• A cyst is an abnormal growth that develops as a closed sac somewhere in the body. A dermoid cyst is a specialized type containing many different kinds of tissues including hair, teeth, nerves, bone or fat. It may be present at birth and can be found in the face, spinal cord or skull. It may also develop in the ovary in women during the childbearing years as an ovarian dermoid cyst.

• There are two classifications of ovarian cyst; the functional that involves the normal physiology of ovary and non-functional that is independent from the functions of the ovary. Dermoid ovarian cyst is a non-functional cyst.
• Dermoid ovarian cyst is considered a cystic teratoma, consisting of mixtures of tissues not normally found in ovary that contains mature skin that is complete with sweat glands, hair follicles, pockets of stale blood, fat, bone, cartilages, nails, teeth, and even traces of thyroid tissues.

• It is common among women in pre-menauposal age, those with unhealthy lifestyle like smokers and heavy drinkers, and women with irregular menstrual cycle. • No statistical data available at DOH Region VII and the only available data is the Vicente Sotto Memorial Medical Center 2012 Statistics. Statistically, there were 153 case as of 2012.

• Jan-Dec 2012 total cases of ovarian cysts: 153 Breakdown: Malignant = 42 (27%) Dermoid = 31 (20%) Other types= 80 (52%)

• DATA BASE AND SOCIAL HISTORY: Name Sex Age Civil Status Nationality Religion Address Occupation Date of Admission Time of Admission Height Weight Accompanied by Mode of Admission Vital signs : : : : : : : : : : : : : : : Maria Clara (fictional) Female 36 years old Married ( year of marriage .95 bpm R . Masbate Housewife February 13.130/90mmHg .2001 ) Filipino Roman Catholic Tuburan. 2013 12:15pm 5 feet 3inches 49kgs (107lbs) Cris Ybarra (Husband .20 cpm BP . Cawayan.6C P .fictional name ) Ambulatory T .36.

Melvin Justimbaste .Has client received blood in the past Allergies Food Drug Admitting Diagnosis Attending Physician : No : : No known food allergy : No known drug allergy : Ovarian cyst. bilateral : Dr.

2013) at Masbate Provincial Hospital. Client was diagnosed of Bilateral ovarian cysts in 2008. . Client did not take any pain medication. Two days PTA. Client was also treated for Urinary tract infection during her admission and was prescribed Ciprofloxacin. and nausea and vomiting secondary to gastritis. graded at 6/10. unable to quantify the amount. client complained of a 2-day. yellowish.• CHIEF COMPLAINT AND HISTORY OF PRESENT ILLNESS: Two weeks PTA. Client was prescribed Omeprazole. Her primary care physician told her that no surgery was needed at that time since the size was too small. both lower quadrants. client complained of a 2-day sharp abdominal pain. sharp abdominal pain. graded at 8/10 and was admitted for 4 days (February 1-4. both lower quadrants. BID with very minimal relief. Client unable to recall dose. 20mg. Vomited several times after every ingestion of food but could not recall exactly how many times. BID. on and off. Characteristics of vomitus: watery. Client made few follow-up visits regarding her condition but missed the succeeding follow-up visits because her doctor went out of town and eventually stopped going.

Client unsure whether or not bleeding was medically managed during hospitalization.In November of 2012. In December of 2012. . client was admitted at Masbate Provincial Hospital for 6 days due to vaginal bleeding of two (2) week duration consuming one pad per day and UTI. client had another episode of Urinary Tract Infection with accompanying fever.

PERSONAL AND SOCIAL HISTORY A. husband and 1 year old adopted daughter ) .house is made of wood and metal roofing • Number of rooms :2 • Number of people staying in the house: 3 ( client. Living Conditions • Client and her husband owned a house . has 6 other siblings : none (client had never been pregnant) : 1st year college : carpenter B. Family History Father Mother Note Rank in the family Number of children Educational attainment Occupation of husband : alive : alive : Client is a biological daughter : youngest.I.

.• Note: Client lived in a remote village in the barrio. away from the town proper where public transportation is poorly accessible.

lunch. dinner.7pm • Client had snacks in between meals Usual 24-hour diet Water intake : rice. banana. dried fish.12nn. egg.8am. bread. papaya : 4-6 glasses per da • very seldom drinks other beverages such as soft drinks. pork. fish. juice and coffee • Food likes and dislikes : None .C. vegetables. Nutrition Mealtimes : breakfast.

