MRKH Final

DEPARTMENT OF HEALTH
JOSE B. LINGAD MEMORIAL REGIONAL HOSPITAL
NURSING SERVICE
A CLINICAL CASE STUDY OF A PATIENT DIAGNOSED WITH MAYER

ROKITANSKY KÜSTER HAUSER SYNDROME
In partial fulfillment of the requirements of Skills Development Program on the Operating Room
Department
Submitted by:
Jose B. Lingad Memorial Regional Hospital Operating Room Department
Submitted to:
JBLMRH Nursing Service Training and Research
Case Presentation JBL OR Department 2017
TABLE OF CONTENTS
Page
I. Introduction
a. Background of the Study…………………………..…3
b. Significance of the Study…………………………..…4
c. Objectives…………………………………………..…5
II. Assessment
a. History………………………………………………...6
b. Physical Assessment………………………………….11
c. Laboratory and Diagnostic Tests……………………...15
d. Pathophysiology of the case…………………………..20
III. Planning and Implementation
a. Nursing Care Plans……………………………………25
b. Medical and Surgical Management……………………42
c. Progress Notes…………………………………………68
IV. Evaluation
a. Summary of the Findings……………………………..70
b. Conclusions……………………………………………71
c. Learning Derived………………………………………71
V. Appendixes and Sources……………………………………..76
MAYER ROKITANSKY KÜSTER HAUSER SYNDROME 2

I. INTRODUCTION
“The essence of a woman is a gift of God which all of us must appreciate and the origin of a
child is a mother and is a woman. The one who shares love and shows what love, caring,
sharing is all about.” This popular statement from a renowned beauty personality encompasses
the true meaning of what women are. They are associated with childbearing because of this great
responsibility. A duty to carry and bring up a child not only for a couple of months but for a
lifetime. As a young girl reaches the puberty stage, she will become conscious of the different
changes in her body. Often, comparison with another individual of the same age is common and
upon learning that one or more adjustment in her physical attributes is not present, it is the time
that she will seek the assistance of her family and the community.
Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome is a rare disorder that affects women.

The name itself is derived from the last names of subsequent researches interested in the matter:
August Mayer, Karl von Rokitansky, Herman Küster and Georges Hauser, thus the name Mayer-
Rokitansky-Küster-Hauser Syndrome (Gontarczyk et. Al.,2012). It is characterized by the failure
of the uterus and the vagina to develop properly in women who have normal ovarian function
and normal external genitalia. Women with this disorder develop normal secondary sexual
characteristics during puberty (e.g., breast development and pubic hair), but do not have a
menstrual cycle (primary amenorrhea). MRKH syndrome is estimated to affect 1 in 4,000-5,000
women in the general population. It is the second most common cause of primary amenorrhea
(Fontana et. Al., 2016). The disorder is thought to be under diagnosed making it difficult to
determine the true frequency of MRKH syndrome in the general population.
The disorder is congenital but is often not identified until early adolescence. Females with
MRKH have normal ovaries and fallopian tubes. Most often the uterus is absent or tiny. The
vaginal canal is typically shorter and narrower than usual or it may be absent. Sometimes, there
may be one kidney instead of two. About 3% of females diagnosed with MRKH will have a
minor hearing loss and some may have spinal problems such as scoliosis (curvature of the spine).
MRKH patients have “normal external genitalia,” which means that everything on the outside of
the vagina is not affected (Morcel et al., 2007). The most common age for MRKH to be
diagnosed is when a young woman is between 15 and 18 years old. Females with MRKH
syndrome come to the attention of physicians due to the failure of menstrual cycles to begin
during puberty (primary amenorrhea). Some may seek medical attention due to fertility
problems. A diagnosis is made based upon identification of characteristic symptoms, a detailed
patient history, a thorough clinical evaluation and a variety of specialized tests such as
specialized imaging techniques (David et al, 2014). Transabdominal ultrasonography must be the

first investigation. It may be complemented by magnetic resonance imaging (MRI). An

ultrasound can depict the uterus and vagina. It can also be used to evaluate the kidneys.
The treatment of MRKH syndrome is directed toward the specific symptoms that are
apparent in everyone. Treatment may require the coordinated efforts of a team of specialists.
Depending upon the affected individual's age at diagnosis, pediatricians or internists,
gynecologists, kidney specialists (nephrologists), endocrinologist, orthopedic surgeons, plastic
surgeons, physical therapists, psychiatrists and other health care professionals may need to work
together to ensure a comprehensive approach to treatment (Fontana et al., 2016).
Women with MRKH syndrome are encouraged to seek counselling after a diagnosis and
before treatment because the diagnosis can cause anxiety and extreme psychological distress
(Sultan et al., 2009). Psychological support and counselling both professionally and through
support groups is recommended for affected females and their families.Treatment will usually
include appropriate management of the physical findings associated with MRKH syndrome and
psychological support for the emotional issues that often accompany the diagnosis.
Rarity of this disease prompted the researchers to seek additional information that will
contribute to the awareness of the community most especially to the people of Pampanga and
Central Luzon. It is intended to pursue supplementary research studies that will greatly benefit
the said affected population.

OBJECTIVES
GENERAL OBJECTIVE:
The aim of this research inquiry is to be able to gather all the necessary and
applicable knowledge, skills and attitude towards assessing and caring for patients with
Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome and patients who will undergo
diagnostic laparoscopic procedure. Thus, nurses will be able to:
Knowledge:
1. To define Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome;
2. To enumerate the signs and symptoms of the syndrome and the pathologic changes
occurring in the condition;
3. To determine the contrast between the anatomical and physiological structures involved
in the Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome and its pathophysiological
explanation;
4. To describe the diagnostic procedure used, its results and how it is performed;
5. To determine appropriate nursing interventions and medical management of the disease
condition and care indicated;
Skills:
1. To develop rapport with the patient and promote wellness;
2. To strictly follow therapeutic regimen for better improvement/recovery;
3. To prioritize appropriate nursing care plans applicable to the patient’s condition and
render an effective nursing intervention;
Attitude:
1. To perform and maintain effective nurse-patient relationship;
2. To show therapeutic respect and empathy towards the client.
This case study would recuperate and mend the quality of nursing duties and
responsibilities by providing care services harmoniously and in a custom that the patient and
healthcare provider would profit.

II. ASSESSMENT
A. HISTORY
PERSONAL HISTORY
The following is a case of a patient, Ms. A, an eighteen-year-old, single, female
Filipino national. She was admitted with findings suggestive of Mayer Rokitansky Küster
Hauser Syndrome.
Ms. A was born at Orion, Bataan through normal spontaneous delivery. She is
now permanently residing in Pandacaqui, Mexico, Pampanga with her family. She is a
Born-again Christian by religion and is currently attending a University as a sophomore
Tourism student.
FAMILIAL HISTORY
Ms. A is the eldest, and the only female among her four siblings. Her mother,
forty-four years old, is currently unemployed and a housewife. Her father, forty-six years
of age, works as a Hotel maintenance crew. She has 3 brothers ages thirteen, seven, and
four, respectively. The client’s mother stated that their monthly income is approximately
15,000 to 20, 000 pesos.
Subsequently, the client’s mother stated that she met her husband in Orion,
Bataan when she was 26 years old. Both were working in a rubber-shoes factory in
Bataan and conceived our client and her 2 nd eldest son. According to her, they were
exposed in fumes from the rubbers although they wore face masks. Their family moved
to Mexico, Pampanga when the client was in grade 4 elementary level.
Upon interviewing about the significant types of illness or conditions their family or
relatives experienced, the client stated that both her parents did not experience any
illnesses aside from common coughs and colds. On her maternal side, her grandfather
died from colon cancer at the age of 79. On her paternal side, his grandmother is diabetic
and hypertensive, while his grandfather died from a stroke.

HISTORY OF PAST ILLNESSES

Ms. A’s mother stated that the client was born with a small anal sphincter, as the
doctor told her. Hence, the client has difficulty passing stools. According to the client,
she used to drink lactulose in the form of “Biguerlai Tea” to help in her bowel movement.
She stated that she doesn’t have a daily bowel movement pattern. She has no difficulty in
voiding except when she was diagnosed with Urinary Tract Infection when she was in 2 nd
year highschool. Her mother also mentioned that the client has completed all her
vaccines.
Ms. A was hospitalized for 3 times, the first hospitalization was when she was about a
year old due to gastroenteritis. Her second hospitalization was in Kindergarten due to
high fever, chills and convulsion (cause cannot be recalled). Her 3 rd hospitalization is due
to her present case.
The client first experienced left lower quadrant abdominal pain when she was in the 4 th
grade, in which she would not be able to attend school when she suffers from it. She did
not take any medications, instead positioning herself in a fetal position helps to alleviate
the pain. She experiences this type of pain occasionally, especially when she was in
highschool, but she does not seek any medical help. She just observes and rest it until the
pain goes away.
Her mother stated that they thought the delay in their daughter’s menstruation was
normal, because they knew that some girls experience late menarche. She stated that their
cousin also had late menarche. They thought that this delay is just normal, hence, they did
not consult any doctor for it.
Their family is not fond of using medicines or being in the hospital. Hence, they
usually self-medicate with herbal plants like tawa-tawa plant, sambong, and oregano
leaves or consult with local Herbolarios/Quack doctors because hospitalization is costly
so they rely on cheaper ways to take care of their health.
HISTORY OF PRESENT ILLNESS

On September 08, 2017, Friday, the client woke up with a moderate abdominal
pain (pain scale score: 6/10), radiating from the right lower-quadrant of her abdomen.
She thought that this was the usual discomfort that she experiences occasionally. Hence,
she did not go to school and just rested at home to relieve it. She and her mother thought
that it was just UTI, so they prepared a concoction of banaba plant and drank it to relieve
the discomfort. She did the same thing the next day.
September 10, 2017, Sunday, the client stated that she was not able to sleep the
previous night because of the pain (pain scale score 7/10). They brought her daughter to
the nearest hospital in their town to get her urine tested because they thought that it was
UTI. The result came with normal results. They did not consult any doctor to lessen their
expenses and went home.
The night of September 10, 2017, the client stated that the she was not able to
sleep because it is too painful (pain scale score: 8 to 9/10). Her mother observed her that
night and tried to alleviate her pain by giving paracetamol tablets. But to no avail, the
client’s condition worsened.
September 11, 2017, Monday, at 09:00am, her mother brought her to the
Emergency Department of a tertiary hospital in Pampanga. The client’s chief complaint
was pain on her right lower quadrant of her abdomen (pain scale score: 9 to 10/10) and
vomiting. The patient was admitted to the surgery department with an initial diagnosis of
Acute appendicitis. Routine blood exams and urinalysis were done. Upon further
interviews, the patient was found out to have not experienced menarche at her age, which
called for the consultation to the OB-GYN department for clearance.
A pregnancy test, internal examination and abdominal ultrasound were made.

