University of Nueva Caceres

College of Nursing

S/Y 2021-2022

CASE STUDY
OB GYN

Submitted by:

MARK ANGELO V. FERNANDEZ

 CLINICAL DIAGNOSIS

Gravida 5 Para 4 (4014), abnormal uterine bleeding; cervical mass; to consider

malignant; anemia very severe secondary probably acute blood loss; status post
cervical punch

DEFINITIONS:

Anemia

• Is a condition in which the body does not have enough healthy red blood cells,
red blood cells provide oxygen to body tissues.
• Lack enough healthy red blood cells to carry adequate oxygen to your body's
tissues.
• Having anemia, also referred to as low hemoglobin, can make you feel tired and
weak.
• Anemia can be temporary or long term and can range from mild to severe.

Cervical mass

• Before cancer appears in the cervix, the cells of the cervix go through changes
known as dysplasia, in which abnormal cells begin to appear in the cervical tissue.
• Cervical cancer, or cancer of the cervix, begins on the surface of your cervix. It
happens when the cells on your cervix begin to change to precancerous cells.

Cervical punch

• A Cervical Punch Biopsy is carried out to remove and examine these cells more
closely. Tiny tissue samples are taken and sent to the laboratory where they are
tested for cervical cancer or pre- cancerous changes.
• Cervical biopsies can be done in several ways. The biopsy can remove a sample
of tissue for testing. It can also be used to completely take out abnormal tissue. It
can also treat cells that may turn into cancer.

Malignant Cancer

• Cells grow in an uncontrolled way and can invade nearby tissues and spread to
other parts of the body through the blood and lymph system.
PATHOPHYSIOLOGY

Anemia

Cervical cancer
PATIENT’S DATA

Name: Jacob Eva Mae Ava

Age: 36 yrs. old

Sex: Female

Address: Zone 4, Hanawan Ocampo, Camarines Sur

Ward: GYNE Room 9

Educational Status:

Marital Status: Separated

Occupation: N/A

Religion: Roman Catholic

Admitting Diagnosis: Gravida 5 Para 4 (4014); Abnormal uterine bleeding; cervical mass;
to consider malignant; anemia very severe secondary acute blood loss; status post
cervical punch.

Date of Admission: 2/22/23 11:00 am

History: Abdominal pain, (+) bleeding, Dizziness

Past Medical History:

Family History: (+) Hypertension

DIAGNOSTIC

• CBC – This allows your doctor to check for a high white blood cell count, which
may indicate an infection. It Check also for anemia, a condition that causes you to
have fewer red blood cells than usual.
• Punch Biopsy – it involves using sharp tool to pinch off small samples of cervical
tissue.
• Endocervical curettage – Uses a small spoon-shaped instrument (curet) or a thin
brush to scrape a tissue sample for the cervix
• Imaging tests - Tests such as X-ray, CT, MRI and positron emission tomography (PET)
help your doctor determine whether your cancer has spread beyond your cervix.
TREATMENT

Cervical cancer surgery

• Surgery to cut away the cancer only. For a very small cervical cancer, it might be
possible to remove the cancer entirely with a cone biopsy. This procedure involves
cutting away a cone-shaped piece of cervical tissue, but leaving the rest of the
cervix intact. This option may make it possible for you to consider becoming
pregnant in the future.
• Surgery to remove the cervix (trachelectomy). Early-stage cervical cancer might
be treated with a radical trachelectomy procedure, which removes the cervix
and some surrounding tissue. The uterus remains after this procedure, so it may be
possible to become pregnant, if you choose.

• Surgery to remove the cervix and uterus (hysterectomy). Most early-stage cervical
cancers are treated with a radical hysterectomy operation, which involves
removing the cervix, uterus, part of the vagina and nearby lymph nodes. A
hysterectomy can cure early-stage cervical cancer and prevent recurrence. But
removing the uterus makes it impossible to become pregnant.

Radiation

• Radiation therapy uses high-powered energy beams, such as X-rays or protons, to

kill cancer cells. Radiation therapy is often combined with chemotherapy as the
primary treatment for locally advanced cervical cancers. It can also be used after
surgery if there's an increased risk that the cancer will come back.

NURSING RESPONSIBILITIES

• Reviewing the patient’s health history

• Listen to the patient’s fears and concerns, and offer reassurance when
appropriate.
• Watch for complications related to therapy by listening to and observing the
patient.
• Remind the patient to watch for and report uncomfortable adverse reactions.
• Explain the importance of complying with the follow check ups
• Keeping track of laboratory, pathology and imaging studies
• Safely administering medications, fluids and cancer treatments