Sleeping Patterns Nap : 2-3hours per day between 1pm and 4pm • Awaken at night as she had to tend to their adopted daughter • Client snored Comfortable sleeping position : varies ( supine and side-lying ) • Used 2 pillows for comfortable sleeping • Denied any other sleeping abnormality .D.

Elimination Patterns Frequency of bowel movements : once every 2-3days (2-3x/week) Usual time of defecation : morning Consistency : hard Color : brown Amount : 1/4 to 1/2 cup (50-100ml) Note : Frequently experienced constipation Frequency of urination : 7x per day Color : yellow Amount : 50ml .E.

F. Physical Hygiene Frequency of Bathing : once a day Used "SAFEGUARD" brand : daily Used "HEAD AND SHOULDER" brand : as often as necessary : once to twice per day Used "CLOSE-UP" brand Frequency of Shampooing Frequency of handwashing Frequency of Toothbrushing .

as per client.Environmental Sanitation Water source : deep well – for laundry and bathing purified water – for drinking (water is stored in a jar with cover) . they had their own water purifier Mode of human waste disposal Garbage disposal : toilet pit : they burned their garbage at the backyard on a daily basis Note: Client’s house is away from industrial factories .G.

. vegetable gardening Vices: Denied engaging in any vices Denied smoking. Social Activity Sports: None Hobby / Habits: Watching TV.H. drinking alcoholic beverages and gambling NOTE: Client's lifestyle is very laid back.

MEDICAL HISTORY A. Heredo-Familial Disease Diabetes Mellitus Hypertension .maternal side . Communicable Diseases Client denied any communicable diseases occurring in the family. .paternal side B.II.

scanty .November 28.abnormal since the last 10 years ( unable to determine variations ) . 2012 .C.16 years old .frequently experienced dysmenorrhea . Obstetrical and Gynecological Menstruation Onset Duration Cycle Character Discomforts OB score LMP .client had never been pregnant .3-5days .

Previous Illness/Surgery Client denied any other illness not related to the current medical condition except for fever. cough and common cold. .D.

responded to every question asked correctly . COMMUNICATION Subjective: " Wala ra koy problema sa akong panan-aw.SYSTEMS ASSESSMENT A. pandungog ug pag-istorya" as verbalized by the to read fine prints without difficulty using magazines .pupils equal in size (4mm) .able to hear whispered words without difficulty .spoken and understood Cebuano .client did not wear hearing aides .able to hear normal voice tone clearly .(+) PERRLA .client did not wear eyeglasses / contact lenses . Objective: .had slight difficulty identifying letters at a distance more than 10feet .spoken without difficulty .

B. no prominent discoloration . Objective: .breathing is cough .no noise heard during normal breathing .RR. regular .20cpm. OXYGENATION Subjective: " Okay lang ang akong pag-ginhawa. relaxed and effortless .(+) equal chest expansion .(+) resonance on percussion .no adventitious sound on auscultation . dili man ko manigarilyo ug wala pud ko kasulay " as verbalized by the client. wala ra man ko giubo.nailbeds have light pink tones .capillary refill time normal (less than 2 sec) .face and lips evenly colored.

no ankle edema . regular.lower extremity sensation intact on palpation .capillary refill time normal (less than 2 secs) . strong . Objective: . Apical pulse.98bpm.Radial pulse .95bpm. CIRCULATION Subjective: " Wala ra koy gipamati nga sakit ug pamanhod sa akong dughan ug tiil " as verbalized by the client.BP.130/90 mmHg .C.

D5 Normal saline solution .53kgs ( 116lbs ) . Objective: . 1. mahadlok ko mokaon kay ako ra unya isuka.D5 normosol-M .49kgs ( 107lbs ) .consumed 1/2 glass water after having oatmeal .consumed 2 individual packs of skyflakes whole day .on DAT (diet as tolerated) .body weight in Feb. NUTRITION Subjective: " Hangtod karon.did not eat hospital food . 2013 . ninggamay akong timbang " as verbalized by the client. wala ra koy problema sa dentures .always lying in bed .body weight in Feb 13.ate 1/2 cup oatmeal prepared by her husband (5 times a day) .appeared tired and weak .D. naa gihapon panahon nga kasukaon ko. 2013.