Upon the internal examination, the resident doctor was not able to fully insert her fingers
inside the patient’s vagina. A blind pouch was noted, as well as an intact hymen.
The abdominal ultrasound revealed the absence of a uterus. The controversial
finding opted the resident to call for a consultant to verify the findings. The patient
remained in the care of the surgery department for re-evaluation wherein a physical
examination was again performed.
The patient was returned to the surgery department for re-evalauation. The
client’s mother stated that they waited for the official reading of the ultrasonography
before they could continue with the treatment.

A diagnostic laparoscopy was performed, in which residents from both the

Surgery and OB departments were present. The surgeons noted a normal appendix, and
further exploration of the abdomen confirmed the absence of the uterus.
The patient was then transferred to the care of the OB department in which a further
explorations was made. A partial oophorectomy and cystectomy was done to remove the
pain-causing ovarian cyst.

Family Health Illness History (GENOGRAM) LEGEND:

-MALE
-FEMALE
Stroke
-DECEASED
DM, Colon Cancer Unknown
Hypertension
- IDENTIFIED
PATIENT
REFERENCE:
Kozier and Erb’s Fundamentals of
Nursing
Page 434

B. PHYSICAL ASSESSMENT (IPPA – Cephalocaudal Approach)
Nurse-Patient Interaction (September 13, 2017; Post-Operation)

General Appearance:
Received lying on bed, awake, conscious and in mild distress.
Vital signs as follows:

BP: 100/60 mmHg CR: 105 bpm
RR: 26-28 cycles per minute Temp: 36.1 degree Celsius
Physical Examination:
Neurologic
 In mild distress, conscious
 Responds appropriately
 No history of convulsion
Skin
Inspection:
 brown skin
 generally uniform except in areas exposed to sun
 moderate amount of body hair
Palpation:
 warm to touch
 with good skin turgor
Head
Inspection:
 symmetrical facial movements
 evenly distributed hair, black in color
 has coordinated head movements with no difficulty upon
flexion, extension and rotation.
Palpation:
 rounded
 thick hair
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 no masses and depressions
Eyes
Inspection:
 hair of the eyebrows are evenly distributed
 symmetrically aligned eyebrows
 eyelids close symmetrically
 pink palpebral conjunctiva
 pupils equally round and reactive to light accommodation
Ears
Inspection:
 color same as facial skin
 auricle aligned with outer canthus of eye
 yellowish dry cerumen
Palpation:
 pinna recoils after it is folded
Nose and Sinuses

Inspection:
 no discharge
 nasal septum is intact and in midline
Mouth and Teeth

Inspection:
 dry, brownish-red lips
 pinkish gums
 with complete set of teeth (32 total number, 16 upper, 16 lower)
Neck
Inspection:
 At midline
Palpation:
12
 no palpable lymph nodes
Chest
Inspection:
 symmetrical chest expansion
Auscultation:
 clear breath sounds
Breast
Inspection:
 areolas are dark in color
Palpation:
 no palpable mass
 warm to touch
Cardiovascular
Palpation:
 pulse rate of 84 beats/minute
Auscultation:
 no murmurs
Abdomen
 globular abdomen
 16 bowel sounds per minute
13
Genito-Urinary
 light yellow colored urine
 absence of difficulty in urinating
 urine output: 39 mL/hr
 no vaginal bleeding
 blind-pouch vaginal canal upon internal examination
Musculoskeletal
 joints have no deformities, no tenderness or swelling and
moved smoothly
14
C. DIAGNOSTIC EXAM AND LABORATORY RESULTS

DATE
EXAMINATION/ ORDERED INDICATION RESULT/NORMAL VALUE ANALYSIS AND
PROCEDURE DATE INTERPRETATION
RESULT IN
Result Normal  Hemoglobin is within normal
- To rule out infection Value range.
Complete Blood Date by examining the Hemoglobin: 12.0 – 16.0  Hematocrit is within normal
Count with Ordered: abnormalities in the 13. 4 g/dL range.
Platelet Count 09-11-2017 production, life span Hematocrit: 37.0 – 47.0  Erhythrocytes is within normal
and destruction of 39.9% range.
blood cells.  Neutrophils is within normal
Result In: Erythrocytes: 4.00 – 5.40 range.
09-11-2017 - Ruling out anemia 4.49 10^12/L  Lymphocytes is within normal
by evaluating the WBC: 4.0 – 10.0 range.
hemoglobin content 10.6 10^9/L  Monocytes is within normal
of the blood. Differential Count range
Neutrophils: 55.0 – 65.0  Eosinophils is within normal
64%  Basophils is within normal range.
Lymphocytes: 25.0 – 35.0  Platelet Count is within normal
28.1% range.
Monocytes: 3.0 – 6.0  MCV is within normal range.
4.5%  MCH is within normal range.
Eosinophils: 2.0 – 4.0  MCHC is within normal range.
2.2%  RDW-CV is within normal range.
Basophils: 0.0 – 1.0  RDW-SD is within normal range.
0.3%  WBC is slightly elevated
Platelet Count: 150 - 450
311 10^9/L
MCV: 88.8% 80.0 – 100.0
15
MCH: 29.9 pg 27.0 – 34.0 Interpretation:

MCHC: 33.7 fL 310 – 370 All parameters are normal expect for
RDW-CV: 12.2 % 0.110 – 0.160 White blood cells which is slightly
elevated from the normal. This could
RDW-SD: 39.1 fL 35.0 – 56.0 indicate a problem such as infection,
stress, inflammation, trauma, or
certain disease. This results required
further investigation.
ABO Blood Date To determine the patient’s ABO Typing: “A” The patient’s Blood type is “A” and
Typing with RH Ordered: blood type and RH type RH “positive” therefore the patient is
Typing 09-11-2017 for possible blood RH Typing “Positive” compatible to receive blood types:
transfusion for the O–
Results In: intended operating O+
09-11-2017 procedure. A–
Electrolytes Date - To identify problems Results Normal Values  Sodium is within normal range
Ordered: with the body Sodium: 139. 1 136-145 mmol/L  Potassium is within normal
09-11-2017 electrolytes. Potassium: 3.47 3.5-5.1 mmol/L range.
Chloride: 101.3 98-107 mmol/L  Chloride is within normal range
Result In:
09-12-2017 - To evaluate kidney Interpretation:
function. All parameters are within normal
range.
Parameters Results Interpretation:

Urinalysis Date Ordered: - General screening Color Yellow The color of the urine is normal. The
09-11-17 to detect renal and transparency Slightly Hazy urine has some yellow pigment
metabolic disease. Sugar Negative called urobilin or urochrome
- Albumin Negative that makes it color yellow and
- Diagnosis disorders pH 7.0 (ALKALINE) darker yellow colored urine is
16
of the kidney, Specific Gravity 1.020 most commonly due to

bladder infection, Pus Cells 4-6 /hpf dehydration. The transparency
urinary tract and RBC 1-2/hpf is slightly hazy which is
other metabolic Epithelial Cells Moderate considered as normal, there are
disorders Mucus Threads Rare substances that can be mixed
in the urine that makes it
slightly hazy such as vaginal
discharge. There was no sugar,
no albumin, with normal
specific gravity, pus cell is
within normal range, epithelial
cells are moderate and mucus
threads is rare which are
considered normal.
- Bacteria causing a urinary tract

infection or bacterial
contamination will produce
alkaline urine.
Electro Date - Evaluation of Interpretation:

cardiogram Ordered: syncope, near
09-11-17 syncope and
palpitations.
Result In:
09-11-17 - Evaluation prior to
an operation.
17
18
19
D. PATHOPHYSIOLOGY
THE FEMALE REPRODUCTIVE SYSTEM
The female reproductive system is a series of organs primarily located inside the body and
around the pelvic region of a female that contribute towards the reproductive process. The
human female reproductive system contains three main parts: the vagina, which acts as the
receptacle for the male's sperm, the uterus, which holds the developing fetus, and the ovaries,
which produce the female's ova. The breasts are also an important reproductive organ during the
parenting stage of reproduction.
The vagina meets the outside at the vulva, which also includes the labia, clitoris and
urethra; during intercourse this area is lubricated by mucus secreted by the Bartholin's glands.
The vagina is attached to the uterus through the cervix, while the uterus is attached to the ovaries
via the fallopian tubes. At certain intervals, typically approximately every 28 days, the ovaries
release an ovum, which passes through the fallopian tube into the uterus. The lining of the uterus,
20
called the endometrium, and unfertilized ova are shed each cycle through a process known as
menstruation.
Major secondary sexual characteristics include: a smaller stature, a high percentage of
body fat, wider hips, development of mammary glands, and enlargement of breasts. Important
sexual hormones of females include estrogen and progesterone.
Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome
Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome is a disorder that occurs in females and
mainly affects the reproductive system. This condition causes the vagina and uterus to be
underdeveloped or absent, although external genitalia are normal. Affected women usually do
not have menstrual periods due to the absent uterus. Often, the first noticeable sign of MRKH
syndrome is that menstruation does not begin by age 16 (primary amenorrhea). Women with
MRKH syndrome have a female chromosome pattern (46,XX) and normally functioning ovaries.
They also have normal breast and pubic hair development. Although women with this condition
are usually unable to carry a pregnancy, they may be able to have children through assisted
reproduction.
21
When only reproductive organs are affected, the condition is classified as MRKH syndrome type
1. Some women with MRKH syndrome also have abnormalities in other parts of the body; in
these cases, the condition is classified as MRKH syndrome type 2. In this form of the condition,
the kidneys may be abnormally formed or positioned, or one kidney may fail to develop
(unilateral renal agenesis). Affected individuals commonly develop skeletal abnormalities,
particularly of the spinal bones (vertebrae). Females with MRKH syndrome type 2 may also
have hearing loss or heart defects (Fontana L, 2016)
MRKH syndrome affects approximately 1 in 4000 to 5000 newborn girls. The cause of MRKH
syndrome is unknown. The reproductive abnormalities of MRKH syndrome are due to
incomplete development of the Müllerian duct. This structure in the embryo develops into the
uterus, fallopian tubes, cervix, and the upper part of the vagina. The cause of the abnormal
22
development of the Müllerian duct in affected individuals is unknown. Originally, researchers
suspected that MRKH syndrome was caused by environmental factors during pregnancy, such as
medication or maternal illness. However, subsequent studies have not identified an association
with any specific maternal drug use, illness, or other factor. Researchers now suggest that in
combination, genetic and environmental factors contribute to the development of MRKH
syndrome, although the specific factors are often unknown. (Herlin M, 2014)
23
PATHOPHYSIOLOGY (Patient-Based)
SCHEMATIC DIAGRAM
Non-Modifiable Modifiable Factors

