Condoms may help reduce the risk
of HPV infection, but it is not known how much protection they provide.

The benefits and effectiveness of each type of treatment need to be compared with the
side effects and cost. Discuss this with your health professional.

CLIENTS RESPONSE TO TREATMENT


CS & BTL
- The dead baby and the retained placenta were successfully evacuated via
transumbilical/lower abdominal midline incisions.
- Vaginal bleeding caused by the retained products of conception was stopped
- Bilateral fallopian tubes were ligated
- Complications that could be brought about the retained products of conception
such as hemorrhage, or worst shock were prevented
- Postoperatively, the client manifested fast recovery from the effects of the
anesthesia
- Physical mobility was impaired due to the pain caused by the surgical incision
- Tissue perfusion was impaired as a result of blood loss of the retained dead baby
boy and placenta and minimal blood loss during the surgical procedure
- Low count of hgb & hct were obtained form the blood sample postoperatively.
- Presence of manifestations of anemia such as pale conjunctiva, pale buccal
mucosa, and cold clammy peripheries.

GENITAL WARTS EXCISION BIOPSY


1. Genital warts in the vulvar, vaginal and perianal area were removed via vaginal
incision
2. Absence of bleeding on the excision sites
3. Absence of outward manifestations of would infections such as presence of
purulent exudates and hyperthermia
4. Therapeutic and palliative goals of excision biopsy were obtain

PROCEDURES FOR MONITORING AN IV SITE AND INFUSION


Nursing Actions
1. Monitor IV infusion at least once every hour. More frequent checks may be
necessary if medication is being infused.
a. Check physician’s order for IV solution
b. Check drip chamber and time drops
c. Check tubing for anything that might interfere with flow. Be sure that clamp is in
the open position. Observe dressings for leakage of IV solution
2. Inspect site for swelling, pain, coolness or pallor at site of insertion, which may
indicate infiltration of IV. This necessitates removing IV and restarting at another
site
3. Check for local or systemic manifestations that indicate and infection present at
the site
VIII. DISCHARGE PLANNING

1. General Condition of Client upon Discharge

Days prior to the patients discharge, she had stable and normal vital signs in the
continuity of consecutive shifts. There were no signs of would dehiscence and
evisceration, outward manifestation of infection such as purulent exudates, hyperthermia,
and inflammation. Her breasts are engorged, firm and globular uterus, regular/normal
urination and intake and output, and regular bowel movement. The patient also had
minimal to moderate production of lochia alba. No sign of dehydration were also
evident, the patient displayed good skin turgor. She is negative of signs of embolism, and
is on an ambulatory status.
The patient was incompliant to undergo the requested follow-up blood
examinations, urinalysis, chest examination and the procedures for several reasons.
Because of these there were no basis for evaluation of the treatment regimens for the
physician such as if the patient’s anemia and infection was treated.
On the other hand, the patient is very compliant/adherent in taking all her
prescribed medications and was placed on a “May Go Home” status by her attending
physician on the date of July 23, 2006.

2. METHOD

M - Mefenamic Acid 500 mg cap 3 x a day (8am-1pm-6pm)


- Ferrous Sulfate, cap OD (8am)
- Methyldopa 250 mg, tab 4 x a day (8am- 2 pm- 8am- 2am)
- Cefuroxime 500 mg cap 2 x a day (8am- 8pm)
E - Mefenamic acid
* There was a decrease in pain level on the incision site and excision site.
* Decrease in the mild inflammation
* Patient increased activity level as a result of decrease pain discomfort
- Ferrous Sulfate
* There was elimination of physical/outward manifestations of anemia
such as pale conjuctiva and buccal mucosa
* improve general well-being as a result of increased/improved RBC
content in the blood which resulted to proper perfusion and gas exchange.
- Methyldopa
* Blood pressure was restored to normal range
* Episodes of acute hypertension were managed
- Cefuroxime
* There were no outward manifestations of infections such as increase
temperature and purulent discharges from incision and excision sites
* The pain and mild redness on incision and excision sites subsided
T - Continue due meds
H - 1. Advised patient to increase fluid intake
2. Advised patient to eat foods rich in vitamin C such as oranges or
guavas.
3. Advised patient to rest
4. Advised patient to exercise
5. Maintain proper hygiene
6. Do perineal wash using “tawas”
O - Advised patient to come for follow-up check-up on July 31, 2006
(Monday)
D - Diet as Tolerated
IX. Conclusion