Objective: . 50ml in amount .Dulcolax suppository given on Feb. magsige gihapon ko ug ihi-ihi ika-7 sa usa ka adlaw. 2013 . aromatic. kausa pa lang ko nakalibang. 50ml . ganinang alas 830 sa buntag.E. 14. yellow. gahi man gihapon akong ta-e.stool characteristics: hard.(+) dullness on percussion . ELIMINATION Subjective: " Sukad sa akong pagka-admit. wala ray sakit inig pangihi nako" as verbalized by the client.hypoactive bowel sound on auscultation .urine: yellow in color.(+) tenderness on both lower quadrants on palpation .

expressed concerns .decreased appetite . nabalaka gyud ko sa resulta sa operasyon.client always lying in bed .F. MANAGEMENT OF HEALTH AND ILLNESS Subjective: " Namaligya na lang mi ug yuta para ibayad sa hospital ug sa operasyon.weakness . Objective: . wala man gyud ko kasulay anang pap smear ug eksaminasyon sa totoy" as verbalized by the client.compliant with medications during hospital stay .diminished productivity .preoccupied .

skin was dry and warm to touch .no rashes/lesions . Objective: . SKIN INTEGRITY Subjective: " Wala ra man koy problema sa akong panit.presence of IV line on the right wrist turgor normal . wala ra koy mga katol-katol " as verbalized by the client.

RR.H. kapoy ug luya lang gyud akong pamati sa akong lawas " as verbalized by the client. ACTIVITY AND SAFETY Subjective: " Dili ra man ko malipong kung mobangon ug mobarog ko. place and person) .95bpm .though client hesitant to get up and move around.exhibited decreased endurance during activity .able to walk without assistive device but slow paced.V/S : BP-130/90mmHg.observed client always lying in bed joint limitation of movement on active-range-ofmotion . steady gait with supervision for safety . was able to use toilet with supervision for safety . decreased cadence .slow. PR. awake and oriented (time.20cpm.minimal guarded movements . Objective: .

COMFORT / SLEEP / AWAKE Subjective: " Sakit pa gihapon akong tiyan pero madala ra man ( 4/10).exhibited minimal guarded movements during activities .I. RR .observed client always lying in bed .facial expression looked tired .20cpm.client hesitant to smile during interview .observed minimal facial grimaces during movements/activities .130/90mmHg.95bpm . magwala-wala lang ang sakit.V/S : BP . PR . Objective: . panagsa makamata ko inig ka gabii para mangihi " as verbalized by the client.

wala pa lang schedule" as verbalized by the client.observed client not smiling during interview/assessment . gusto man ko magpa-opera.client frequently demonstrated attention-seeking behavior from the husband .client open to questions regarding her medical condition . COPING Subjective: " Nag-guol ko sa akong kahimtang.J. Objective : .observed client dependent on the husband and hesitant to perform ADLs .

HEAD TO TOE ASSESSMENT dandruff and head lice noted . HEAD AND FACE HAIR: .symmetrical.scalp was clean and oily .no involuntary movements noted .shoulder length . erect and in the midline .no visible lesions noted .no lesions HEAD: . round.consistency was hard and smooth without lesion on palpation .hair color was black .

trachea located at the midline .neck movements Within Normal Limits during active range of motion (flexion.symmetrical with an elongated appearance .lower jaw moved laterally both sides B.FACE: .temporal artery non-tender on palpation and pulsation is palpable . cricoid cartilage and thyroid gland moved upward symmetrically during swallowing . non-tender and no crepitation during movement . NECK . lateral flexion and rotation) . extension.the thyroid cartilage.symmetrical with the head at the center and without bulging masses .mouth opened and closed fully .no abnormal movements noted .Temporo Mandibular Joints no swelling.

superficial cervical.pupils equal in size (4mm). tonsillar. occipital. posterior cervical. reactive to light and accommodation (PERRLA) . submandibular. EYES . LYMPH NODES OF THE HEAD AND NECK . post-auricular.the upper and lower eyelids closed easily and met completely when closed .eyelids no redness.sclera is white .eyelashes were evenly distributed .C. deep cervical and supra-clavicular nodes) D. submental. no enlargement and no tenderness on palpation ( preauricular. no swelling. round and centered in the iris .pupils equally round. no lesions .iris round and evenly colored (black) .

complete set of teeth noted .the auricles aligned with the corner of each discharges noted .no repaired or decayed areas . MOUTH .no lesions.light pink .lips are smooth. lumps or nodules is smooth . no lesions/masses . dry and without lesions/swelling . equal in size .color consistent with facial color . EARS . dry and no lesions .no tenderness on palpation F.light pink .tongue.lip color.light pink.gum color.