Factors N/A
Female
Filipino/Asian
Age- 18y/o
Primordial germ cells

migrate to genital
edge
Primordial gonadal
tissues
XY chromosones
XX chromosomes
No Testosterone
No Androgen
Regression of
Wolffian ducts
Underdeveloped Development of
Mullerian Mullerian
Formation of fallopian
Failure of formation
tubes, uterus 1/3 of
of Uterus and Vagina
vagina
Amenorrhea
Blind pouch of vagina
24
III. PLANNING AND IMPLEMENTATION

A. NURSING CARE PLANS
1. Acute Pain
2. Ineffective Breathing Pattern
3. Risk for Deficient Fluid Volume
4. Disturbed Body Image
5. Deficient Knowledge
25
1. Acute Pain (Post-Operative)
ASSESSMENT NURSING SCIENTIFIC PLANNING NURSING RATIONALE EXPECTED

DIAGNOSIS EXPLANATION INTERVENTIONS OUTCOMES
Subjective: Acute pain Acute pain Short term: Assess nature of Some pain is Short term:
postoperatively is Patient pain (location, expected after Patient has
“Masakit ang multifactorial and verbalizes relief quality, onset, abdominal verbalized relief
lalamunan ko at predominantly of of pain using a frequency, radiation surgery; of pain using a
tyan ko. inflammatory pain rating and duration). Have appropriate pain pain rating
nature from skin scale. the patient rate pain management scale.
Objective: incision and tissue intensity on a scale will provide
damage. Acute (1 to 10 or Faces comfort and
 Guarded pain, which enable patient to
movement usually occurs in move and rest.
response to tissue
 Poor coughing injury, results Long term: Long term:
effort from activation of Patient Note patient’s age, Approach to Patient has
peripheral pain demonstrates weight, coexisting postoperative demonstrated
receptors and effective use of medical or pain effective use of
their specific A alternative pain psychological management is alternative pain
delta and C control conditions, based on control
sensory nerve measures, idiosyncratic multiple measures,
fibers appears sensitivity to variable factors. appears relaxed,
(nociceptors). relaxed, able to analgesics, and able to
rest/sleep and intraoperative rest/sleep and
participates in course. participates in
activities activities
appropriately Review Presence of appropriately
intraoperative record narcotics and
for type of barbiturates in
anesthesia and the patient’s
26
medications system
previously potentiates
administered narcotic
analgesia, while
some inhaled
gases have no
residual effects
Monitor change in Distention of

patient’s perception the abdomen by
of pain associated accumulation of
with abdominal gas and fluid
distention occurs
postoperatively
because normal
peristalsis does
not return until
a few days after
surgery;
distention
stresses suture
lines and causes
pain
Assess vital signs, Changes in

noting tachycardia, these vital signs
hypertension, and often
increased indicate acute
respiration, even if pain and
patient denies pain. discomfort.
Some patients
may have a
27
slightly lowered
BP, which
returns to
normal range
after pain relief
is achieved
Assess causes of Discomfort can

possible discomfort be caused or
other than operative aggravated by
procedure presence of non-
patent
indwelling
catheters, NGT,
parenteral lines
(bladder pain,
gastric fluid and
gas
accumulation,
and infiltration
of IV fluids or
medications).
Assist the patient to May relieve

a comfortable pain and
position enhance
circulation.
Semi-Fowler’s
position relieves
abdominal
muscle tension
and stress on
suture lines
28
Use non- This helps

pharmacological reduce
treatment measures perception and
such as deep sensation of
breathing. pain
Administer pain Patients have

medications as individualized
ordered and pain-tolerance
document patient’s levels, and not
response to pain- all will be made
relieving measures comfortable
with standard
doses.
Individualized
differences must
be recognized.
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2. Ineffective Breathing Pattern

Subjective: Ineffective Most patients who Short term: Assess respiratory Respiratory rate Short term:
N/A Breathing undergo surgical After an hour rate, rhythm and and rhythm The patient
Pattern related procedures of nursing depth changes are shall have
Objective: to abdominal experience acute interventions, early warning established an
incision pain postoperative the patient will signs of effective
 Tachypnea pain. A patient be able to impending respiratory
(post- who underwent establish an respiratory pattern, free of
extubation) with abdominal effective difficulties cyanosis and
a respiratory surgery, the pain respiratory other signs of
rate of 26-28 may be worse pattern, free of Auscultate lung The bases of the hypoxia.
cpm upon movement, cyanosis and sounds at least every lungs are least
especially of the other signs of 4 hours for the first likely to be
abdomen. During hypoxia. 48 hours ventilated, Long term:
 Shallow respiration, the postoperatively therefore lung The patient’s
respirations abdominal sounds may be breathing
muscles contract Long term: diminished over pattern is
which can cause After 3-4 hours the bases effectively
 Poor coughing pain in the of nursing maintained as
effort incision site interventions, evidenced by
Observe for Splinting refers
which then results the patient’s splinting to the conscious eupnea,
to the patient breathing minimization of (RR=12-
having shallow pattern is an inspiration to 20cpm), non-
breaths to prevent effectively reduce the labored deep
much movement maintained as amount of respirations,
of the abdominal evidenced by discomfort clear lung
muscles. eupnea, caused by full sounds, normal
(RR=12- expansion skin color, with
20cpm), non- no complaints
30
labored deep Assess for Distention can of dyspnea.

respirations, abdominal impair thoracic
clear lung distention excursion and
sounds, normal result in an
skin color, with ineffective
no complaints breathing
of dyspnea. pattern
Position patient with This position

head of bed elevated puts the least
to 30 degrees strain on the
abdominal
muscles and
enhance
diaphragmatic
expansion
Encourage or assist This will aid in

the patient to turn mobilizing
side-to-side every 2 secretions by
hours. using gravity to
increase
drainage
Teach and Deep breathing

encourage deep- keeps alveoli
breathing exercises from collapsing,
and coughing and coughing
clears the
bronchial tree of
secretions
Help the patient Splinting the
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splint the abdomen abdomen eases

by using hand or the discomfort
pillow of coughing and
deep breaths
Administer oxygen Promotes

as ordered oxygenation of
the tissues
Manage pain with This will aid the

the ordered pain patient’s ability
medications to tolerate and
participate in
activities and
health teachings
32
3. Risk for Deficient Fluid Volume

Risk Factors: Risk for Patients who have The patient will Measure and record Accurate The patient has
Deficient Fluid will undergo or be able to I&O documentation maintained
 Restriction of Volume have undergone a maintain helps identify normal fluid
oral intake surgical normal fluid fluid losses or volume
(NPO) procedure are at volume replacement balance, as
risk for fluid balance, as needs and evidenced by
 Loss of fluids volume deficit or evidenced by influences stable vital
from blood loss hypovolemia stable vital choice of signs, palpable
in surgery or which can occur signs, palpable interventions pulses of good
postoperative from a loss of pulses of good quality, good
bleeding
body fluid or the quality, good Monitor and report This may occur skin turgor,
shift of fluids into skin turgor, any postoperative from any vessel moist mucous
the third space. moist mucous bleeding in the dissected membranes and
membranes and area, usually individually
 Vomiting individually seen as appropriate
appropriate increased blood urine output
urine output drainage on
dressing
Asses hydration Hypotension

status: and/or
Monitor BP and HR tachycardia may
indicate fluid
volume deficit
Check mucous Increasing thirst

membranes, skin and a coated
turgor and thirst tong may occur
33
with fluid
volume deficit
Monitor urine output Output of

30mL/hr
indicates
adequate
hydration
Administer IV fluids IV fluids are

as ordered prescribed to
correct fluid
volume deficit
and maintain
fluid balance
postoperatively
34
4. Disturbed Body Image

Subjective: Disturbed body A woman’s sexual Short term: Assess meaning of The extent of Short term:
image related identity and self- After 3-4 hours loss or change to response is The patient has
“babae ako pero to congenital esteem is closely or nursing patient and SO, more related to verbalized
hindi ko man infertility connected with interventions, including future the value or feelings related
mararanasan secondary to their reproductive the patient will expectations and importance the to the situation
magbuntis kasi congenital capability and is be able to impact of cultural or patient places in
wala ako matris” absence of a reinforced by social verbalize religious beliefs. the part or Long term:
reproductive expectations feelings related function than The patient has
Objective: organ. concerning the role to the situation the actual value demonstrated
N/A of a female. or importance. enhanced self-
The feeling of Long term: This esteem as
being unable to After 2-3 days necessitates evidenced by
fulfill socially of nursing support to work the ability to
accepted functions interventions, through to verbalize
such as the patient will optimal positive
menstruation, be able to resolution. statements
sexual relations and demonstrate about body and
motherhood can enhanced self- Assess the result of Adolescents and self, and talk
cause serious esteem as body image young adults about the
damage to a evidenced by disturbance in may be acceptance of
woman’s self- the ability to relation to the individually altered
image. verbalize patient’s affected by function with
 positive developmental stage changes in the the family,
 statements structure or significant
about body and function of their other and
self, and talk bodies at a time healthcare
about the when provider.
acceptance of developmental
35
altered changes are

function with normally rapid
the family, and at a
significant time when
other and developing
healthcare social and
provider. intimate
relationships is
particularly
important.
Acknowledge and Acceptance of

accept expression of these feelings as
feelings of a normal
frustration, response to
dependency, anger, what has
grief, and hostility. occurred
Note withdrawn facilitates
behavior and use of resolution. It is
denial. not helpful or
possible to push
patient before
ready to deal
with situation.
Denial may be
prolonged and
be an adaptive
mechanism
because patient
is not ready to
cope with
personal
problems.
36
Exhibit positive Positive

caring in routine remarks by the
activities nurse may
encourage the
patient develop
more positive
responses to the
changes in his
or her body
Be realistic and This enhances
positive during trust and rapport
treatments, in health between patient
teaching, and in and nurse
setting goals within
limitations.
Encourage family A good

interaction with each conversation
other provides
ongoing support
for patient and
family.
Provide support Support groups
group for SO. Give promotes
information about ventilation of
how SO can be feelings and
helpful to patient. allows for more
helpful
responses to
patient
Refer to physical These are
37
and occupational helpful in

therapy, vocational identifying
counselor, ways/devices to
psychiatric regain and
counseling, clinical maintain
specialist psychiatric independence.
nurse, social Patient may
services, and need further
psychologist, as assistance to
needed resolve
persistent
emotional
problems
38
5. Deficient Knowledge