In our practice of nursing, we have been made aware that sexually transmitted
diseases cases continue to increase. On the other hand, not all of these diseases or
cases are reported to health care provider because of the common misconception that
they may be looked upon as immoral, and/or unclean. For this reason, numerous
cases of STD’s are left untreated, and worst, there is already a poor prognosis of the
ailment due to secondary complications that arise.
Conducting a case study about a sexually transmitted disease (condyloma
acuminata) is a very challenging task for us as student nurses. It was our first time to
deal with a sexually transmitted disorder. Unlike in our previous case studies which
dealt with pathological deranges wherein we have knowledge about, condyloma
acuminata, encouraged us to strive and exert extra effort in order for us to accomplish
this case study. Accomplishing this case study really helped us enhance the
resourcefulness, critical thinking, and knowledge that we possess especially in cases
where limited facts and information’s are available. It also enabled us to be tactful in
dealing with a patient with such disease because of the fact that they get easily
offended and they will not present all the essential information that we need. We
were able to develop and apply the principles of therapeutic communications during
our nurse-patient interaction and history taking, making it easier for us to
extract/obtain information from the patient without causing negative feelings. We
learned how to be efficient and consistent in prioritizing nursing interventions
through proper history taking and accurate physical assessment. We were also able to
improve our skills in building links and relationship between cause and effect
relationship between the information obtained in the physical assessment and the
disease condition in a highbrow and intellectual manner. Because of this, we were
able to establish strong factual relationship of the factors contributing to the disease,
the synthesis of the disease condition, and its effects on the laboratory and diagnostic
procedures.
Most importantly, with all the new knowledge we have acquired as we conducted
and accomplished or case study about condyloma acuminata, we were able to
ameliorate our nursing skills, hence, enabling us to be efficient and effective in
performing and delivering nursing care and interventions appropriate for the client
with condyloma acuminate and other related sexually transmitted disease. All the
nursing objective of this case study as enumerated in the introduction were met and
attained
X. Recommendations
We, as student nurses, should be proficient in performing our tasks and
responsibilities. We should never take for granted even the simplest tasks that we are
to perform when handling patients. Learning how to adjust in circumstances that are
unexpected should be learned by every nursing student. This could be developed by
reading books and being assertive in learning new things. Each clinical exposure and
lecture that we have should be considered a new learning experience because through
this, we would improve not only our academic and clinical competency but also our
values and attributes as well.
A broad continuum of skills and knowledge is needed in order to be flexible,
efficient and effective in performing nursing interventions and health teachings nor
only in patients with condyloma acuminate but also with patients having other
ailments as well. The knowledge of a nurse should not only be limited to what is
currently existing, but to what is important in the nursing practice. As nurses, we
should be concerned of the importance of preventive, curative, and rehabilitative
treatment approaches. More importantly, we should show more importance in
promoting preventive measures because, as factually known by the many, “Prevention
is better than cure”. We should also be able to learn the art of consolidating the 3 H’s
of nursing, the head, the hands, and the heart. If this art is developed by all nursing
students, nurses, and other medical-related professionals, there will be a remarkable
change in the medical field service.
VII. CLIENT'S DAILY
PROGRESS

DAYS ADMISSION DAY 1 DAY 2 DAY 3 DAY 4 DISCHARGE


7/18/2006 7/19/2006 7/20/2006 7/21/2006 7/22/2006 7/23/2006
Nursing Problems
1
2
3
4
5
6
Vital Signs
PR 92 bpm 90 bpm 85bpm 73 bpm 84 bpm 83 bpm
RR 24 bpm 23 bpm 20 bpm 23 bpm 22 bpm 21 bpm
160/90 160/90 120/80 120/80
BP 180/100 mmHg mmHg mmHg mmHg mmHg 120/60 mmHg
Temp 36.0oC 36.4 oC 38.5oC 36.4 oC 36.0oC 36.3oC
Diagnostic & Laboratory
Procedure
CBC * * *
U/A * *
HbSAg *
CXR *
ECG *
Platelet ct. * *
Medical Management
O2 Inhalation *
Folley Catheter *
D5LRS * *
I&O *
CS *
BTL *
BT-PRBC * *
Excision biopsy *
Drugs
MgSO4 * *
Cefuroxime * * * * * *
Metronidazole * * *
DAYS ADMISSION DAY 1 DAY 2 DAY 3 DAY 4 DISCHARGE
7/18/2006 7/19/2006 7/20/2006 7/21/2006 7/22/2006 7/23/2006
Drugs
Ketorolac *
Famotidine * *
Tranexamic Acid * *
Tramadol * *
Paracetamol * * *
Ranitidine * *
Metochlopramide *
Nifedipine * *
Mefenamic Acid * * * * *
FeSO4 * * * *
Methyldopa * * * *
Diet
NPO *
Gen Liquid to Soft diet *
Soft diet *
DAT * * *
Activity/Exercise
FOB *
CBR *
ambulatory * * * *
XI. BIBLIOGRAPHY

1981. The American Heritage Desk Dictionary. Hughton Mifflin Company


1991. Essentials of Maternity Nursing. 3rd edition. Bobak & Jensen
1993. Nursing 93 Drug Handbook. C & E Publishing Co.
1994. Pathologic Basis of Disease. 5th edition. Cotran, Kumar & Robbins
1996. Handbook of Drugs for Nursing Practice. 2nd edition. Karb, Queener &
Freeman.
2002. Mosby’s Pocket Dictionary of Medicine, Nursing, and Allied Health Sciences.
4th edition. El Sevier (Singapore) PTE LTD, Mary A. Allen et. Al.
2003. Maternal and Child Health Nursing. 4th edition Vol 1 & 2. Lipincott, Williams
& Adele Pillitteri.
2004. Nurses Pocket Guide. 9th edition. F.A. Davis Company, Marlyn E Doenges et
al.
2005. Essentials of Anatomy and Physiology. 6th edition. McGrawhill Companies
INC., Rod R. Seeley et al.
2005. Medical-Surgical Nursing. 7th edition Vol 1 & 2. El Sevier (Singapore) PTE
LTD, Joyce M. Black et. Al.
2005. Bansal’s New Medical Dictionary. A.I.T.B.S Publisher & Distributors (Regd;
Dr. Shiramandau Bansal)

URL’s
http://www.niaid.nih.gov/factsheets/stdhpv.htm
http://www.medicalgeo.com/Med-Diseases-Ci---Cy/Condyloma.html
http://www.5mcc.com/Assets/SUMMARY/TP0222.html
http://www.indiana.edu/~health/hw/hpv.shtml
http://www.total-health-care.com/family-health/condyloma-acuminata.html
http://www.webmd.com/hw/std/tw3555.asp