NOSE .nasal color is consistent with facial color .RR 20cpm .no cough noted . THORAX AND LUNG GENERAL ASSESSMENT discharges . rhythm and depth ) .no lesions/tenderness . effortless and quiet .lips and face evenly colored and no prominent discoloration .nasal structure is smooth and symmetrical .no noise heard during respiration -breathing pattern is normal ( no abnormality in the rate.presence of nasal hairs noted H.nail beds light pink in color .breathing is swelling/flaring .no pain/discomfort during respiration .

POSTERIOR THORAX: .no kyphosis noted .symmetrical chest expansion noted -normal tones elicited on percussion (resonance over lung tissue and flatness over the scapula) .no adventitious sounds noted on auscultation .no masses noted .scapulae are symmetrical and non-protruding .no tenderness/pain or unusual sensations .

no tenderness/pain on palpation .sternum is straight and positioned at midline .no sternal retractions noted .no retractions/bulging of intercostal spaces during respirations .chest color is fairer compared to the rest of the body and without lesions/masses .no masses/lesions .no adventitious sounds noted on auscultation .normal tones elicited on percussion ( resonance over lung tissue and intercostal spaces ) .expansion of the abdomen and lower ribs noted on inspiration and return to resting position on expiration .ANTERIOR THORAX: .symmetrical chest expansion noted .ribs sloped downward with symmetrical intercostal spaces .anteroposterior diameter is less than the transverse diameter .

28 inches (measurement taken at the level of the umbilicus) .smooth and without lesions/rashes .hypoactive bowel sounds noted .umbilical skin tone similar to the surrounding abdominal skin tones .heart sound audible with the use of a stethoscope .umbilicus is located at midline.tenderness elicited on palpation .apical pulse .no scars noted . inverted (recessed) -abdominal contour.palpable masses noted on both lower quadrants .I. protuberant due to the cysts .distended. ABDOMEN . HEART .abdominal is fairer compared to the rest of the body . left side is bigger than the right side .98bpm J.dullness elicited on percussion on both lower quadrants .apical impulse not visible on inspection .abdominal asymmetry noted.

no lesions. nodules . no numbness no joint limitation on AROM against resistance .no lesions. masses.sensation is intact. Hands and Fingers ) .skin color-brown .no swelling . color is brown .no joint limitation on AROM except the right wrist due to presence of IV line tenderness .joints are stable. masses and nodules . no crepitus . LOWER EXTREMITIES ( redness . UPPER EXTREMITIES ( Shoulders. sensation is intact .no swelling . no numbness. redness .K. Knees and Ankles ) .

no fainting spells Headache : Denied occurrence of headache History of Stroke : Denied history of stroke Seizure : Denied occurrence of seizures Mental Status : Oriented x 3 (time. place and person) Memory : Intact both recent and remote memory Client was able to recall both recent and remote events Speech Pattern : Normal Speech pattern No slurring of speech Words are clear and comprehensible Deep Tendon Reflexes : Triceps. Biceps and Patellar Reflexes : 2+ (Normal) .NEURO-SENSORY ASSESSMENT Fainting spells / Dizziness : Denied experiencing dizziness.

2) OPTIC NERVE (CN II) Note : Snellen chart not available Remarks : Client was able to read fine prints without difficulty using magazines. Exhibited difficulty identifying letters at a distance of more than 10feet. Client was able to identify scent correctly (bath soap).CRANIAL NERVES 1) OLFACTORY NERVE (CN 1) Remarks : Intact. Reactive to Light and Accommodation ) . Peripheral vision intact. 3) OCULOMOTOR NERVE (CN III) Remarks : PERRLA ( Pupils Equally Round.

4) TROCHLEAR AND ABDUCENS NERVES (CN IV AND VI) Remarks : Intact cardinal gaze Client able to move each eye upward. Client's eyelids blinked bilaterally when cornea was lightly touched with a fine wisp of cotton. Intact sensory function Client was able to correctly identify sharp and dull stimuli and light touch to the forehead. 5) TRIGEMINAL NERVE (CN V) Remarks : Intact motor function Positive contraction of the temporal and masseter muscles when client clenched her teeth Positive corneal reflex. diagonally and laterally. cheeks and chin. . downward.