DIAGNOSIS EXPLANATIO INTERVENTION OUTCOMES
N S
Subjective: Deficient A deficit in Short term: Assess ability to Cognitive Short term:
Knowledge knowledge is After 3-4 hours learn or perform impairments must The patient has
“Paano ako related to commonly or nursing desired health- be recognized so an showed
nagkaroon ng emotional experienced by interventions, related care appropriate motivation to
ganitong sakit?” state affecting individuals the patient will teaching plan can learn about
learning coping with new be able to show be outlined. condition and
Objective: medical motivation to management.
N/A diagnosis varied learn about Assess motivation Learning requires
pharmacologic condition and and willingness of energy. Patients Long term:
and treatment management. patient to learn. must see a need or The patient has
regimens, purpose for identified
unfamiliar and Long term: learning. They also sources that
often complex After 2-3 days have the right to can be used for
problems, as well of nursing refuse educational more
as by individuals interventions, services. information
entering stages or the patient will and will be
role relationships be able to Determine priority This is to know able to identify
that demand new identify of learning needs what needs to be support
pattern of sources that within the overall discussed systems
response. can be used for care plan. especially if the
more patient already has
Some patients information a background about
may have access and will be the situation.
to information or able to identify Knowing what to
know where to support prioritize will help
seek it, others systems prevent wasting
39
may have valuable time.

providers who
are not teaching Observe and note Assessment
them or who existing provides an
cannot be misconceptions important starting
understood. This regarding material point in education.
lack of an open to be taught. Knowledge serves
information, to correct faulty
flowing ideas.
relationship with
provider often Render physical Based on Maslow’s
causes the client comfort for the theory, basic
to misinterpret patient. physiological needs
information or must be addressed
forget it because before the patient
of the disuse/ education. Ensuring
lack of physical comfort
reinforcement for allows the patient
correct use. to concentrate on
what is being
discussed or
demonstrated.
Consider what is Allowing the

important to the patient to identify
patient. the most significant
content to be
presented first is
the most effective.
Provide clear, Patients are better

thorough, and able to ask
40
understandable questions when

explanations and they have basic
demonstrations information about
what to expect.
41
B. MEDICAL AND SURGICAL MANAGEMENT

Brand Name/ DATE GENERAL ADVERSE REACTIONS/ NURSING RESPONSIBILITIES
Generic Name ORDERED / DESCRIPTION /
DATE INDICATION
GIVEN /
DATE
CHANGED
Brand: (Taladine, Date Mechanism of action: Adverse Reaction:

Nursing Responsibilities:
Zantac) ordered:
09-11-17  Blocks histamine  Headache, dizziness, rarely · Check doctors order
Generic: H2- receptors in the hepatitis, thrombocytopaenia,
Ranitidine stomach and leucopaenia, hypersensitivity, · Observe 10 R’s in giving medication
prevents histamine- confucion, gynecomastia,
Classification: mediated gastric impotence, somnolence, · Assess patient for epigastric pain or
Anti- Ulcer acid secretion. It vertigo, hallucinations abdominal pain and frank or occult
does not affect
pepsin secretion, blood in the stool, emesis, or gastric
Potentially fatal:
pentagstrin- aspirate.
Anaphylaxis, hypersensitivity
stimulated factors
reaction
or serum gastin. · Inform patient that it may cause
 Has some dizziness or drowsiness.
antibacterial action
against H. pylori. · Inform patient that increase fluid
and fiber intake may minimize
Indication:
constipation.
 Treatment and
prevention of
· Advice patient to report onset of
heartburn, acid
42
indigestion, and black, tarry stools; fever; sore

sour stomach
throat; diarrhea; dizziness; rash;
confusion; or halloucination to
health care professional promptly.
· Document
Brand: Date Mechanism of Action: Adverse Reaction:

Mefoxin Ordered: Nursing Responsibilities
09-11-17  Inhibits bacterial cell  Hypersensitivity reactions;  Check doctors order
Generic: 09-12-17 wall synthesis by elevated serum creatinine and  Observe the 10 Rs of drug
Cefoxitine binding to 1 or more or BUN concentrations, anemia, administration
of the penicillin- transient increase in serum AST,  Ask for drug allergy
Classification: binding proteins, ALT, LDH and alkaline  Perform skin testing
Cephalosporins, 2nd which in turn inhibit phosphatase levels; jaundice;  Advise patient to report signs of
Generation the final thrombophlebitis. Rarely allergy
transpeptidation oliguria, renal toxicity,  Instruct patient to notify
step of neutropenia, transient healthcare professional if fever
peptidoglycan leucopenia, granulocytopenia, and diarrhea develop, especially
synthesis in the thrombocytopenia, bone if stool contains blood, pus, or
bacterial cell walls, marrow depression; nausea, mucus.
this inhibiting cell vomiting, diarrhea  Alcohol and alcohol-containing
wall biosynthesis medications should be avoided
and arresting cell during and for several days after
wall assembly therapy.
resulting in bacterial  document
cell death.
43
Indication:
 Gynecological
Infection including
endometritis, pelvic
cellulites, and pelvic
inflammatory
disease caused by
E.choli, Neisseria
Gonorrhea.
 UTI caused E.choli,

klebsiella species,
hemophilus
infleunzae, and
Bacteriodes species
Metoclopramide Date Mechanism of Action: Adverse Effect: Nursing Responsibilities:

Ordered:  Dopamine  Depression (with suicidal  Inject Iv slowly over 1-2 mins to
09-12-17 antagonist that acts ideation), seizures, prevent transient feeling of
by increasing agranulocytosis, hypotension. anxiety.
sensitivity to  Not reaction for therapy
acetylcholine;  Assess abdomen bowel sounds,
Indication:
results in increase distention and Nausea and
To prevent post operative nausea and
motility of the Vomiting.
vomiting
upper GI tract and
relaxation of pyloric Contraindication:
spincter and Concurrent use of butyrophenones
duodenal bulb. phenothiazines, or other drugs that
44
may cause extrapyramidal reactions;

GI hemorrhage, mechanical
obstruction, or perforation;
hypersensitivity to metocplopramice
or its components; seizure disorders.
Ketorolac Date Mechanism of action: 1. Adverse Effect:  Nursing Responsibilities:

Ordered: Anti-inflammatory and 2. Respiratory:  assess first the patient before
09-12-17 analgesic activity; inhibits
3. rhinitis, hemoptysis, dyspnea administering this drug: know
prostaglandins and
the history (e.g. allergies, renal
leukotriene synthesis. 4.
5. GI: GI pain, diarrhea, vomiting, impairment, etc.) and physical
nausea condition of the patient
6. (reflexes, ophthalmologic and
7. CNS: dizziness, fatigue, insomnia, audiometric evaluation,
headache orientation, clotting times,
serum electrolytes, etc.)
8.
 In case of hypersensitivity, be
9. Hematologic: neutropenia,
sure that emergency equipment
leukopenia, decreased Hgb or Hct,
is available.
bone marrow depression
 Drug vials should be protected
10. Dermatologic: sweating, dry mucous
from light.
membrane, pruritus
 To maintain serum levels and
control pain effectively,
Contraindication: administer it every six hours.
 use cautiously with patients  Report any signs of itching,
who have impaired hearing, swelling in the ankles, sore
allergies, and throat, easy bruising, etc
cardiovascular/gastrointestinal/
hepatic conditions.
 Mothers in labor and delivery
45
who gives breastfeeding to their

baby.
 Patients wear soft contact
lenses.
 Patients who use NSAIDS
simultaneously.
 Patients who have a history of
gastrointestinal bleeding or
peptic ulcer.
 Patients who are suspected or
confirmed cerebrovascular
bleeding.
Celecoxib Date Mechanism of action: NS: Nursing Responsibilities:

Ordered: Exhibits anti- Dizziness, drowsiness, headache, Before:
Class: 09-12-17 inflammatory, analgesic, insomnia, fatigue  Assess patient history of allergic
Non steroidal and anti-pyretic action due reaction to the drug
cyclooxygenase-2 to inhibition of the CV: Peripheral edema  Monitor complete blood count,
(cox-2) inhibitor, enzyme COX-2 electrolytes level, creatinine
anti inflammatory Indication: EENT: clearance, and occult fecal
drug Ophthalmic effects, tinnitus, blood test and liver function
pharyngitis, rhinitis, sinusitis. test.
Indication:
Adjunctive treatment to GI:
decrease the number of Nausea, diarrhea, constipation, During:
adenomatous colorectal abdominal pain, dyspepsia, dry  Instruct patient to take drug
polyps in familial mouth,GI bleeding with food or milk; teach patient
adenomatous polyposis. to avoid aspirin and other
GU: NSAIDs (such as ibuprofen
Menprrhagia
46
Contraindication:
Hypersensitivity to drug Hematologic: After:
sulfonamides or other Deacrease hemoglobin,  Advise patient to immediately
NSAIDs hematocrit,eosinophil report bloody stools, blood in
 Severe hepatic vomit, or signs of symptoms of
impairment liver damage (nausea, fatigue,
 History of asthma or lethargy, pruritus, yellowing of
urticuria eyes or skin tenderness on
 Advance adrenal upper right side of abdomen or
disease flu like symptoms).
 Late pregnancy
 Breast feeding
Butorphanol Date Mechanism Of Action: Adverse Effect: Nursing Responsibility

Ordered:  Know that butorphanol
Classification: 09-12-17 Narcotic agonist-analgesic CNS: Anxiety, confusion, difficulty should be used cautiously, if
Opioid Analgesics; of kappa opiate receptors making purposeful movements, at all, in patients with
Analgesics, Opioid and partial agonist of mu difficulty speaking, dizziness, depression, suicidal tendency,
opiate receptors; inhibits euphoria, floating feeling, headache, history of drug abuse, or
Partial Agonist
ascending pain pathways, insomnia (with nasal form), lethargy, hepatic or renal dysfunction.
which causes alteration in nervousness, paresthesia, sensation  Be aware that butorphanol
response to pain; produces of heat, somnolence, syncope, has a high potential for abuse.
analgesia, respiratory tremor, vertigo  Monitor patient after first
depression, and sedation dosehypotension and syncope
CV: Chest pain, hypotension, may occur.
palpitations, tachycardia,  Take safety precautions
Indication: vasodilation because butorphanol causes
To manage pain CNS depression.
EENT: Blurred vision, dry mouth,
47
Contraindication: ear pain, epistaxis, nasal congestion

Hypersensitivity to or irritation (with nasal form),
butorphanol or its pharyngitis, rhinitis, sinus
components (including the congestion, sinusitis, tinnitus,
preservative unpleasant taste
benzenthonium chloride)
GI: Anorexia, constipation,
epigastric pain, nausea, vomiting
RESP: Apnea, bronchitis, cough,

dyspnea, respiratory depression,
shallow breathing, upper respiratory
tract infection
SKIN: Clammy skin, pruritus
Anesthesia Agents
Fentanyl Date Given: Mechanism of Action: Adverse Effect: Nursing Interventions:
09-12-17 Binds to opioid receptors CNS:  Monitor patients respiratory
Class: sites in the CNS, altering Agitation, amnesia, anxiety, asthenia, status closely, especially during
Opioid perception of and ataxia, confusion, delusion, the first 24 hours after therapy
emotional response to depression, dizziness, drowsiness, starts or with dosage increases,
pain by inhibiting euphoria, fever, hallucinations sever hypo-ventilation may
ascending pain pathways. occur without warning at
Fentanyl may alter CV: anytime during therapy.
neurotransmitter release Asystole, bradycardia, cheast pain,
from afferent nerves edema, hypotension, orthostatic  Implement cardiac monitoring
responsive to painful hypotension, tachycardia
as ordered and assess heart
stimuli, and it causes
rate and rhythm frequently
respiratory depression by EENT:
during therapy.
acting directly on Blurred vision, dental caries, dry
48
respiratory center in the mouth, gum-line erosion,

brain stem. laryngospasm, rhinitis, sneezing, tooth
loss.
Indication: GI:
To induce and or maintain Anorexia, constipation, elevated
anesthesia serum amylase levels, ileus,
indigestion, nausea, spasm of the
spincter of Oddi, vomiting.
Contraindication: GU:
Hypersensitivity, Anorgasmia, decreased libido,
intermittent pain, opioid ejaculatory difficulty, urinary
nontolerance, significant hesitancy, urine retention.
respiratory depression
treatment or mild to RESP:
moderate pain responsive Apnea, depressed cough reflex,
to nonopioid drugs, upper dyspnea, hypoventilation, respiratory
airway obstruction. depression.
Skin:
Doaphoresis, exfoliative dermatitis,
localized skin redness and swelling,
pruritus, rash
Others:
Anaphylaxis, drug tolerance, physical
or psychological dependence with
long-term use, weigh loss.
Propofol Date Given: Mechanism Of Action: Adverse Effect: Nursing Interventions:
09-12-17 Decrease cerebral blood CV:  Monitor patient for propofol
flow, cerebral metabolic Bradycardia, hypotension infusion syndrome, especially
49
oxygen consumption, and with prolonged high-dose

intracranial pressure and GI: infusions. It may cause severe
increase cerebrovascular Nausea and Vomiting metabolic acidosis,
resistance, which may hyperkalemia, lipemia.
play a role in propofols MS:
hypnotic effects. Involuntary muscle movement
(transient)
Indication: RESP:
To provide sedation for Apnea
critically ill patient in
intensive care, induction Other:
and maintenance of Anaphylaxis, injection-site burning,
anesthesia. pain or stinging.
Contraindication:
Hypersensitivity to
propofol or its
components, to egg or egg
products, or to soybeans
or soy products.
Atropine Sulfate Date Given: Mechanism of Action: Adverse Effect: Nursing Interventions:
09-12-17 Inhibits acethycholine’s  Assess for symptoms of toxic
muscarinic action at the CNS: Agitation, amnesia, anxiety, doses, such as agitation,
neuroeffectors junctions ataxia, Babinski’s or Chaddock’s
confusion, drowsiness, and
of smooth muscles, reflex, behavioral changes, CNS
extreme excitement, which are
cardiac muscles, exocrine stimulation (at high doses), coma,
likely to affect elderly patients
glands, SA and AV nodes, confusion, decreased concentration,
even with low doses. If
and the urinary bladder.in decreased tendon reflexes, delirium,
dizziness, drowsiness, fever, symptoms occur, take safety
small doses, stropine precaution.
inhibits salivary and hallucinations, headache,
50
bronchial secretions and  Assess bowel and bladder

diaphoresis. In moderate hyperreflexia, insomnia, lethargy, elimination. Notify prescriber
doses, it increases impulse mania, mental disorders, nervousness,
of constipation, diarrhea,
conduction though the AV paranoia, restlessness, seizures,
urinary hesitancy, or urine
node and increases heart somnolence, stupor, syncope, vertigo,
retention.
rate. In large doses, it weakness
decrease GI and urinary CV: Arrhythmias, bradycardia (at low
tract motility and gastric doses), cardiac dilation, chest pain,
acid secreation. hypertension, hypotension, left
ventricular failure, MI, palpitations,
Indication: tachycardia (at high doses), weak or
To reduce respiratory tract impalpable peripheral pulses
secretions related to
anesthesia. EENT: Acute angle-closure
glaucoma, altered taste, blepharitis,
blindness, blurred vision,
conjunctivitis, cyclophoria,
cycloplegia, decreased visual acuity
or accommodation, dry eyes or
conjunctiva, dry mucous membranes,
dry mouth, eye irritation, eyelid
crusting, heterophoria, increased
intraocular pressure,
keratoconjunctivitis, lacrimation,
laryngitis, laryngospasm, mydriasis,
nasal congestion, oral lesions,
photophobia, pupils poorly reactive to
light, strabismus, tongue chewing
GI: Abdominal distention, abdominal
pain, bloating, constipation, decreased
bowel sounds or food absorption,
51
delayed gastric emptying, dysphagia,

heartburn, ileus, nausea, vomiting
GU: Bladder distention, enuresis,
impotence, polydipsia, urinary
hesitancy, urinary urgency, urine
retention
MS: Dysarthria, hypertonia, muscle
twitching
RESP: Bradypnea, dyspnea,
inspiratory stridor, pulmonary edema,
respiratory failure, shallow breathing,
subcostal recession, tachypnea
SKIN: Cold skin, cyanosis, decreased
sweating, dermatitis, flushing, rash,
urticaria
Other: Anaphylaxis, dehydration,
injection-site reaction, sensations of
warmth
Midazolam Date Mechanism of Action Adverse Effects Nursing Interventions

administered Benzodiazepine, it works Depending on its dose, midazolam  Inspect insertion site for
09-12-17 in the central nervous can cause any stage of a redness, pain, swelling, and
system to decrease cardiovascular and respiratory other signs of extravasation
anxiety, produces sedation depression. High i.v. doses have during IV infusion.
and induces amnesia. caused cardiac and respiratory arrest  Monitor for hypotension,
with lethal consequences. Usual doses especially if the patient is
normally cause a minor decrease of premedicated with a narcotic
52
the blood pressure and oxygen agonist analgesic.

saturation. The amnesia desired, e.g.  Monitor vital signs for entire
for endoscopies, can last much longer recovery period. In obese
than the intervention, sometimes for patient, half-life is prolonged
hours (semiconsciousness). during IV infusion;
Occasionally daydreams with sexual therefore, duration of effects
content occur. In addition to a is prolonged (i.e., amnesia,
multitude of central nervous postoperative recovery).
symptoms (vertigo, dizziness,  Be aware that overdose
headaches, rarely hallucinations, etc.), symptoms include
midazolam can also cause visual somnolence, confusion,
disturbances and nausea. Repeated sedation, diminished
administration (e.g. as a sleeping aid) reflexes, coma, and
leads to tolerance and dependence untoward effects on vital
within weeks; withdrawal syndrome signs.
often occurs if the drug is
discontinued abruptly.
Atracurium Date Mechanism of Action Adverse Effects Nursing Interventions
administered Is an intermediate- General: Allergic reactions  Inspect insertion site for
09-12-17 duration, nondepolarizing, (anaphylactic or anaphylactoid redness, pain, swelling, and
skeletal muscle relaxant responses) which, in rare instances, other signs of extravasation
indicated as an adjunct to were severe (e.g., cardiac arrest) during IV infusion.
general anesthesia, to Musculoskeletal: Inadequate block,  Monitor for hypotension,
facilitate endotracheal prolonged block especially if the patient is
intubation and to provide premedicated with a narcotic
skeletal muscle relaxation Cardiovascular: Hypotension, agonist analgesic.
during surgery or vasodilatation (flushing), tachycardia,  Monitor vital signs for entire
mechanical ventilation. bradycardia recovery period. In obese
patient, half-life is prolonged
Respiratory: Dyspnea, bronchospasm, during IV infusion;
laryngospasm therefore, duration of effects
is prolonged (i.e., amnesia,
53
Integumentary: Rash, urticaria, postoperative recovery).

reaction at injection site  Be aware that overdose
symptoms include
somnolence, confusion,
sedation, diminished
reflexes, coma, and
untoward effects on vital
signs.
Succinylcholine Date Mechanism of Action Adverse Effects Nursing Interventions

administered Ultra short-acting CNS: Muscle fasciculations, profound  Inspect insertion site for
09-12-17 depolarizing-type, skeletal and prolonged muscle relaxation, redness, pain, swelling, and
muscle relaxant, Relaxing muscle pain. CV: Bradycardia, other signs of extravasation
muscles during surgery or tachycardia, hypotension, during IV infusion.
when using a breathing hypertension, arrhythmias, sinus  Monitor for hypotension,
machine (ventilator). It is arrest. Respiratory: Respiratory especially if the patient is
also used to induce depression, bronchospasm, hypoxia, premedicated with a narcotic
anesthesia or when a tube apnea. Body as a Whole: Malignant agonist analgesic.
must be inserted in the hyperthermia, increased IOP,  Monitor vital signs for entire
windpipe excessive salivation, enlarged salivary recovery period. In obese
glands. Metabolic: Myoglobinemia, patient, half-life is prolonged
hyperkalemia. GI: Decreased tone and during IV infusion;
motility of GI tract (large doses). therefore, duration of effects
is prolonged (i.e., amnesia,
postoperative recovery).
 Be aware that overdose
symptoms include
somnolence, confusion,
sedation, diminished
reflexes, coma, and
untoward effects on vital
signs.
54
Intravenous Fluids
PLRS Date Mechanism of Action: Adverse Effect: Nursing Interventions:
(lactated Ringers) ordered:  Provide sources Fever, infection at administration  Monitor patient frequently for:
09-11-2017 of water and site, venous thrombosis, a. Signs of infiltration/
Classification: electrolytes. Their extravasation, hypervolemia sluggish flow.
Isotonic electrolyte content b. Signs of
intravenous resembles that of phlebitis/infection.
Solution the principal ionic c. Well time of catheter
constituents and need tobe replaced.
of normal plasma d. Condition of catheter
and the solutions dressing.
therefore are e. Check the level of the
suitable for IVF.
parenteral f. Correct solution,
replacement of medication and volume.
extracellular losses g. Check and regulate the
of fluid and drop rate.
electrolytes. Calciu
m chloride in water
Change the IVF
dissociates to
provide calcium
(Ca++) and chloride
(Cl−) ions. They are
normal constituents
of the body fluids
and are dependent
on
various physiologic
mechanisms for
55
maintenance of
balance between
intake and output.
Indication:
Extracellular
fluid/electrolytes
replacement
Contraindication:
No known
contraindications. Use
precaution with CHF,
renal insufficiency,
edema states with
sodium retention,
Hyperkalemia, metabolic
or respiratory alkalosis,
DO NOT administer
simultaneously with blood
through same
administration set because
of the likelihood of
coagulation
PNSS Date Mechanism of Action: Adverse Effect: Nursing Interventions:

(.9% Normal ordered: Normal saline is a sterile, -febrile response, infection at the site  Monitor patient frequently for:
Saline Solution) 09-11-2017 nonpyrogenic solution for of injection, venous thrombosis of a. Signs of infiltration/
fluid and electrolyte phlebitis extending from the site of sluggish flow.
56
Classification: replenishlemt. It contains injection, extravasation and b. Signs of

Isotonic antimicrobial agents. hypovolemia. phlebitis/infection.
Intravenous c. Well time of catheter
Solution -pH is 5.0 (4.5-7.0) and need tobe replaced.
- it contains 9 g/L sodium d. Condition of catheter
Chloride with an dressing.
osmolality of 308 e. Check the level of the
mOsmol/L. IVF.
-it contains 154 mEq/L f. Correct solution,
Sodium and Chloride. medication and volume.
g. Check and regulate the
drop rate.
h. Change the IVF solution
Indication:
Used because it has little if needed.
to no effect on the tissues i. Do not connect flexible
and make the person feel plastic.
hydrated preventing
hypovolemic shock or
hypotension.
Contraindication:
Heart failure, pulmonary
edema, renal impairment,
sodium retention
57
Diagnostic Laparoscopy
 It is a surgical diagnostic procedure used to examine the organs inside the abdomen.
 It is a low risk, minimally invasive procedure that requires only small incisions.
 Laparoscopy, uses an instrument called a laparoscope which is a long, thin tube with a
high-intensity light and a high-resolution camera at the front to look at the abdominal
organs.
Indications:
1. Abdominal Pain
Laparoscopy has a role in the diagnosis of both acute and chronic abdominal pain. There are
many causes of abdominal pain. Some of these causes include appendicitis, adhesions or
intra-abdominal scar tissue, pelvic infections, endometriosis, abdominal bleeding and, less
frequently, cancer. It is used in patients with irritable bowel disease to exclude other causes
of abdominal pain. Surgeons can often diagnose the cause of the abdominal pain and, during
the same procedure, correct the problem.
2. Abdominal Mass
A patient may have a lump (mass or tumor), which can be felt by the doctor, the patient, or
seen on an X-ray. Most masses require a definitive diagnosis before appropriate therapy or
treatment can be recommended. Laparoscopy is one of the techniques available to your
physician to look directly at the mass and obtain tissue to discover the diagnosis.
3. Ascites.
The presence of fluid in the abdominal cavity is called ascites. Sometimes the cause of this
fluid accumulation cannot be found without looking into the abdominal cavity, which can
often be accomplished with laparoscopy.
4. Liver disease.
Non-invasive X-ray imaging techniques (sonogram, CT scan and MRI) may discover a mass
inside or on the surface of the liver. If the non-invasive X-ray cannot give your physician
enough information, a liver biopsy may be needed to establish the diagnosis. Diagnostic
laparoscopy is one of the safest and most accurate ways to obtain tissue for diagnosis. In
other words, it is an accurate way to collect a biopsy to sample the liver or mass without
actually opening the abdomen.
5. “Second look” procedure or cancer staging.
Your doctor may need information regarding the status of a previously treated disease, such
as cancer. This may occur after treatment with some forms of chemotherapy or before more
chemotherapy is started. Also, information may be provided by diagnostic laparoscopy before
planning a formal exploration of the abdomen, chemotherapy or radiation therapy.
6. Unexplained infertility
Laparoscopy is a surgical procedure that allows a fertility doctor to see inside of the
abdomen. It also allows the fertility doctor to see abnormalities that might interfere with a
58
woman’s ability to conceive a pregnancy. The most common problems are endometriosis,
pelvic adhesions, ovarian cyst and uterine fibroids.
7. Other.
Some types of Gynecological laparoscopic treatment include:

 Hysterectomy
 Oophorectomy
 Removal of ovarian cyst
 Removal of fibroids
 Blocking blood flow to fibroids
 Endometrial tissue ablation (treatment for endometriosis)
 Adhesion removal
 Reversal of a contraceptive surgery (tubal ligation)
 Burch procedure for incontinence
 Vault suspension (treatment of prolapsed uterus)
Risk of Laparoscopy
 Bleeding
 Infection
 Damage to organs in your abdomen
Less common risks include:
 Complications from general anesthesia
 Inflammation of the abdominal wall
 A blood clot, which could travel to your pelvis, legs, or lungs.
Conditions that increase your risk of complications include:

 Previous abdominal surgeries
- which increases the risk of forming adhesions between structures in the
abdomen, in which it will take much longer and increases the risk of organ injuries.
 Obesity
 Being very thin
 Extreme endometriosis
 Pelvic infection
 Chronic bowel disease
59
The Procedure
During laparoscopy, the surgeon makes a small cut (incision) of around 1-1.5cm (0.4-0.6
inches), usually near your belly button.
A tube is inserted through the incision, and carbon dioxide gas is pumped through the
tube to inflate your tummy (abdomen). Inflating your abdomen allows the surgeon to see
your organs more clearly and gives them more room to work. A laparoscope is then
inserted through this tube. The laparoscope relays images to a television monitor in the
operating theatre, giving the surgeon a clear view of the whole area.
If the laparoscopy is used to carry out a surgical treatment, such as removing your
appendix, further incisions will be made in your abdomen. Small, surgical instruments
can be inserted through these incisions, and the surgeon can guide them to the right place
using the view from the laparoscope. Once in place, the instruments can be used to carry
out the required treatment.
After the procedure, the carbon dioxide is let out of your abdomen, the incisions are
closed using stitches or clips and a dressing is applied.
When laparoscopy is used to diagnose a condition, the procedure usually takes 30-60
minutes. It will take longer if the surgeon is treating a condition, depending on the type of
surgery being carried out.
60
Recovery
After laparoscopy, you may feel groggy and disorientated as you recover from the effects of
the anesthetic. Some people feel sick or vomit. These are common side effects of the
anesthetic and should pass quickly.
You'll be monitored by a nurse for a few hours until you're fully awake and able to eat, drink
and pass urine.
Before you leave hospital, you'll be told how to keep your wounds clean and when to return
for a follow-up appointment or have your stitches removed (although dissolvable stitches are
often used).
For a few days after the procedure, you're likely to feel some pain and discomfort where the
incisions were made, and you may also have a sore throat if a breathing tube was used. You'll
be given painkilling medication to help ease the pain.
Some of the gas used to inflate your abdomen can remain inside your abdomen after the
procedure, which can cause:
 bloating
 cramps
61
 shoulder pain, as the gas can irritate your diaphragm (the muscle you use to breathe),
which in turn can irritate nerve endings in your shoulder
These symptoms are nothing to worry about and should pass after a day or so, once your
body has absorbed the remaining gas.
In the days or weeks after the procedure, you'll probably feel more tired than usual, as your
body is using a lot of energy to heal itself. Taking regular naps may help.
Recovery times
The time it takes to recover from laparoscopy is different for everybody. It depends on factors
such as the reason the procedure was carried out (whether it was used to diagnose or treat a
condition), your general health and if any complications develop.
If you've had laparoscopy to diagnose a condition, you'll probably be able to resume your
normal activities within five days.
The recovery period after laparoscopy to treat a condition depends on the type of treatment.
After minor surgery, such as appendix removal, you may be able to resume normal activities
within two weeks. Following major surgery, such as removal of your ovaries or
kidney because of cancer, the recovery time may be as long as 12 weeks.
Your surgical team can give you more information about when you'll be able to resume
normal activities.
62
Oophorectomy
It is the surgical removal of the ovaries.

Partial oophorectomy or ovariotomy is a term sometimes used to describe a variety of
surgeries such as ovarian cyst removal or resection of parts of the ovaries.[1] This kind of
surgery is fertility-preserving, although ovarian failure may be relatively frequent. Most of
the long-term risks and consequences of oophorectomy are not or only partially present with
partial oophorectomy.
In humans, oophorectomy is most often performed because of diseases such as ovarian
cysts or cancer; as prophylaxis to reduce the chances of developing ovarian cancer or
breast cancer; or in conjunction with hysterectomy (removal of the uterus).
Oophorectomy for benign causes is most often performed by abdominal laparoscopy.
Abdominal laparotomy or robotic surgery is used in complicated cases or when a malignancy
is suspected.
Most bilateral oophorectomies (63%) are