Client was able to hear whispered words at a distance of 2feet. Tuning fork not available. Intact Vestibular component. Note : Weber and Rinne Tests not done. Balance was intact. 8) GLOSSOPHARYNGEAL NERVE (CN IX) Remarks : Motor function intact. Gag reflex elicited upon touching the posterior pharynx with a tongue depressor. Sensory function intact. . Client was able to correctly identify coffee and table salt.7) ACOUSTIC NERVE (CN VIII) Remarks : Intact cochlear component. Client was able maintain standing position for 20secs with minimal swaying with feet together and arms on the sides and eyes open and then closed. (-) Romberg test.

put it back in the mouth and move it side to side against resistance. 11) HYPOGLOSSAL NERVE (CN XII) Remarks : Intact Client was able to protrude the tongue. . 10) ACCESSORY NERVE (CN XI) Remarks : Intact Client was able to do shoulder shrugs against resistance. Client was able to swallow without difficulty by drinking a glass of water.9) VAGUS NERVE (CN X) Remarks : Motor and Sensory functions intact.

Laboratory tests and Diagnostic Tests .

0 gm/dL improvement in the value. But based on reference value it’s below normal limit Hct (RBC vol.5 Significance Patient’s Result Feb 14 1:55pm 12 Significance Reference Value Hgb mass conc.0 an 16. Based on reference values it’s within normal limit There shows F: 0. Decreased due to history of blood loss There shows F: 12. fraction) 0.3 Decreased due to history of blood loss 0.36 .37 an 0.47 % improvement in the value.Hematology Laboratory Patient’s Result Feb 13 11:40pm 9.

06 There shows F: 4.Laboratory Patient’s Result Feb 13 11:40pm Significance Patient’s Result Feb 14 1:55pm Significance Reference Value WBC 9.5.8 x 109cells/L RBC 3. it’s within normal limit .25 Within normal limit 10.76 Decreased due to history of blood loss 4.38 Within normal limit 5-10.5 x an 1012 cells/L improvement in the value.0 . Based on reference values.

Based on reference value. it’s within normal limit 140-440 x 109/L .Laboratory Patient’s Result Feb 13 11:40pm Significance Patient’s Result Feb 14 1:55pm Significance Reference Value Thrombocytes (Platelets) 469 Increased due to history of blood loss 410 There shows an improveme nt in the value.

40 Monocytes 0.25 – 0.08 Eosinophils 0.63 Within normal limit Within normal limit 0.Differential Counts Neutrophils 0.67 Lymphocyt es 0.06 Within normal limit No data available 0.05 Within normal limit Within normal limit 0.06 .38 0.01-0.51 – 0.02 0.55 Within normal limit Within normal limit 0.02-0.31 0.

2013 2:45 PM Laboratory Urinalysis Reference Value Significance Patient’s Result Macroscopic: Color Transparency Specific gravity Protein Glucose Yellow Clear 1. 13.02 Negative Negative Yellow Clear 1.03 Negative Negative Normal Normal Within normal limit Normal Normal .003 – 1.Feb.

Microscopic RBC/HPF 0-2 1-2 Within normal limit Increased in UTI Increased in UTI Increased in UTI WBC/HPF 3-6 2-4 Epithelial cells Moderate None Bacteria Abundant None .

Feb. 13, 2013 Laboratory

Creatinine Patient’s Result Reference Value Significance

Creatinine Priority: routine Fluid : serum

0.7 mg/dL


Within normal limit

Feb. 13, 2013 Laboratory

1:00 PM Patient’s Result

Chemistry Reference Value Significance

Glucose (RBS)


70 – 130 mg/dL

Within normal limit

Feb. 13, 2013 1:07 AM

Blood Typing

Laboratory or Diagnostic Testing

Patient’s Result



A To anticipate Blood Transfusion, should the patient need one



2013 Radiology Report Name : Maria Clara Address: Tuburan. Cawayan Masbate Age : 36 years old Gender: Female DOB: 12/19/1976 Conclusion: Negative Chest Favorable . 13.Feb.