performed without any medical indication, most
(87%) were performed together with a
hysterectomy. Conversely, unilateral
oophorectomy is commonly performed for a
medical indication (73%; cyst, endometriosis, benign tumor, inflammation, etc.) and less
commonly in conjunction with hysterectomy (61%).
Special indications include several groups of women with substantially increased risk of
ovarian cancer, such as high-risk BRCA mutation carriers and women with endometriosis
who also suffer from frequent ovarian cysts.
Bilateral oophorectomy has been traditionally done in the belief that the benefit of preventing
ovarian cancer would outweigh the risks associated with removal of ovaries. However, it is
now clear that prophylactic oophorectomy without a reasonable medical indication decreases
long-term survival rates substantially and has deleterious long-term effects on health and
well-being even in post-menopausal women.
63
Cancer prevention
Oophorectomy can significantly improve survival for women with high-risk BRCA
mutations, for whom prophylacticoophorectomy around age 40 reduces the risk of ovarian
and breast cancer and provides significant and substantial long-term survival advantage. On
average, earlier intervention does not provide any additional benefit but increases risks and
adverse effects.
For women with high-risk BRCA2 mutations, oophorectomy around age 40 has a relatively
modest benefit for survival; the positive effect of reduced breast and ovarian cancer risk is
nearly balanced by adverse effects. The survival advantage is more substantial when
oophorectomy is performed together with prophylactic mastectomy.
It is important to understand that the risks and benefits associated with oophorectomy in the
BRCA1/2 mutation carrier population are different than those for the general population.
Prophylactic risk-reducing salpingo-oophorectomy (RRSO) is an important option for the
high-risk population to consider. Women with BRCA1/2 mutations who undergo salpingo-
oophorectomy have lower all-cause mortality rates than women in the same population who
do not undergo this procedure. In addition, RRSO has been shown to decrease mortality
specific to breast cancer and ovarian cancer. Women who undergo RRSO are also at a lower
risk for developing ovarian cancer and first occurrence breast cancer. Specifically, RRSO
provides BRCA1 mutation carriers with no prior breast cancer a 70% reduction of ovarian
cancer risk. BRCA1 mutation carriers with prior breast cancer can benefit from an 85%
reduction. High-risk women who have not had prior breast cancer can benefit from a 37%
(BRCA1 mutation) and 64% (BRCA2 mutation) reduction of breast cancer risk. These
benefits are important to highlight, as they are unique to this BRCA1/2 mutation carrier
population.
Endometriosis
In rare cases, oophorectomy can be used to treat endometriosis by eliminating the menstrual
cycle, which will reduce or eliminate the spread of existing endometriosis as well as reducing
pain. Since endometriosis results from an overgrowth of the uterine lining, removal of the
ovaries as a treatment for endometriosis is often done in conjunction with a hysterectomy to
further reduce or eliminate recurrence.
Oophorectomy for endometriosis is used only as last resort, often in conjunction with a
hysterectomy, as it has severe side effects for women of reproductive age and a low success
rate.
Partial oophorectomy (i.e., ovarian cyst removal not involving total oophorectomy) is often
used to treat milder cases of endometriosis when non-surgical hormonal treatments fail to
stop cyst formation. Removal of ovarian cysts through partial oophorectomy is also used to
treat extreme pelvic pain from chronic hormonal-related pelvic problems.
Long-term effects
Oophorectomy has serious long-term consequences stemming mostly from the hormonal
effects of the surgery and extending well beyond menopause. The reported risks and adverse
effects include premature death, cardiovascular disease, cognitive impairment or
64
dementia, parkinsonism, osteoporosis and bone fractures, decline in psychological well-

being, and decline in sexual function. Hormone replacement therapy does not always reduce
the adverse effects.
WHO SURGICAL SAFETY CHECKLIST
WHO has undertaken a number of global and regional initiatives to address

surgical safety. Much of this work has stemmed from the WHO Second Global Patient
Safety Challenge “Safe Surgery Saves Lives”. Safe Surgery Saves Lives set about to
improve the safety of surgical care around the world by deﬁning a core set of safety
standards that could be applied in all WHO Member States.
To this end, working groups of international experts were convened to review the
literature and the experiences of clinicians around the world. They reached consensus on
four areas in which dramatic improvements could be made in the safety of surgical care:
surgical site infection prevention, safe anaesthesia, safe surgical teams and measurement of
surgical services.
The checklist essentially identifies three distinct phases of an operation, each

corresponding to a specific period in the normal flow of work: Before the induction of
anesthesia, before the incision of the skin, and before the patient leaves the operating facility.
In each phase, a 'checklist. coordinator' must confirm that the surgical team has completed the
listed tasks before it proceeds with the procedure
65
The intention of such a checklist is to systematically and efficiently ensure that all
conditions are optimum for patient safety, and that all staff are identifiable and accountable,
and errors in patient identity, site and type of procedure are avoided completely. By following
a few critical steps, health care professionals can minimize the most common and avoidable
risks endangering the lives and well-being of surgical patients.
REQUIRED INSTRUMENTS, DEVICES, SUPPLIES, EQUIPMENT

AND FACILITIES
DRAPING:
Folded towels and a laparotomy sheet
EQUIPMENT/S:
1. Electrical/hydraulic OR table
2. Suction Machine
3. Electrosurgical unit
4. Laparoscopy Tower and instruments
66
ROLES OF A SCRUB NURSE:

 Gathering all equipment for procedure
 Preparing all instruments and supplies using sterile technique
 Maintaining sterility within the sterile field during surgery
 Handling instruments and supplies during the surgery and cleaning up after the case.
 During surgery, the scrub person maintains an accurate count of sponges, sharps and
instruments on the sterile field and counts the same materials with the circulating
nurse before, during and after the surgery.
ROLE OF CIRCULATING NURSE

 Assure that sterility is maintained at all times
 The nurse is responsible in preparing the operating room and the operative site and
assisting the scrub nurse and the anesthesiologist.
 Has also the task of caring for the patient before, during and after s/he is taken in the
operating room.
 Check for the completeness of the specimen forms and labels, observes the scrub team
for perspiration, gives any requested medication, and provides supplies needed.
 Should be alert of any emergency procedures required.
 Counts the instruments used and check if they are complete.
 Sponges are also counted and estimated blood loss noted. Lastly, the circulating nurse
must accompany the patient in the transfer to the post anesthesia care unit.
PERI-OPERATIVE NURSING RESPONSIBLITIES
A. Pre-operative Tasks
1. Check if the general consent was signed during admission in the hospital. A signed
operative permit must also be available before the procedure.
2. Perform physical and psychological assessment on the patient. Determine his/her health
status, obtain baseline data, and determine operative risks. Assess the psychological aspect by
determining the patient’s fears related to surgery as well as the physiologic manifestations of
anxiety.
3. Check if the patient underwent screening tests necessary for the surgery.
4. Preparations done an evening before the procedure:
 Hair removal and/or skin cleansing if needed
 NPO post midnight or six to eight hours before the procedure
 Administer bedtime sedatives if necessary
 Remove nail polish
 Pre-operative visit by the anesthesiologist and the Operating nurse
5. Preparations done before going to the operating room (ward nurse):

 Put a clean hospital gown on the patient.
 Be sure that all jewelries, wigs, dentures, and prosthesis are removed
 Instruct patient to void before giving pre-anesthesia medications.
67
 Administer pre-anesthesia meds.
B. Intra-operative Tasks
1. Place the patient in a supine position; both arms extended on armboards (Nursing
Attendant).
2. Cleanse the site of incision (Surgeon).
3. Drape the patient (Nurse/surgeons).
4. Monitor vital signs (Anesthesiologist).
5. Assist the surgeon as a scrub nurse.
6. Ensure complete count of instruments, sponge, sharps and needles before, during and after
surgery.
C. Post-operative Tasks
1. Admit patient in the post-anesthesia care unit
2. Accompany (circulating nurse) the patient in the transfer from the operating room to the
recovery room making sure to prevent exposure, rough handling, hurried movements, and
rapid changes in position.
2. While on stretcher, cover the patient with blanket and secure with safety belts or restraints
over the elbows and knees if necessary. Side rails should also be up.
3. Obtain data when the patient is in the recovery room such as the time of admission, current
medical diagnosis, surgical procedures performed, agents administered, complications during
surgery, pertinent pre-operative problems, fluids and contraptions and other important details.
68
C. PROGRESS NOTES
a. Nurses’ Intraoperative Record

b. Post-Operative Management
69
9/12/2017 Risk for post- D

6:30pm operative ➢ In from Operating room via roller bed accompanied
complications by nursing attendant on duty
➢ Status post diagnostic laparoscopy and right partial
oophorectomy by cutting of the cystic portion from
ovarian tissue done by Dr. Trojillo, Dr. Clemente,
Dr. Zamora and Dr. Catli under general anesthesia
inducted by Dr. Sucaldito
➢ With intact and dry wound dressing
➢ With Indwelling foley catheter connected to urine
bag draining yellow amber urine at 100 cc in volume
A
➢ Placed on PACU bed no. 7

➢ Hooked to oxygen support via face mask at 5 lpm
➢ Kept head elevated at 30 degrees
➢ Vital signs monitored and recorded
➢ Watched out for hypotension, oxygen desaturation,
bradycardia and profuse bleeding at surgical site
➢ 12 lead ECG post op facilitated as ordered
➢ ECG tracing referred to Dr. Jaybert Sucaldito,
AROD
➢ Noted Normal Sinus Rhythm
➢ Seen and examined by Anesthesia Resident on duty

with orders made and carried out
➢ Aldrete score of 10, not in distress, oxygen saturation
at 99 percent
➢ Facilitated transferring of patient back to ward
➢ Accompanied by Nursing Attendant on duty
R
9/13/2017 Rounds with
➢ BP 110/70 mmHg, HR 84 bpm,
1:45AM Doctor
➢ RR 19 cpm, T 36.9 C
➢ Conscious, coherent, no complaints of chest

tightness and breakthrough pain
➢ No excessive bleeding at surgical site
➢ Endorsed to ward Nurse on duty for continuity of

care.
70
IV. EVALUATION
A. Summary of the Findings

This study attempted to examine the disease condition in relation to Ms. A. It includes the
changes that occurred in the body which were brought about by the condition, as well as
the diagnostic and laboratory tests to come up with the proper diagnosis and assessment
of the patient and the effective management instituted for her care. The following are the
findings of the study:
The subject of the study is Ms. A, an 18-year-old female diagnosed with Mayer-
Rokitansky-Küster-Hauser (MRKH) syndrome. She was admitted on September 11, 2017 due
to right lower quadrant abdominal pain. She has been experiencing occasional abdominal
pain since childhood, but did not seek medical help. Her family believes on alternative ways
of treatment, which brought relief to her pain.
Upon admission, her initial diagnosis was Acute Appendicitis but further evaluation
revealed primary amenorrhea and a blind vaginal pouch. A diagnostic laparoscopy was done
for further assessment which revealed the absence of a uterus and the confirmation of MRKH
syndrome.
Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome is a rare disorder that affects

women which is characterized by the failure of the uterus and the vagina to develop properly
in women who have normal ovarian function and normal external genitalia. MRKH
syndrome is estimated to affect 1 in 4,000-5,000 women in the general population. It is the
second most common cause of primary amenorrhea. The disorder is congenital but is often
not identified until early adolescence. It is diagnosed through imaging techniques such as
Transvaginal ultrasonography and Magnetic Resonance Imaging (MRI). Treatment requires
the coordinated efforts of a team of specialists which are directed towards the promotion of
sexual functions (e.g. vaginoplasty). Counselling after a diagnosis and before treatment is
important because the diagnosis can cause anxiety and extreme psychological distress.
Psychological support and counselling both professionally and through support groups is
recommended for affected females and their families.
71
B. Conclusion
The prevalence rate of Mayer-Rokitansky-Küster-Hauser Syndrome in our country is

merely unrecognized with a vast unapprehensiveness of the inhabitants in our region. The
incidence of this idiopathic syndrome apparently leads to poor outcomes and high cost of
surgical treatment that might have a higher chance of organ donor rejection. Poverty also is
another thing to consider, because people do not have enough knowledge about the presence
of this kind of congenital anomaly. Awareness and early diagnosis will have a huge impact
on the patient’s acceptance of her condition.
Healthcare providers should work with the patient and her family to develop a plan to
help the patient cope up with her condition. Continuity of care for the patient does not end
when she goes home, it will be a lifelong process to prevent psychological instabilities.
C. Recommendation
The case presented an in-depth analysis of Ms. A’s condition which is Mayer-
Rokitansky-Küster-Hauser Syndrome, but before the case venture ends, the researchers deem
to confer the following recommendations.
It is imperative for the patient and her family to understand, if not completely, enough
information regarding the condition that they are dealing with. Based from the information
gathered through this study, it was shown that the patient and her family were not fully aware
of the condition that Patient A was experiencing. In order to gain knowledge regarding a
particular condition, they should consult a doctor so that a proper diagnosis can be made
instead of relying on their own beliefs.
The patient’s family should provide support, comfort and encouragement to help give the
patient strength to cope up with her condition. Together with the patient, the family should
also be involved in the planning of care so that they could ask questions from their health
care provider regarding some of the information that is not clear to them. They should also
inquire about possible treatment options so that they would be able to choose whichever will
be suitable for them. By doing such, they will have an involvement in their care, thus leading
to cooperation and arriving to attainable outcomes.
The most serious concerns for a woman with MRKH syndrome are the unlikelihood of
72
having biological children and vaginal sexual intercourse.
An essential element of care provided to those women is cooperation with a psychologist.

Psychologists need to be involved in four critical periods, which are: the diagnosis of the
malformation, vaginoplastic surgery (formation of vagina), entering a relationship with a man
and starting a family. It is important that upon the diagnosis of the syndrome the patient
should be referred to additional examinations in which other defects could be discovered.
At present, several methods of surgical and non-surgical treatment of MRKH are

available. Among them is the vaginoplastic surgery, which allows the patient to have her
vagina surgically formed and makes sex life available.
Other alternatives include in vitro fertilization, uterine transplant, surrogacy and adoption.
In an article written by Tim Lewis from The Guardian, he talks about a woman with MRKH
who has undergone a successful uterine transplant from her sister. She was able to conceive
and deliver a healthy baby, and is now pregnant with her second child.
In a Catholic and conservative country, such as the Philippines, alternative methods of

conception is a debatable topic. Surrogacy has been present for a long time and is being
practiced in other developed countries. It should be noted that even in some countries where
surrogacy is allowed, soliciting or brokering for surrogacy is criminalized. This only shows
how this complex phenomenon has turned into an industry. In June 7, 2006, senator Manuel
Villar proposed a bill on surrogate motherhood. The bill proposes to penalize not only
surrogacy arrangement but also the act of selling infants by their mothers, thus, in the
Philippines, the contract of surrogacy is not expressly stated as illegal but it is viewed as
morally and religiously wrong.
Additionally, this case study opens opportunities for further researches. The table below
shows the possible topics for research and an estimated timeline.
73
Possible research Time Frame Steps

titles
 psychological 2 months 1) Conduct continuous, thorough

impact and coping literature review to identify gaps in
strategies among knowledge and experts in the field
women with
2) Identify specific aims of project based
infertility
on your research vision, plan, preliminary
 sexual functioning, data results and literature review results
beliefs about
sexual functioning
and quality of life 1 month 3) Begin drafting proposal budget to
of women with insure project goals can be met
infertility problems
4) Obtain advice/ guidance from
 a survey of colleagues and sponsor sources (e.g.,
infertile women’s program officers)
attitudes towards
4 months 5) Write proposal draft:
surrogacy
-introduction and literature review

 attitude of Filipino
couples towards -research problem
surrogacy
-hypothesis
-type of research design
-respondents and sampling design
-research instruments
-data collection
-data analysis to be used
74
-ethical considerations
6) Put proposal draft aside for a time,

then edit
7) Employ outside readers to review

proposal draft and provide comments
8) Revise the proposal according to the

comments made
3 months 9) Upon approval of the proposal proceed

to obtaining permissions for data collection
10) Start data collection immediately

after obtaining consent
2 months 11) After all data is collected, review for

completeness of data collection instruments
used can be done
12) Encode the data
3 months 13) Data analysis
14) Write the body of the research

(results, discussion and conclusion)
1 month 15) Compile the bibliography
2 months 16) Submit the research project to the

review board of the institution
17) Revise the research project according

to the suggestions of the review board
18) Print final output
75
LEARNING DERIVED
In this case study, the researchers became aware that there is such a case as MRKH.
This syndrome may be present in some women without their knowledge until they reached
their reproductive age. Awareness of this condition is an essential component to take in
consideration by the health providers. As nurses, it is important that adequate knowledge is
present to efficiently render quality services to the affected population most especially it is a
rare disorder. In addition, by pursuing this endeavor, researchers were able to impart
additional data that hopefully will contribute to the development of learning of the institution
they were affiliated. Partaking in this study made them realize further the importance and the
critical role a woman plays in this society, that behind the wonders of motherhood is the
soulful uncertainty that accompanies it.
76
BIBLIOGRAPHY
Fontana L, Gentilin B, Fedele L, Gervasini C, Miozzo M. Genetics of Mayer-Rokitansky-

Küster-Hauser (MRKH) syndrome. Clin Genet. 2017 Feb;91(2):233-246. doi:
10.1111/cge.12883. Epub 2016 Nov 16.
David S. Bombard II and Shaker A. Mousa Gynecol Endocrinol, 2014; 30(9): 618–623. 2014
accessed last October 10,2017 at http://web.a.ebscohost.com/ehost/pdfviewer/pdfviewer?
vid=7&sid=28d752a0-33d0-4365-8681-1989824676e8%40sessionmgr4006
Gontarczyk, K, Kozłowska, D, Kopański, Z. Specyficzne problemy pielęgnacyjne osób z

zespołem Mayera-Rokitańskyego-Küstera- Hausera.Journal of Public Health, Nursing and
Medical Rescue Vol, 1, pp 44-47.2012
Herlin M, Højland AT, Petersen MB. Familial occurrence of Mayer-Rokitansky-Küster-

Hauser syndrome: a case report and review of the literature. Am J Med Genet A. 2014
Sep;164A(9):2276-86. doi: 10.1002/ajmg.a.36652. Epub 2014 Jun 26.
Morcel K, Camborieux L; Programme de Recherches sur les Aplasies Müllériennes, Guerrier

D. Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome. Orphanet J Rare Dis. 2007 Mar
14;2:13.
Sultan C, Biason-Lauber A, Philibert P. Mayer-Rokitansky-Kuster-Hauser syndrome: recent

clinical and genetic findings. Gynecol Endocrinol. 2009 Jan;25(1):8-11. doi:
10.1080/09513590802288291.
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DEPARTMENT OF HEALTH

JOSE B. LINGAD MEMORIAL REGIONAL HOSPITAL

A CLINICAL CASE STUDY OF A PATIENT DIAGNOSED WITH MAYER

MAYER ROKITANSKY KÜSTER HAUSER SYNDROME 2

Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome is a rare disorder that affects women.

MAYER ROKITANSKY KÜSTER HAUSER SYNDROME 3

first investigation. It may be complemented by magnetic resonance imaging (MRI). An

MAYER ROKITANSKY KÜSTER HAUSER SYNDROME 4

MAYER ROKITANSKY KÜSTER HAUSER SYNDROME 5

MAYER ROKITANSKY KÜSTER HAUSER SYNDROME 6

HISTORY OF PAST ILLNESSES

HISTORY OF PRESENT ILLNESS

MAYER ROKITANSKY KÜSTER HAUSER SYNDROME 7

A pregnancy test, internal examination and abdominal ultrasound were made.

MAYER ROKITANSKY KÜSTER HAUSER SYNDROME 8

A diagnostic laparoscopy was performed, in which residents from both the

MAYER ROKITANSKY KÜSTER HAUSER SYNDROME 9

Family Health Illness History (GENOGRAM) LEGEND:

MAYER ROKITANSKY KÜSTER HAUSER SYNDROME 10

B. PHYSICAL ASSESSMENT (IPPA – Cephalocaudal Approach)

Nurse-Patient Interaction (September 13, 2017; Post-Operation)

Vital signs as follows:

 no masses and depressions

Nose and Sinuses

Mouth and Teeth

 no palpable lymph nodes

C. DIAGNOSTIC EXAM AND LABORATORY RESULTS

MCH: 29.9 pg 27.0 – 34.0 Interpretation:

Parameters Results Interpretation:

of the kidney, Specific Gravity 1.020 most commonly due to

- Bacteria causing a urinary tract

Electro Date - Evaluation of Interpretation:

THE FEMALE REPRODUCTIVE SYSTEM

Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome

Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome is a disorder that occurs in females and

(unilateral renal agenesis). Affected individuals commonly develop skeletal abnormalities,

have hearing loss or heart defects (Fontana L, 2016)

syndrome is unknown. The reproductive abnormalities of MRKH syndrome are due to

development of the Müllerian duct in affected individuals is unknown. Originally, researchers

combination, genetic and environmental factors contribute to the development of MRKH

Non-Modifiable Modifiable Factors

Primordial germ cells

III. PLANNING AND IMPLEMENTATION

1. Acute Pain (Post-Operative)

ASSESSMENT NURSING SCIENTIFIC PLANNING NURSING RATIONALE EXPECTED

Monitor change in Distention of

Assess vital signs, Changes in

Assess causes of Discomfort can

Assist the patient to May relieve

Use non- This helps

Administer pain Patients have

2. Ineffective Breathing Pattern

ASSESSMENT NURSING SCIENTIFIC PLANNING NURSING RATIONALE EXPECTED

labored deep Assess for Distention can of dyspnea.

Position patient with This position

Encourage or assist This will aid in

Teach and Deep breathing

Help the patient Splinting the

splint the abdomen abdomen eases

Administer oxygen Promotes

Manage pain with This will aid the

3. Risk for Deficient Fluid Volume

ASSESSMENT NURSING SCIENTIFIC PLANNING NURSING RATIONALE EXPECTED

Asses hydration Hypotension