Feb. 13, 2013 Laboratory

8:39 AM Patient’s Result

Immunology Reference Value Significance



< 35 U/mL, the generally accepted upper limit


Feb. 123, 2013

4:05 PM

Ultrasound Report
Name : Maria Clara Address: Tuburan, Cawayan Masbate Age : 36 years old Gender: Female DOB : 12/19/1976

Case # : 13-033 Date : 2/13/13


Examination: Whole abdomen LMP : November 28, 2012 Remarks: The right kidney measures 9.6 cm x 4.3 cm. The right renal cortex measures 1.2 cm. Mild hydro-nephrosis The left kidney measures 9.2 cm x 5.4 cm. The left renal cortex measures 1.7 cm Conclusion: Normal liver, Pancreas, GB, Spleen, Left Kidney, Ureters, Urinary Bladder, and Uterus

Mild hydro-nephrosis in the right kidney probably due to infections.

Not favorable

Feb. 14, 2013

12:33 PM Ultrasound Report Gender: Female DOB : 12/19/1976

Name : Maria Clara Address : Tuburan, Cawayan Masbate Age : 36 years old Case # : 035 Date : 2/14/13


Examination: Transvaginal Ultrasound LMP : November 28, 2012 Remarks: Posterior to the uterus and within the right adnexa is a cystic structure measuring 59. x 6.9 x 4.4 cm, thick-walled, unilocular, containing hyperechoic lines and dots. Posterior to the uterus and within the left adnexa is a cystic structure measuring 8.2 x 5.3 x 6.2 cm, thick-walled, multilocular, also containing hyperechoic lines and dots

Impression: Normal-size anteverted uterus with intact trilaminar endometrium Bilateral ovarian cyst, probably dermoid No culdesac fluid

Favorable Not favorable Favorable

Human Anatomy and Physiology .


the ovaries are held suspended and in close contact with the ends of the Fallopian tubes by three strong supporting ligaments attached to the uterus or the pelvic wall. . or with minute indentations on the surface. .Ovaries: . or the size and shape of almonds. the ovaries produce estrogen and progesterone and initiate and regulate menstrual cycles. mature and discharge ova .the function of the two ovaries is to the process.the ovaries are approximately 4 cm long by 2 cm in diameter and approximately 1. . It is difficult to locate them by abdominal palpation because they are situated so low in the abdomen.5 cm thick.Ovaries are located close to and on both sides of the uterus in the lower abdomen. . .they are grayish white and appear pitted.

bean-sized organ that is located at the base of the brain and is connected to the hypothalamus by a stalk.Pituitary Gland is a small. follicle stimulating hormone and luteinizing hormone . The pituitary gland secretes many essential hormones for growth and sexual maturation.• Pituitary Gland . .produces two hormones.


which is termed a corpus luteum -If fertilization does not occur.lutein is high in progesterone and contains some estrogen. the production of progesterone and estrogen decreases. a brightyellow fluid. This yellow fluids fill the empty follicle .the second pituitary hormone. the corpus luteum in the ovary begins to regress after 8 to 10 days. .. It influences the follicle cells to produce lutein. luteinizing hormone continues to rise in amount and acts on the follicle cells of the ovary. As it regresses. .

. • . it's cells produce a clear fluid that contains a high degree of estrogen and some progesterone. a process termed ovulation .the ovum is set free from the surface of the ovary.when the graafian follicle is mature. it is propelled toward the surface of the ovary. A full maturation the small ovum with its surrounding follicle membrane and fluid.every month during fertile period of a women's life.the pituitary gland releases luteinizing hormone that increases the prostaglandin so the graafian follicle ruptures .as it the follicle reaches its maximum size. one of the ovary's primordial follicles is activated by follicle stimulating hormone to begin to grow and mature . is termed a graafian follicle.

Pathophysiology .

Medical-Surgical Management .

13. 2013) -Not done.IDEAL DIAGNOSTICS: •Urinalysis -To identify presence of infection.14.13. •Abdominal Ultrasonography -Allows assessment of other intraabdominal structure. •Transvaginal Ultrasonography -To define cyst’s morphologic characteristics. •CT Scan -Best in imaging the ovarian cysts and distinguish other intra abdominal causes. 2013) -Done (Feb. .2013) -Done (Feb. ACTUAL -Done (Feb.

using a single blood sample. -Not done. 2013) •Laparascopy . .13.and post menopausal women.Evaluates hormonal balance in both pre.for visualization.To identify fat and blood products and provide idea of the organ of origin for gynecological masses. •Hormone Test .IDEAL ACTUAL DIAGNOSTICS: •MRI . lungs and blood vessels. -Not done. •Chest X-Ray -Use ionizing radiation to create pictures of structures inside the chest such as heart. -Done (Feb. •Pregnancy Test -To detect pregnancy -Not done.

14.IDEAL LABORATORY: •Complete Blood Count -To detect any blood dyscrasias. 2013) Done (Feb. •Blood Typing -To identify blood group to anticipate blood transfusion should the patient requires.13. 2013) Done ( Feb. 2013) . 14. ACTUAL Done (Feb. 2013 and Feb. •Creatinine Test -Measures kidney function. 13.

2013) Done (Feb. •D5 NM -Hypertonic solution.IDEAL MEDICATIONS: •Nonsteroidal Anti-inflammatory Drugs (NSAIDS) -Pain reliever. moderate to severe pain. mild to moderate pain •Narcotic Analgesics -Pain reliever.14. for replacement or maintenance of fluid and electrolyte. 13. •D5 NSS -Hypertonic solution. Not ordered. parenteral maintenance of routine daily fluid and electrolyte requirement w/ minimal carbohydrate calories from dextrose. 2013) . ACTUAL Not ordered. Ordered (Feb.

IDEAL MEDICATIONS: ACTUAL •Ranitidine -Anti.2013) once only •Omeprazole -Gastric Anti-secretory agent -Ordered (Feb.2013) . 14.reflux agent -Ordered (Feb. 14. 2013) •Dulcolax Suppository -Laxative -Ordered (Feb.14.

14.IDEAL MEDICATIONS: ACTUAL •Metoclopramide -Anti-emetic agent -Ordered (Feb. 2013) •Ciprofloxacin -Antibiotic -Ordered (Feb. 14. 2013) . 2013) STAT •Metronidazole -antibiotic -Ordered (Feb. 14.

2013) DAT ( DIET AS TOLERATED) .IDEAL TREATMENT: • Blood Transfusion used to replace blood lost. DIET : • Increase fluid intake -fluid and electrolyte replenishing • Foods rich in Protein -to promote tissue repair and healing • Foods rich in Carbohydrates -provide energy for the body ACTUAL Ordered (feb.14.

parenteral maintenance of routine daily fluid and electrolyte requirement w/ minimal carbohydrate calories from dextrose. ACTUAL Done (Feb. 2013) Done (Feb.IDEAL DIET : •Foods rich in Iron -Manage and prevent anemia •Foods rich in Vitamin C -To boost immune system •Foods rich in Vitamin E -antioxidant that protects body tissue from damage caused by substances called free radicals •D5 NM -Hypertonic solution. •D5 NSS -Hypertonic solution.14.2013) .13. for replacement or maintenance of fluid and electrolyte.

. •Colostomy .IDEAL ACTUAL SURGICAL: •Laparatomy -to remove cyst in a large incision.for visualization.provides an alternative channel for feces to leave the body. •TAHBSO ( Total Abdominal Hysterectomy Bilateral Salpingo Oophorectomy) -surgical removal of the affected ovaries and uterus Not done. •Laparascopy .


– – – – – – Safe and Quality Nursing Care Assisted patient during ambulation. upon getting up and in lying down. Given patient enough time to rest in between procedures. Minimized noise to promote comforting/relaxing environment. and in going to the comfort room.A. intake/output and administration of medications. Obtained consent from the patient when taking vital signs. Explained to patient the purpose and/or significance of the procedure done to her present condition like monitoring of vital signs. . Made sure nothing was cluttered on the floor especially where patient is walking around.

.Discussed patient’s medical condition only among healthcare providers involved in the patient’s healthcare management.A. . Avoid gas-forming foods like potatoes and sweet potatoes and carcinogenic foods like grilled and char-broiled foods. – Evaluated patient’s response to medication after 30 minutes of administration. Safe and Quality Nursing Care – Made sure the floor was not wet and/or slippery. – Taught patient and significant other regarding proper hygiene especially stressing on the importance of hand washing to prevent spread of microorganisms that may cause infection. – Stressed on patient and significant other regarding food intake especially foods rich in protein which promotes tissue repair and vitamin C to boost immune system as well as high in fiber to manage constipation.

.B. – Checked IVF patency regularly. Management of Resources and Environment – Took patient’s vital signs as scheduled. – Accompanied patient to the comfort room. – Discarded used needles at the sharp box/receptacles as delegated by the nurse. – Encouraged patient to reposition every 2 hours to prevent respiratory complications.

C. – Documented patient’s vital signs and referred to patient’s baseline data at the patient’s chart for any abnormalities. vitamin C to boost immune system and those rich in fiber to manage constipation.) Avoid gas-forming foods like potatoes and sweet potatoes. Health Education – Taught patient and significant other regarding proper hygiene especially the importance of hand washing to avoid spread of microorganisms that may cause infection. – Reinforced to patient and significant other that patient should eat foods that are rich in protein to promote tissue repair. (At least small frequent feedings. . – Monitored family/client’s response by letting them verbalize what they understood about the procedures done to her.

– Referred to patient’s chart to check for interventions/procedures ordered by the physician.D. and done every intervention with the consent and supervision of the clinical instructor. – Documented every intervention/procedure done to patient like taking of vital signs and administration of medication carefully and correctly in the patient’s chart with the clinical instructor’s supervision and had it countersigned. Legal Responsibility – Carefully identified the right patient and rechecked data before administering medications. .

Ethico-Moral Responsibility – Provided confidentiality by discussing patient’s medical condition only among healthcare providers involved in the healthcare team.E. . – Respected patient’s religious practices.

– Involved patient as well as her significant other in the plan of care management for the patient.F. – Addressed patient’s needs and set them to priorities based on clinical judgment. – Discussed with the healthcare team involved in the patient care relevant data regarding patient’s condition and suggested ideas which may be helpful to the patient care. Personal and Professional Development – Done every nursing interventions/procedures especially the administration of medications always with the supervision of the clinical instructor. .

– Documented carefully all data gathered after every interventions done like taking of vital signs and administration of medications. – Took vital signs when patient reported that she felt dizzy after she took one of her medications. – Monitored patient’s response after every intervention/procedure done. .G. Quality Improvement – Referred to patient’s chart for data regarding patient’s health status to know whether she has improved with all the interventions/procedures done. – Reported to the nurse-in-charge any deviances noted with the patient like her increase in blood pressure after she took one of her medication. reported the data to the nurse-in-charge and documented it accurately on the patient’s chart.

– Consulted with the clinical instructor/ nurse on duty regularly to discuss patient’s health status as well as data gathered from the patient. . Research – Discussed among healthcare team regarding priority needs and problems of the patient.H.

. Records Management – Documented accurately relevant data of interventions done like taking of vital signs and administration of medication on the patient’s chart with the supervision of the clinical instructor. – Asked permission when using the chart.I. Returned the chart after using.

• J. – Reported/relayed patient’s concerns regarding her condition/care to the appropriate member of the healthcare team. needs and problems with regards to the patient’s condition. (Clinical Instructor/Nurse-in-charge) . – Allowed patient to verbalize feelings and concerns after every intervention/procedure done to her. – Stayed and listened to patient. Communication – Provided open communication with the patient and significant other to allow them to express feelings. given her time to talk to establish rapport and confidence. – Readily addressed patient’s concerns and needs right away.

– Assisted nurse-in-charge whenever she performed certain interventions/procedures to the patient like administration of medication. and reported and documented accurately data gathered especially any deviations noted. Collaboration and Teamwork – Reported to nurse-in-charge/clinical instructor any deviances noted with the patient especially when taking vital signs and administration of medications.• K. – Coordinated with the nurse-in-charge and clinical instructor whatever interventions/procedures to be done like monitoring of vital signs every 4 hours and administration of medications. . – Referred patient to social welfare services for financial support.

Discharge Planning .

-properly and safely store medications -report/ call physician for any signs of adverse/anaphylactic reactions. EXERCISE .Encourage patient to perform progressive ambulation exercises by gradually increasing distance and/or duration.MEDICATIONS -Advise patient to : -take medications with right dose. frequency and route as prescribed. . -complete full course of medications as ordered.

-take enough rest/sleep at least 8 hours -observe proper perineal care. front to back -Avoid interacting with people having infections -have small frequent feeding . TREATMENT HEALTH TEACHING -Advise patient to : -practice proper hygiene especially hand washing and mouth care.-Advise patient to comply with all laboratory examinations as ordered.

-Respect patient religious practices. DIET SPIRITUAL . Iron and carbohydrates.OUT.500ml daily -Encourage patient to eat foods rich in Vitamin C. protein. -Avoid fatty/oily and spicy foods -Encourage patient to include high fiber in the diet. -Advise patient to: -increase fluid intake at least 2.PATIENT -Advise patient to comply with scheduled follow up visits with her primary care physician. Vitamin E.

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